Journal Of Mental Science 65.1919 Princeton

The journal of mental science.

London : Longman, Green, Longman & Roberts, 1859-1962.

http://hdl.handle.net/2027/nj p.32101074924505

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PRINCETON UNIVERSITY

THE JOURNAL

OF

MENTAL SCIENCE.

EDITORS:

J. R. Lord, C.B.E., M.B. Thomas Drapes, M.B

Assistant Editors:

Henry Devine, M.D. 6. Douglas MoRae, M.D

VOL. LXV.

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCXIX.

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PRINCETON UNIVERSITY

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

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PRINCETON UNIVERSITY

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1918-19.

BDITOKS OF JOURNAL.

PKB8IUF.NT.— JOHN KEAY, M.D., C.M., F.R.C.P.
president ELECT.— BEDFORD PIERCE, M.D., F.R.C.P.
ex-president. —DAVID GEORGE THOMSON, M.D., C.M.
treasurer. —JAMES CHAMBERS, M.A., M.D.

r JOHN R. LORD, M.B.

IT. DRAPES, M.B.

DIVISIONAL SECRETARY FOR SOUTH-EASTERN DIVISION.

J. NOEL SERGEANT, M.B.

DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVISION.

G. N. BARTLETT, M.B.

DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

T. STEWART ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

ROBT. B. CAMPBELL, M.D,, F.R.C.P.

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. DEEPER, F.R.C.S.

GENERAL SECRETARY. —R. U. STEEN, M.D., M.R.C.P.
CHAIRMAN OF PARLIAMENTARY COMMITTEE.

H. WOLSELEY-LEWIS, M.D., F.R.C.S.

SECRETARY OP PARLIAMENTARY COMMITTEE.

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

(both appointed by Parliamentary Committee, and with scats on Council).

SECRETARY OF EDUCATIONAL COMMITTEE.

J. G. PORTER PHILLIPS, M.IL, M.R.C.P.

(appointed by Educational Committee, and with seat on Council).
registrar.— ALFRED A. MILLER, M.B.

MEMBERS OF COUNCIL.

REPRESENTATIVE.

R. ARMSTRONG-JONES
DAVID BOWER
MAURICE CRAIG
A. W. DANIEL
H. T. S. AVELINE
H. C. MACBliYAN
J. W. GEDDES
H. J. MACKENZIE
L. R. OSWALD
J. H. SKEEN

j-S.E. Div.

}S.W. Div.
}N.&M. Div
} Scotland.

REPRESENTATIVE.

M. J. NOLAN
J. MILLS

- Ireland.

NOMINATED.

HELEN BOYLE
RICHARD EAGER
R. I). HOTCHKIS

F. W. MOTT
DAVID ORR

G. E. SHUT1LEWORTH

[The above form the Council.]

ENGLAND

SCOTLAND

IRELAND

EXAMINERS.

R. II. STEEN, M.D., M.R.C.P.

J. O. PORTER-PHILLIPS, M.D., B.S., M.R.C.P.Lond.,
M.P.C.

H. do M. ALEXANDER, M.D., C.M.Edin.

L. R. OSWALD, M.D., C.M.

M. J. NOLAN, L.R.C.P.&S.I., M.P.C.

F. E. RAINSFORD, M.D., B.A.Dubl., L.R.C.P.I.,
L.R.C.P.&S.E.

Examiners for the Nursing Certificate of the Association :

Final.- J. REDINGTON, F.R.C.S., L.R.C.F.I.; HENRY DEVINE, M.D., B S.,
M.R.C.P., M.R.C.S., M.P.C.; N. T. KERR, M.D., C.M.Edin.
Preliminary .—GEORGE DUNLOP ROBERTSON, L.R.C.S. & P.F.din., Dipl. Psych.;
A. W. DANIEL, B.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond. ;

H. BROUGHAM LEECH, M.D., B Ch.Dublin.

AUDITORS.

G. F. BARHAM, M.A., M.D.Camb.

2W

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PARLIAMENTARY COMMITTEE.

T. S. ADAIR.

SIR R. ARMSTRONG-JONES.
H. T. S. AVEL1NE.
FLETCHER BEACH.

E. H. BERESFORD.

JAMES V. BLACHFORD.
DAVID BOWER.

A. HELEN BOYLE.

LEWIS C. BRUCE.

R. B. CAMPBELL.

JAMES CHAMBERS.

R. H. COLE.

M. A. COLLINS.

MAURICE CRAIG.

J. F. DIXON.

J. O’C. DON ELAN.

THOs. DRAPES.

H. EAGER.

J. It. OILMOUR.

R. D. HOTCHKIS.

P. T. HUGHES.

D. HUNTER.

THEO. B. HYSLOP.

JOHN KEAY (ex officio).

N. T. KERR.

R. L. LANGDON-DOWN.

R. R. LEEPER.

J. R. LORD.

P. W. MACDONALD.

T. W. McDOWALL.

W. F. MENZIES.

CHAS. A. MERCIER.
JOHN MILLS.

W. F. NELIS.

M. J. NOLAN.

JAMES ORR.

L. R. OSWALD.

E. S. PASMORE.
BEDFORD PIERCE.
HENRY KAYNER.

G. M. ROBERTSON.

SIR GEO. II. SAVAGE.

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

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.
T. E K STANSFIELD.
R. H. STEEN.

ROTHSAY C. STEWART.

F. R. P. TAYLOR.

DAVID G. THOMSON.
ERNEST W. WHITE
J. R. WHIT WELL.

H. WOLSELEY-LEW1S.

EDUCATIONAL COMMITTEE.

T. S. ADAIR.

II. do M. ALEXANDER (ex officio).
3. SIR R. ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCHER BEACH.

J. V. BLACHFORD.

,1. J. S. BOLTON.

LEWIS C. BRUCE.

R. B. CAMPBELL.

22. JAMES CHAMBERS.

18. R. H. COLE.

M. A. COLLINS

2. MAURICE CRAIG.

A. W. DANIEL (txoffioio).

H. DEVINE.

J. FRANCIS DIXON.

10. J. O'C. DONELAN.

THOS. DRAPES.

R. EAGER.

C. C. EASTERBROOK.

J. R. GILMOUR.

17. B. HART.

R. D. HOTCHKIS.

16. P. T. HUGHES.

12. JOHN KEAY.

N. T. KERR.

H. B. LEECH (ex officio).

R. R. LEEPER.

13. J. H. MACDONALD.

P. W. MACDONALD.

4 THOS. W. McDOWALL.

16. W. TUACII MACKENZIE.

21. E. 1). MACNAMARA.

8. R. MACPHAIL.

W. F. MENZIES.

C. A. MERCIER.

JAMES MIDDLEMASS.
ALFRED MILLER (ex officio).
W. F. NELIS.

MICHAEL J. NOLAN.

25. H. J. NORMAN.

DAVID ORR.

JAMES ORR.

5. L. R. OSWALD.

23. J. G. PORTER PHILLIPS.
BEDFORD PIERCE.

F. E. RAINSFORD (ex officio.)-
J. REDINGTON (ex officio.)

G. D. ROBERTSON (exofficio).

6. GEORGE M. ROBERTSON.

R. G. ROWS.

20. W. SCOWCRUFT.

E. B. SHERLOCK.

G. E. SHUTTLEWORTH.

J. H. SKEEN.

R. PERCY SMITH.

J. 0. SOUTAR.

J. BEVERIDGE SPENCE.

_ T. E. K. STANSFIELD.

7. ROBERT H. STEEN.

8. W. H. B. STODDART.
FREDERICK R. P. TAYLOR.
DAVID G. THOMSON.

19. W. R. VINCENT.

24. J. K. WILL

H. WOLSELEY-LEWIS.

9 JAMES COWAN WOODS.

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LIBRARY COMMITTEE.

FLETCHER BEACH.
HELEN BOYLE.

M. A. COLLINS.
HENRY DEVINE.
BERNARD HART.
THEO. B. HYSLOP.

JOHN KEAY (ex officio).

K. MAPOTHER.

HENRY KAYNER (Chairman).
R. H. STEEN ( Secretary ).

W. H. B. STODDART.

DAVID G. THOMSON.

RESEARCH COMMITTEE.

T. STEWART ADAIR.
J. SHAW BOLTON.

J. CHAMBERS.

M. A. COLLINS.

H. DEVINE.

T. DRAPES.

E. GOODALL.

JOHN KEAY.

J. R. LORD.

DAVID ORR.

FORD ROBERTSON.
R. G. ROWS.

R. PERCY SMITH.
R. H. STEEN.

D. G. THOMSON.

W. J. TULLOCH.

Lectures at:—(1) University of Leeds , (2) Guy's Hospital; (3) St. Bartholomew’s
Hospital; (4) University of Durham ; (5) University of Glasgow ; (61 University of
Edinburgh and Medical College for Women, Edinburgh ; (7) King’s College Hospital;
(8) St. Thomas’s Hospital; (9) St. George's Hospital; (10) University of Dublin and
National University of Ireland ; .(11) Queen's University of Belfast; (12) Lecturer at
School of Medicine, Royal Colleges and Medical College for Women, Edinburgh;
(13) St. Mungo's College, Glasgow; (14) Aberdeen University; (15) St. Andrew’s
University and Dundee University ; (16) Birmingham University ; (17) University
College, London ; (18) St. Mary’s Hospital, London; (19) University of Sheffield ;
(20) Victoria University, Manchester; (21) Charing Cross Hospital(22) Middlesex
Hospital; (23) Royal Free Hospital; (24) London Hospital; (25) Westminster
Hospital.

LIST OF CHAIRMEN.

1841. l)r. Blako, Nottingham.

1842. Dr. de Vitre, Lancaster.

1843. Dr. Conolly, Hanwell.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Wintle, VVarneford House, Oxford.

1861. Dr. Conolly, Hanwell.

1862. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS.

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

1856. J. Thurnam, M.D., Wilts County Asylum.

1866. J. Hitchinan, 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. Wm. Wood, M.D., Kensington House.

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

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

1868. W. H. 0. 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.

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

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

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

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

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

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

1879. J. A. Lush, M.D., Fisherton 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 Roynl Hospital.

1887. Sir Fred. Needlmm, 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. VVhitcombe, 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.B.,M.I)., 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. Urquliart, M.D., James Murray’s Royal Asylum, Perth.

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

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

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

1902 J. Wiglesworth, M.D., F.R.C.P., Rainhill Asylum, near Liverpool.

1903. Ernest W. White, M.B.,M.R.C.P., City of London Asylum, Dartford, Kent.

1904. R. Percy Smith, M.D., F.R.C.P., 36, Queen Anne Street, Cavendish

Square, Loudon, W. 1.

1905. T. Outterson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish

Square, London, W. 1.

1906. Sir Robert Armstroug-JoneF, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,

Claybury Asylum, Woodford Bridge, Essex.

1907. P. W. MacDonald, M.I)., County Asylum, Dorchester.

1908. Clias. A. Mercicr, M.D., F.R.C.P., F.R.C.S., 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., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh.

1911. Wm. R. Dawson, B.A., M.D., F.R.C.P.I., D.P.H., Inspector of Lunatic

Asylums, Dublin Castle, Dublin.

1912. J. Greig Soutar, M.B., Barnwood House, Gloucester.

1913. James Chambers, M.D., M.Ch., The Priory, Roehamptou, S.W.

1914-18. David G. Thomson, M.D., C.M.Kdin., County Asylum, Thorpe, Norfolk.
1918. John Keay, M.D., C.M., F.R.C.P., Edinburgh War Hospital, Baugour.

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Honorary and Corresponding Members. v

HONORARY MEMBERS.

1896. Allbutt, Sir T. Clifford, K.C.B., M.D., D.Sc., LL.D., F.R.C.P., F.R.S.,

Regius Professor of Physic, Uni v. Ciunl).,St. Radegund’s, Cambridge.
1881. Beuedikt, Prof. M., Franciskaner Platz 6, Vienna.

1918. Bevnn-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., Elsinore,
Dyke Road Avenue, Brighton. (President, 1909-10.)

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

1900. Blunier, G. Alder, M.D., L.R.C.P.Edin., Butler Hospital, Providence,
U.8.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.D., Obernrtzt, Liiben in Schlesien, Germany.

(Corr. Mem. 1896.)

1881. Brosius, Dr.,

1902. Brush, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson,
Maryland, U.S.A.

1917. Colies, John Mayue, LL.D. (Univ. Dub.), K.C., J.P., Registrar iu Lunacy

(Supremo Court of Judicature in Ireland), Lunacy Office, Four
Courts, Dublin.

1909. Collins, Sir William J„ D.L., M.D., M.S., B.Sc.Loud., F.K.C.S.Eng.,
1, Albert Terrace, Regent’s Park, London, N.W. 1.

1918. Cooke, Sir Edward Marriott, K.B.E., M.D., M.R.C.S.Eng., Commissioner

in Lunacy, 69, Onslow Square, London, S.W. 7.

1912. Considine, Thomas Ivory, F.R.C.S.I., L.R.C.P.I., Inspector of Lunatic
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin.
1902. Coupland, Sidney. M.D., F.R.C.P.Lond., Commissioner of the Board of
Control, “ Plan Gwyu,” Frognnl, Hampstead, Loudon, N.W. 3.

1876. Orichton-Browne, Sir J., M.D.Edin., LL.D., D.Sc., 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. Donkiu, 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.

1879. Echeverria, M. G., M.I).

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

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

1909. Kraepelin, I)r. Emil, Professor of Psychiatry, The University, Munich.
1887. Lentz, Dr., Asile d’Alilnes, Tournai, Belgique.

1910. Macpberson, John, M.D., F.ll.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh. (President, 1910-11.) ( Ordinary

Member from 1886.)

1911. Moeli, Prof. Dr. Karl, Director, Herzberge Asylum, Berlin.

1897. Morel, M. Jules, M.D., 56. Boulevard Leopold, Ghent, Belgium.

1889. Needham, Sir Frederick, M.D.St. And., M.R.C.P.Edin., M.R.C.S.Eng.,
Commissioner of the Board of Control, 19, Campden Hill Square,
Kensington, London, W. 8. (President, 1887.)

1909. Obersteiner, Dr. Heinrich, Professor of Neurology, The University, Vienna.
1881. Peeters, M., M.D., Gheel, Belgium.

1900. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

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

1911. Semelaigne, R6ne, M.D.Paris, Secretaire des Stances de la Socifjte
Medico-Psychologiqne de Paris, 16, Avenue de Madrid, Neuilly,
Seine, France. ( Corresponding Member from 1893.)

1881. Tamburini, A., M.I)., Reggio-Einilia, Italy.

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

mental & l’Ecole des Hautes Etudes Paris et Medecin en chef de
l’Asile de Villejuif, Seine, France.

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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VI

CORRESPONDING MEMBERS.

1904. Bierio, Caetauo, 48, Rua Formosa, Lisbonne, Portugal.

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privat Docent and Director,
Fichhenhof Asylum, Schlactensee, Berlin.

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

1904. CaroleS, Wilfrid, Manicomia de Sta. Crur, St. Andreo de Palamar,
Barcelona, Spain.

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

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

1911. Falkenberg, Dr. Wilhelm, Oberarzt, Irrenanstalt, Herzberge, Berlin.

1907. Ferrari, Giulio Cesare, M.D., Director of the Manicoinio Provinciale,
Iniola, Bologna, Italy.

1911. Friedlander, Prof. Dr. Adolf Albrecht, Director of the Holie Mark Klinik,
nr. Frankfort.

1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.

1880. Kornfeld, Dr. Hermann, Fr. Schlesien, Hauptpostluyerstr., Breslau.

1889. Kowalowsky, Professor Paul, Kbarkoff, Russia.

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

1901. Manheimer-Gommfcs, Dr., 32, Rue de l'Arcade, Paris.

1909. Moreira, Dr. Julien, M.D.Bahia, Professor and Director of the National
Manicomium of Rio de Janeiro ( Editor of the Brazilian Archives oj
Psychiatry, etc.).

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

1909. Pilcz, Dr. Alexander (Professor of Psychiatry in the University of
Vienna), Superintendent Landcssanatorium fur Nerven und Geistes-
kranke Steinhof, Vienna.

Mevibers of the Association.

Digitized by

vii

MEMBERS OF THE ASSOCIATION.

Alphabetical Lift of Members of the Association on December 3 \st, 1918, with
the x/ear in which they joined.

1900. Abbott, Henry Kingsmill, B.A., M.D.Dub., D.P.H.Irel., Medical Superin¬
tendent, Hants County Asylum, Fareham.

1891. Adair, Thomas Stewart, M.D., C.M.Ediu., F.R.M.S., Medical Superin¬
tendent, Stortlies Hall Asylum, Kirkburton, near Huddersfield.
(Hon. Sec. N. and M. Division since 1908.)

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

1913. Adams, John Barfield, L.R.C.P.&S.Edin., M.P.C., 119, Redlmid Roud,
Bristol.

1868. Adams, Josiah O., M.D.Durli., F.R.C.S.Eng., J.P., 117, Cazenove Road,

Stamford Hill, London, N. 16.

1886. Agar, S. Hollingsworth, jun., B.A.Cantab., M.lLC.S.Eng., L.S.A., Hurst
House, Henley-in-Arden.

1869. Aldridge, Chas., M.D., C.M.Aber., L.lt.C.P.Lond., Bellevue House,

Plympton, Devon.

1899. Alexander, Hugh de Maine, M.D., C.M.Ediu., Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Newmaehar, Aberdeen.
1899. Allmann, Dorah Elizabeth, M.B., B.Ch.R.U.l., Assistant Medical Officer,
District Asylum, Armagh.

1908. Anderson, James Richard Sumner, M.B., Ch.B.Glas., Senior Assistant

Medical Officer, Cumberland and Westmorland Asylum, Garlands,
Carlisle.

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

1918. Anderson, William Kirkpatrick, M.B., Ch.B.Glas., Visiting Physician,
Eastern District Hospital, Glasgow ; 3, Ashton Terrace, Glasgow.
1912. Annandale, James Scott, M.B., Ch.B.Edin., Second Assistant Physician,
District Asylum, Murthly, Perth.

1912. Aplhorp, Frederick William, M.R.C.S.Eng., L.R.C.P.Edin., M.P.C.,

Senior Medical Officer, St. George’s Retreat, Itavensworth, Burgess
Hill.

1904. Arclidale, Mcrvyn Alex., M.B., B.S.Durh., Medical Superintendent,
County Mental Hospital, Cambridge.

1906. Archdall, Mervyn Thomas, L.R.C.P.&S.Edin., L.S.A.Lond., Brynn-y-
Nenadd Hall, Llanfairfechan, N. Wales.

1918. Archibald, Alexander John, M.B., Ch.B.Glas., Acting Medical Superin¬
tendent, Argyll and Bute District Asylum, Lochgilphead, Argyllshire.
1918. Archibald, Madeline, L.R.C.P., L.R.C.S., Assistant Medical Officer, Argyll
and Bute District Asylum, Lochgilphead.

1882. Armstrong-Jones, Sir Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,
9, Bramhnm Gardens, London, S.W. 5 (and Pl&s Dinas, Carnarvon,
North Wales). ( Gen. Secretary from 1897 to 1906.) (President,
1906-7.)

1910. Auden, G. A., M.A., M.D., B.C., D.P.H.Cautnb., M.R.C.P.Lond., F.S.A.,
Medical Superintendent, Educational Offices, Edmund Street,
Birmingham.

1891. Aveline, Henry T. S., M.D.Durli., M.lt.C.S., L.R.C.P.Lond., M.P.C.,
Medical Superintendent, County Asylum, Cotford, near Taunton,
Somerset. (Eon. Sec. for S.W. Division, 1905-11.)

1903. Bailey, William Henry, M.D.Lond., M.R.C.S.Eng., L.S.A., D.P.H.Lond.,
Featherstone Hall, Southall, Middlesex.

1909. Bain, John, M.A., M.B., B.Ch.Glasg. (address uncommunicated).

1913. Bainbridge, Charles Frederick, M.B., Ch.B.Edin., Assistant Medical

Officer, Devon County Asylum, Exeter.

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

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viii Members of the Association.

1878. Baker, H. Morton, M.B., C.M.Edin., 7, Belsizo Square, London, N.W. 3.
1888. Baker, John, M.D., C.M.Aberd., Medical Superintendent, State Asylum,
Broadmoor, Berks.

1916. Ballard, E. F., 13, Lynclhurst Road, Hove, Sussex. (Deceased.)

1904. Barham, Guy Foster, M.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Acting Medical Superintendent, Claybury Asylum, Woodford
Bridge, Essex.

1913. Barkley, James Morgan, M.B., Ch.B.Edin. (Senior Medical Officer,
Bracebridge Asylum, Lincolnshire); c/o Dr. J. B. Hunter, Brace-
bridge Heath, Lincoln.

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

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

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

1874. Beach, Fletcher, M.B., F.R.C.P.Lond.,/brmeWy Medical Superintendent,

Darenth Asylum, DartJord ; Cane Hill, Coulsdou, Surrey. (Secre¬
tary Parliamentary Committee, 1896-1906. General Secretary,
1889-1896. President, 1900.)

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

1902. Benle-Brownc, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., c/o
P.M.O. Lagos, Nigeria, West Africa.

1913. Bedford, Percy William Page, M.B., Ch.B.Edin., County Asylum, Lan¬

caster.

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, JS. Sussex Educational
Committee), Windybnnk, Kingston Road, Lewes.

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

Yorks.

1912. Benson, Henry Porter D’Arcv, M.D., C.M.Edin., M.R.C.P., F.R.C.S.

Edin., Medical Superintendent, Furnhum House, Fimrlas, Dublin.
1914. Benson, John Robinson, F.R.C.S.Eng., L.R.C.P.Lond., Resident Physi¬
cian and Proprietor, Fiddington House, Market Lavington, Wilts.

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

Tooting Bee Asylum, Tooting, London, S.W. 17.

1912. Berncastle, Herbert M., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical,

Officer, Croydon Mental Hospital, Warlingham, Surrey.

1894. Blaeliford, James Vincent, M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,
M.P.C. (City Asylum, Fishponds, Bristol), Beaufort War Hospital,
Bristol.

1913. Black, Robert Sinclair, M.A.Edin., M.D., C'.M.Aberd., D.P.H., M.P.C.,

Medical Supt., Pietermaritzburg Mental Hospital, Natal, .South
Africa.

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

1897. Blandf'ord, Joseph John Guthrie, B.A., D.P.H.Camb., M.R.C.S., L.R.C.P.
Lond.; Rainliill Asylum, Lancashire.

1918. Blandford, Walter Foliiott, B.A.Camb., M.1LC.S., L.R.C.P.Lond.,
Temporary Assistant Medical Officer, Caterham Asylum, Caterham,
Surrey.

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

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

intendent, West Riding Asylum, Wakefield.

1892. Bond, Charles Hubert, D.Sc., M.D., C.M.Edin., M.R.C.P.Lond., M.P.C.,
Commissioner of the Board of Control, 66, Victoria Street, London,
S.W. 1. (Hon. General Secretary, 1906-12.)

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

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

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uncomraunicated.)

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ix

1917. Bowie, Edgar Ormoud, L.A.H.Dnb., Dip. Grant Mod. Coll. Bombay,

L.M.Coombe, Dublin; c/o W. II. Halliburton, Esq., 18, South
Frederick Street, Dublin.

1900. Bowles, Alfred, M.R.C.S., L.R.C.P.Lond., 10, South Cliff, East-
bourne.

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

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

1888. Boys, A. H„ L.R.C.P.Edin., M.R.C.S.Eng., L.S.A.Lond., The White
House, St. Albans.

1891. Braine-Hartnell, George M. P., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, County and City Asylum, Powick, Worcester.

1911. Brander, John, M.E., C.B.Edin., Assistant Medical Officer, London

County Meutal Hospital, Bexley, Kent.

1918. Brend, William Alfred, M.D.Lond., 14, Bolingbroke Grove, London,

S.W. 11.

1905. Brown, Harry Egerton, M.D., Ch.B.Glasg., M.P.C., Mental Hospital,
Fort Beaufort, Cape Province, S. Africa.

1908. Brown, Robert Cunynghain, M.I)., B.S.Durh. (General Board of Lunacy,
25, Palmerston Place, Edinburgh); Administrator, Spriugburn and
Woodsido Central Hospital, Glasgow.

1908. Brown, It. 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.Glas., M.P.C., District Medical Officer,

Adviser in Lunacy to Bristol Magistrates (1, Manor Road, Fish¬
ponds, Bristol) ; 2nd Southern General Hospital, Southmead, Bristol.

1916. Brown, William, M.A., M.B., B.Ch.Oxon., D.Sc.Lond., Reader in

Psychology in the University of London (King’s College), (King’s
College, Strand, London, W.C. 2); Craiglockhart War Hospital,
Slateford, Midlothian.

1917. Bruce, Alexander Ninian, M.D., D.Sc., F.R.C.P.E., Lecturer on Neuro-

logy, University of Edinburgh, 8, Ainslie Place, Edinburgh.

1893. Bruce, Lewis C., M.D., E.R.C.P.Edin., M.P.C. Medical Superintendent,

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

1913. Bruuton, George Llewellyn, M.D., Ch.B.Edin., North Ridiug Asylum,

Clifton, York.

1912. Buchanan, William Murdoch, M.B., Ch.B.Glas., Kirklands Asylum,
Bothwell, Lanarkshire.

1908. Bullmore, Charles Cecil, J.P., L.R.C.P.&S.Ediu., L.R.F.P.&S.Glas.,

Medical Superintendent, Flower House, Catford, London, S.E. 6.

1912. Burke, J. D., St. Amlry’s Hospital, Melton, Suffolk.

1911. Buss, Howard Dccimus, B.A., B.Sc.France, M.D.Brux.&Cape, M.It.C.S.,
L.R.C. P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. Cahir, John P., M.B., B.Ch.R.U.I., 198, Camberwell New Road, Camber¬
well, London, S.E. 5.

1891. Culdecott, Charles, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Earlswood Asylum, Redliill, Surrey.

1913. Cameron, John Allan Munro, M.B., Ch.B.Glas., Pathologist, Scalebor

Park Asylum, Burley-in-Wharfedale, Yorks.

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

183, Macquarie Street, Sydney, Nerv South Wales.

1909. Campbell, Donald Graham, M.B., C.M.Edin., “ Auchinellan,” 12, Reid-

haven Street, Elgin.

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

Services, Ministry of National Service, Ayr, Scotland.

1880. Campbell, Patrick E., M.B., C.M.Edin., Medical Superintendent, Metro¬
politan Asylum, Caterham, Surrey.

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1897. Campbell, Robert Brown,M.D., C.M., F.R.C.P.E., 6, Abbotsford Crescent,
Edinburgh. (Secretary for Scottish Division from 1910.)

1905. Carre, Henry, L.R.C.P.&S.Irel., Woodilee Asylum, Lcnzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.R.F.P.&S.Glnsg., 43, Moray Place,

Edinburgh ; Commissioner-General, Hoard of Control, Scotlnnd.
1874. Cassidy, 1). M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Public
Health) 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, Roeliampton,
Loudon, S.W. 15. ( Co-Editor of Journal 1905-1914, Assistant
Editor 1900-05.) (Phesident, 1913-14.) ( Treasurer since

1917.)

1911. Chambers, Walter Duncuuon, M.A., M.D., Ch.B.Edin., M.P.C., Crichton
Royal Institution, Dumfries.

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

1915. Cheyne, Alfred William Hnrper, M.B., Ch.B.Aber., Assistant Medical
Officer, Royal Asylum, Aberdeen.

1917. Chisholm, Percy, L.lt.C.P. A S.Edin., Assistant Medical Officer, Stirling
District Asylum, Larbert.

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

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

1878. Clapham, Win. Crocliley S„ M.D., F.R.C.P.Ed., M.R.C.S.Eng., F.S.S., The
Five Gables, Maj field, Sussex. (Eon. Sec. E. and M. Division,
1897-1901.)

1907. Clarke, Geoffrey, M.D.Lond., Senior Assistant Medical Officer, London
County Mental Hospital, Bnnstead, Sutton, Surrey.

1910. Clarke, James Kiliau P., M.B., B.Ch.R.U.I., D.P.H., High Street,
Oakham.

1907. Clarkson, Robert Durward, H.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.Lond., 25, Upper Berkeloy

Street, London, W. 1. ( Secretary of Parliamentary Committee

since 1912.)

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

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Ewell War Hospital, Ewell, Surrey. (Hon. General Secretary,
1912-18.)

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

1914. Connolly, Victor Lindley, M.B., B.Cl).Belfast, Assistant Medical Officer,
Colney Hatch Mental Hospital, London, N. 11.

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

1905. Cooper, K. D., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., c/o Leopold & Co.

Apollo, Bunder, Bombay.

1903. Cormac, Harry Dove, M.B., B.S.Madias, Medical Superintendent,
Cheshire County Asylum, 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., Assistant Medical Officer, Portrane Asylum,
Ireland.

1906. Cotter, James, L.R.C.P.&S.E., L.R.F.P.&S.Glas., Down District Asylum,

Downpatrick.

1897. Cotton, William, M.A., M.D.Edin., D.P.H.Cantab., M.P.C., c/o D. N.
Cotton, Esq., 9, St. David Street, Edinburgh.

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Members of the Association.

1910. Coupland, William Henry, L.R.C.S.&P.Edin., Medical Superintendent,

Royal Albert Institution, Albert House, Hnverbreaks, Lancaster.

1913. Court, E. Percy, M.R.C.S., L.R.C.P. Lond., Severalls Asylum,

Colchester.

1893. Cowen, Thomas Philip, M.D., B.S. M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, County Asylum, liuinhill, Lancashire.

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

Bristol.

1918. Cox, Francis Michael, M.D.,F.R.C.P.L., Physician, St. Vincent’s Hospital,
Dublin; Lord Chancellor’s Consulting Visitor in Lunacy for County
and City of Dublin; 20, Merrion Square, Dubliu.

1893. Craig, Maurice, M.A., M.D., B.C.Cuntab., F.R.C.P.Lond., M.P.C., 87,
Harley Street, London, W. 1. ( Hon. Secretary of Educational Com¬
mittee, 1905-8; Chairman of Educational Committee since 1912.)
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.Glas. 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.

1914. Crookshank, Francis Graham, M.I)., M.R.C.P.Lond., 15, Harley Street,

London, W. 1.

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

1915. Crosthwaite, Frederick Douglas, M.B., Ch.B.Edin., D.P.H.Cantab.,

Assistant Physician, Pretoria Mental Hospital, South Africa.

1914. Cruickshank, J., M.D., Ch.B.Glas., Pathologist, Crichton Royal Hospital,
Dumfries.

1907. Daniel, Alfred Wilson, B.A., M.D..B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Acting Medical Superintendent, Loudon County Mental Hospital,
Hanwell, London, W. 7.

1896. Davidson, Andrew, M.D., C.M.Aber., M.P.C., Wyoming, Macquarie
Street, Sydney, N.S.W.

1914. Davies, Laura Katherine, M.B., Ch.B.Edin., Pathologist and Assistant

Medical Officer, Edinburgh City Asylum, Bangour, Dechmont,
Linlithgowshire.

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

1894. Dawson, William R., B.A.,M.D.,B.Ch.Dubl., F.R.C.P.I..D.P.H., Inspector
of Lunatics in Ireland, 7, Ailesbury Road, Dublin. (Son. Sec. to
Irish Division, 1902-11; Prbsidbnt, 1911-12.)

1901. De Steiger, Ad&le, M.D.Lond., County Asylum, Breutwood, Essex.

1905. Devine, Henry, M.D., B.S., M.R.C.P.Lond., M.R.C.S.Eng., M.P.C.,
Medical Superintendent, The Asylum, Milton, Portsmouth. (A«w-
tant Editor of the Journal since 1916.)

1904. Devon, James, L.R.C.P. & S.Ediu., 1, North Park Terrace, Hillhead,

Glasgow.

1903. Dickson, Thomas Graeme, L.R.C.P. & S.Ediu., The Merse Cottage,
Bakcwel), Derbyshire.

1915. Dilion, Frederick, M.B., Ch.B.Edin. (Clinical Assistant, West End

Hospital for Nervous Diseases; Assistant Medical Officer, Northum-
btrlund House, Green Lanes, Finsbury Park, London, N. 4); Craigen-
hall, Falkirk, N.B.

1909. Dillon, Kathleen, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Mullingar.

1905. Dixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Super¬

intendent, Borough Mental Hospital, Humberstone, Leicester.

1879. Dodds, William J., M.D., C.M., D.Sc.Edin., Glencoila, Bellahouston,
Glasgow.

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xii Members of the Association.

1908. Donald, Robert, M.D., Ch.B.GIas., 3, Gilmour Street, Paisley.

1889. Donaldson, William Ireland, B.A., M.D., B.Cli.Dubl., Medical Superin¬

tendent, London County Mental Hospital, Cane Hill, Coulsdon,
Surrey.

1892. Donelan, John O’Conor, L.R.C.P.AS.l., M.P.C., St. Dyinpbna’s, North
Circular Road, Dublin (Med. Supt., Richmond Asylum, Dublin).

1890. Douglas, William, M.D.R.U.I., M.R.C.S.Eng., F.R.G.S., Brandfold,

Goudhurst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durh., M.R.C.S.Eng., “ Brightside,”
Crouch End Hill, London, N. 2.

1897. Dove, Emily Louisa, M.B.Lond., 11, Jenner House, Hunter Street,
Brunswick Square, London, W.C. 1.

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

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

1884. Drapes, Thomas, M.B.Dubl., L.R.C.S.I., Medical Superintendent, District
Asylum, Enuiscorthy, Ireland. (Peesidhnt-elect, 1910-11; Co-
Editor of Journal since 1912.)

1916. Drummond, William Blackley, M.B., C.M.Edin., F.R.C.P., Medical

Superintendent, Baldovan Institution, Dundee.

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Senior A.M.O., Woodilee Mental
Hospital, Lenzie.

1902. Dudgeon, Herbert Win., M.D., B.S.Durh., M.R.C.S., L.R.C.P.Loud.,

Medical Super 5 ntendent, Khanka Government Asylum, Egypt.
1899. Dudley, Francis, L.R.C.P.AS.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1915. Duff, Thomas, L.R.C.P., L.R.C.S.Edin., L.R.F.P.&S.Glasg., Colliugton
Rise, Bexhill-on-Sea.

1917. Dunn, Edwin Lindsay, M.B., B.Ch.Dub., Medical Superintendent, Berks

County Asylum, Wallingford, Berks.

1903. Duuston, John Thomas, M.D., B.S.Loud., Medical Superintendent, West

Koppies Asylum, Pretoria, South Africa.

1911. Dykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., c/o Messrs. Holt

and Co., 3, Whitehall Place, London, S.W. 1.

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

1906. Eager, Richard, M.D., Ch.B.Aber., M.P.C., Assistant Medical Officer,

The Devon Mental Hospital, ExmiiiBter.

1881. Earle, Leslie M., M.I)., C.M.Edin., 108, Gloucester Terrace, Hyde Park,
London, W. 2.

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

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

H.M. Prison, Manchester; 17, Walton Park, Liverpool.

1895. Easterbrook, CharlesC., M.A..M.D., F.R.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Crichton Roval Institution, Dumfries.

1914. Eder, M. I)., B.Sc.Loud., M.R.C.S., L.R.C.P.Lond. (Medical Officer,
Deptford School Clinic), 37, Welbeck Street, London, W. 1.

1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten¬
dent, West Riding Asylum, Menston, nr. Leeds.

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

Medical Superintendent, Camberwell House, London, S.E.5.

1901. Klgee, Samuel Charles, L.R.C.P.&S.l. (Colney Hatch Mental Hospital,
New Southgate). The Manor (County of London) War Hospital,
Epsom, Surrey.

1898. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Medical Superintendent,

Metropolitan Asylum, Leavesden, Herts.

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

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Member* of the Association. xiii

1917. Ellis,VincentC., M.B., Assistant Medical Officer, Portrane Asylum, Ireland.

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

Prison, Leeds, 120, Domestic Street, Holbeck, Leeds.

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

1911. Emslie, Isabella Galloway, M.D., Ch.B.Edin., West House, Royal Asylum,
Morningside, Edinburgh.

1911. English, Ada, M.B., B.Ch.R.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe.

1901. Erskinc, Wrn.J. A., M.D., C.M.Edin., Medical Superintendent, County
Asylum, VVhitecroft, Newport, 1. of W.

1895. Euricb, Frederick Wilhelm, M.D., C.M.Edin., 8, Morningtou Villas,
Maningham Lane, Bradford.

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

1909. Eustace, William Ncilson, 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.

1909. Evans, George, M.B.Lond., Senior Assistant Medical Officer, Severalls
Asylum, Colchester.

1918. Evans, Tudor Benson, M.B., Cli.B.Liverp., Lord Derby War Hospital,
Warrington. Home address : The Pharmacy, Denbigh.

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

1914. Ewing, Cecil Wilmot, L.R.C.P.I.& L.R.C.S.I. (Socond Assistant Medical
Officer, Chartham Asylum, near Canterbury), Lord Derby War
Hospital, Warrington.

1907. Exley, John, L.R.C.P.I., M.R.C.S.Eng., Medical Officer, H.M. Prison;
Grove House, New Wortley, Leeds.

1894. Farquharson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Counties Asylum, Garlands, Carlisle.

1907. Farries, John Stotlmrt, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., Yrthington,

Carlisle.

1917. Fearnsides, Edwin Greaves, M.D.Camb., B.C'., M.A., 46, Queen Anne
Street, Cavendish Squaro, London, W. 1.

1903. Fennell, Charles Henrv, M.A.. M.D.Oxon, M.R.C.P.Lond., Reform Club,

Pall Mall, London, S.W. 1.

1908. Fenton, Henry Felix, M.B., Ch.B.Edin., Assistant Medical Officer,

County and City Asylum, Powick, Worcester.

1907. Ferguson, J. J. Harrower, M.B., Ch.B.Edin., Senior Assistant Medical

Officer, Fife and Kinross Asylum, Cupar, Fife.

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

1873. Finch, John E. M., M.A., M.D.Cantab., M.R.C.S.Eng.. L.S.A.Lond.,
Holmdnle, Stoneygate, Leicester.

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

1906. Firth, Arthur Harcus, M.A., M.D., B.Cli.Edin., Deputy Medical Super¬
intendent, Barnsley Hall, Bromsgrove, Worcestershire.

1908. Fitzgerald, Alexis, L.R.C.P. & S.I., Medical Superintendent, District

Asylum, Waterford.

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

1908. Fitzgerald, James Francis, L.R.C.P.&S.Irel., Assistant Medical Officer,
District Asylum, Clonmel, co. Tipperary, Ireland.

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

Pirbright, Surrey.

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

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Digitized by

xiv Members of the Association.

1908. Flynn, Titos. AloyMus, L.R.C.P.AS.)., County Asylum, Thorpe, Norwich.
1902. Forde, Michael J., M.D., B.Ch.U.U.l., Assistant Medical Officer, Rich¬
mond Asylum, Dublin.

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

Loud., Senior Assistant Medicnl Officer, Leicester and Rutlaud
Counties Asylum, Narborough.

1916. Forsyth, Charles Wesley, M.B.Lond., M.R.C.S., L.U.C.P., Assistant
Medical Officer, Kesteven County Asylum, Sleaford, Lines.

1913. Forward, Ernest Lionel, M.R.C.S., L.R.C.P.Lond. (Assistant Medical
Officer, The Coppice, Nottingham); 2/2 East Lancs] Field
Ambulance.

1913. Fothergill, Claude Francis, B.A., M.B., B.C.Cantab., M.R.C.S., L.lt.C.P.

Loud.; Hensol, Chorley Wood, Herts.

1912. Fox, Charles J., M.R.C.S., L.R.C.P.Lond., The Moat House, Alnechurch

Birmingham.

1881. Fraser, Donald, M.D., C.M.Glasg., F.R.F.P.S., 13, Royal Terrace
West, Glasgow.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P.Lond., “Locksley,”

Willingdon, Eastbourne.

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬

intendent, Three Counties’ Asylum, Arlesey, Beds.

1914. Gage, John Munro, L.R.C.P.AS.I., M.P.C., Royal Earlswood Institution,

Redhill, Surrey.

1906. Gnnc, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond.,
Cane Hill Mental Hospital, Conlsdon, Surrey.

1912. Garry, John William, M.B., B.Ch., N.U.I., Assistant Medical Officer
Ennis District Asylum, Ireland.

1912. Gavin, Lawrence, M.B., Cli.B.Edin,, L.R.C.P.AS.Edin., L.R.F.P.AS.
Glasg., Superintendent, Mullingar District Asylum, Ireland.

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

Hospital, Middlesbrough, Yorks.

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

1899. Gilfillan, Samuel James, M.A., M.B., C.M.Edin., Medical Superintendent,
London County Mental Hospital, Colney Hatch, London, N. 11.
1912. Gill, Eustace Stanley Hayes, M.B., Ch.B.Liverp., Shaftesbury House,
Formby, Liverpool.

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

1904. Gillespie, Daniel, M.D. B.Ch.R.U.I., Dipl. Psych. (Wadsley Asylum,

near Sheffield); Wharncliffe War Hospital, Middlewood Road,
Sheffield.

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

Superintendent, West Riding Asylum, Scalebor Park, Burley-in-
Wharfedale, Yorks.

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

1878. Glendinning, James, M.D.Glasg., L.R.C.S.Ediu. Hill Crest, Lansdown
Road, Abergnvenny.

1897. Good, Thomas Saxty, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, County Asylum, Littlemore, Oxford.

1889. Goodall, Edwin, M.D., B.S., F.R.C.P.Lond., M.P.C. (Medical Superin¬
tendent, City Mental Hospital, Cardiff); The Welsh Metropolitan
War Hospital, Whitchurch, nr. Cardiff.

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

1899. Gordon, James Leslie, M.D., C.M.Aberd. (Medical Superintendent,
Fountain Temporary Asylum, Tooting Grove, Tooting Graeeney,
London, S.W. 17).

1905. Gordon-Munn, John Gordon, M.D.Edin., F.R.S.E., Heigham Hall,

Norwich.

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XV

Members of the Association.

1901. Gostwyck, C. H. G., M.B., Ch.B., F.R.C.P.Edin., M.P.C., Dipl. Psych.,
Stirling Diitrict Asylum, Larbert.

1912. Graham, Gilbert Malise, M.B., Ch.B.Edin., R.N., H.M.S. “ Emperor of
India.”

1914. Graham, Norman Bell, B.A., R.U.I., M.B., B.Ch.Belfast, Assistant

Medical Officer, District Asylum, Belfast; 24, Ocean Buildings,
Belfast.

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

1918. Graham, Samuel John, L.R.C.P., L.R.C.S.Edin., L.R.F.P.S.Glasg.,
Resident Medical Superintendent, Villa Colony Asylum .Purdys-
burn, Belfast.

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

Somerset and Bath Asylum, near Taunton.

1915. Graves, T. Cbivers, M.B., B.S., B.Sc.Lond., F.R.C.S.Eug., Medical Super¬

intendent, City and County Asylum, Burgliill, Hereford.

1916. Gray, Cyril, L.R.C.P.&.S.Edin., Gateshead Borough Asylum, Stannington,

Newcastle-on-Tyne.

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

District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., C.M.Edin., F.R.S.E., Rostrevor, Kirtleton
Avenue, Weymouth.

1912. Greeson, Clarence Edward, M.D., Ch.B.Aberd., c/o Messrs. Holt & Co.,
3, Whitehall Place, London, S.W. 1.

1915. Grigsby, Hamilton Maiie, L.R.C.P.&S.Edin., 79, Victoria Road North,

Southsea.

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

1916. Grimbly, Alan F., B.A., M.A., M.D.Trin.Coll.Dublin, B.Ch., B.A.O.,

L.M.Rot.Dub. (Assistant Medical Officer, St. Edmondsbnry, Lucan,
Ireland); R.N., H.M.S. “Indomitable,” Naval Post Office B, c/o
G.P.O., Edinburgh.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P.Lond., Bootham Park, York.
1894. Gwynn, Charles Henry, M.D., C.M.Edin., M.R.C.S.Kng., 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.

* 1901. Harding, William, M.D.Edin., M.R.C.P.Lorid., Medical Superintendent,

Northampton County Asylum, Berry Wood, Northampton.

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

Private Asylum, Tonbridge, Kent.

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

(Senior Assistant Medical Officer, Brighton County Borough
Asylum, Haywards Heath), May Cottage, Loughton, Essex.

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.Eng., 29 b, Wirapole Street, London,

W. l.aud Northumberland House, Finsbury Park, London, N. 4.
1886. Harvey, Bagenal Crosbie, L.R.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.
1891. Havelock, John G., M.D., C.M.Edin., Little Stodham, Lies, Hants.

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., M.R.C.S.Eng., L.S.A., J.P., Littleton Hall, Brent¬

wood, Essex.

1911. Heffernan, P., B.A., M.B., B.Ch.C.U.I.

1916. Henderson, David Kennedy, M.D.Edin., (Senior Assistant Physician,
Royal Asylum, Gartnavel, Glasgow); c/o John Henderson and Sons,
Solicitors, Dumfries, Scotland.

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Digitized by

xvi Members of the Association.

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

1877. Hetherington, Charles E., B.A., M.B., M.Ch.Dubl., Medical Superin¬
tendent, District Asylum, Londonderry, Ireland.

1877. Hewson, R. W., 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.Glas., Coton Hill
Hospital, Stafford.

1912. Higson, William Davis, M.B., Ch.B.Liverp., D.P.H., Deputy Medical
Officer, H.M. Prison, Brixton; 7, Clovelly Gardens, Upper Tulse
Hill, London, S.W. 2.

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

1914. Hills, Harold William, B.S., M.B., B.Sc.Loud., M.R.C.S., L.R.C.P.Lond.;
Lord Derby War Hospital, Warrington.

1907. Hine, T. Guy Macaulay, M.A., M.D., B.C.Cantab., 37, Hertford Street,

Mayfair, Loudon, W. 1.

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

1908. Hogg, Archibald, M.B., Ch.B.Glas., 54, High Street, Paisley, N.B.

1900. Hollander. Bernard, M.D.Freib., M.R.C.S., L.R.C.P.Lond, 57, Wimpolc

Street, London, W. 1.

1912. Holyoak, Walter L., M.D., B.S.Lond., 45. Welbeck Street, London, W. 1.

1903. Hopkius, Charles Leighton, B.A., M.B., B.C.Cantab., Medical Superin¬

tendent, York City Asylum, Fulford, York.

1918. Horton, Wilfred Winnall, M.D.Edin., Medical Superintendent, Wye
House Asylum, 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 Pereira], 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 Asylum, Barnesley Hall, Bromsgrovc.

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

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

1897. Hunter, David, M.A., M.1L, B.C.Cantab., L.S.A., Medical Superintendent,
The Coppice, Nottingham. {Secretary for S. K. Division, 1910-1913.)

1909. Hunter, Douglas William, M.B., Ch.B.Glasg., Assistant Medical Officer,

10, Halllield Road, Bradford.

1912. Hunter, George Yeates Cobb, 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
Asylum, Arlesey, Beds.

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

1915. Ingall, Frank Ernest, F.R.C.S.Eng., L.R.C.P.Lond., D.P.H., Tue Brook
Villa, Liverpool.

1908. Inglis, J. P. Park, M.B., Cli.B.Edin., Assistant Medical Officer,
Caterham Asylum, Caterham, Surrey.

1906. Irwin, Peter Joseph, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Limerick.

1914. James, George William Blomfield, M.B., B.S.Lond., c/o 20, Homesgarth,
Letchworth, Herts.

1908. Jeffrey, Geo. Rutherford, M.D., Ch.B.Glas., F.R.C.P.E., M.P.C.,
Medical Superintendent, Boothnm Park, York.

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PRINCETON UNIVERSITY

Members of the Association. xvii

1910. Johnson, Cecil Webb, D.S.O., M.B., Ch.B.Vict. (“ Cricklewood,” East
Sheen, London, S.VV. 14) j 10th Middlesex Regiment, Fort William,
Calcutta, India.

1893. Johnston, Gerald Herbert, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., Brooke
House, Upper Clapton, London, N. 6.

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

1912. Johnstone, Emma May, L.R.C.P. & S.Ediu., L.R.F.P.&S.Glas., M.P.C.,
Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.D., C.M.Glas., Melrose, Roxburgh.

1903. Johnstone, Thomas, M.D., C.M.Edin., M.R.C.P.Lond., Annandale,
Harrogate.

1880. Jones, D. Johnston, M.D., C.M.Edin.

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

Harrogate.

188C, Keay, John, M.D., C.M.Glasg., F.R.C.P.Ediu. (Medical Superintendent,
Bangour Village, Uphall, Linlithgowshire); Edinburgh War
Hospital, Bangour. (President, 1918.)

1909. Keith, William Brooks, M.B., Ch.B.Aberd., M.P.C.,81st Field Ambulance,
27th Division.

1908. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Storthes

Hall Asylum, Kirkburton, near Huddersfield.

1907. Keene, George Henry, M.D., The Asylum, Goodmayes, Ilford, Essex.
1899. Kennedy, Hugh T. J., L.R.C.P.&S.L, Assistant Medical Officer, District
Asylum, Enuiscorthy, Co. Wexford.

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

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

District Asylum, Hartwood, Shotts, N.B.

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

1897. Kidd, Harold Andrew, M.R.C.S.Eng., L.It.C.P.Lond. (Medical Superin¬

tendent, West Sussex Mental Hospital, Chichester) ; Graylingwell
War Hospital, Chichester.

1916. Kilgarriff, Joseph O’Loughlin, A.B., M.B., B.Ch., B.A.O.Univ., Dublift,
Assistant Medical Officer, County Asylum, Prestwich, Lancs.

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

■hire.

1916. Kirwan, Richard R., M.B., B.Ch. R.U.I., Assistant Medical Officer,
West Riding Asylum, Menston, Leeds.

1915. Kitson, Frederick Hubert, M.B., Ch.B.Leeds, Assistant Medical Officer,
West Riding Asylum, Wakefield.

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

Medical Officer, County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin¬

tendent, Public Asylum, Jersey.

1902. Laugdon-Down, Percival L., M.A., M.B..B.C.Cantab., Dixland, Hampton
Wick, Middlesex.

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

1914. Ladell, R. G. Macdonald, M.B., Ch.B.Vict., The Gables, Killinghall,
Harrogate.

1909. Laurie, James, M.B., Ch.M.Glasg. ( Medical Officer, Smithston Asylum),

(Red House, Ardgowan Street, Greenock); 3rd Scottish Hospital.
1902. Laval, Evariste, M.B., C.M.Edin., The Guildhall, Westminster, London,
S.W. 1.

1898. Lavers, Norman, M.D.Brux., M.R.C.S., L.R.C.P.Lond. (Medical Super¬
intendent, Bailbrook House, Bath); Red Cross Military Hospital,
Moss Side, Maghull, near Liverpool.

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Digitized by

xviii Members of the Association.

1892. Lawless, George Robert, F.R.C.S.I., L.R.C P.I., Medical Superintendent,
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.Eng., L.R.C. I’.Edin., 26, Kimbolton Road,
Bedford.

1916. Leech, H. Brougham, M.D., B.Ch.Dublin, Assistant Medical Officer,
County Asylum, Hatton, Warwick.

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

1899. Leeper, Richard It., F.R.C.S.I., L.R.C.P.I., 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., " Comeragb,” Leek-

liampton Road, Cheltenham.

1906. Leggett, William, B.A., M.D., B.Ch.Dubl., Assistant Medical Officer,
Royal Asylum, Sunnyside, Montrose).

1916. Lewis, Edward, L.R.C.P., L.R.C.S.Edin., L.F.P.S.Glasg., Cwirlai, Ty-
Cross, Anglesey.

1914. Lindsay, David George, L.R.C.P.&S.Edin., Senior Assistant Medical
Officer, Dundee District Asylum, West Green, Dundee.

1908. Littlejohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Acting Medical
Superintendent, London County Mental Hospital, Cane Hill, Surrey.
1916. Lloyd, Brindley Richard, M.B., B.S.Loud., D.P.H.Lond., Assistant
Medical Officer, Monmouthshire Asylum, Abergavenny.

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

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

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

Leicester.

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

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., (Assistant Medical Officer,
Coluey Hatch Mental Hospital, London, N. 11); Mediterranean
Expeditionary Force.

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

1900. McCliutoek, John, L.R.C.P.&S.Edin., Resident Medical Superintendent,

Grove House, All Stretton, Church Stretton, Salop.

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

Asylum, Hawkhead, Paisley, N.B.

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

(First Hon. Sec. S. W. Div. 1894 to 1905.) (President, 1907-8.)
1911. MacDonald, Ranald, M.D., Ch.B.Edin., London County Mental Hospital,
Bexley, Kent.

1906. MacDonald, William Frpser, M.B., Ch.B.Edin., M.P.C., 96, Polworth
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, Snndle Bridge, near Aldcrley
Edge, Cheshire.

1911. McDougall, William, M.A., M.B., B.C.Cantab., M.Sc.Vict., 89, Banbury
Road, Oxford.

19u6. McDowall, Colin Francis Frederick, M.D., B.S.Durh., Medical Superin¬
tendent, Ticehurst House, Ticehurst, Sussex.

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

1895. Macfarlane, Neil M., M.D., C.M.Aber., Medical Superintendent, Govern¬
ment Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.

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

County Asylum, Bridgend, Glam.

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PRINCETON UNIVERSITY

Members of the Association. xix

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

1914. Mackny, Magnus Ross, M.D., Ch.B.Edin., British Expeditionary Force,
France.

19L7. Mackay, Norman Douglas, M.D., B.Sc., D.P.H., Dall-Avon, Aberfeldy,
Perthshire.

1916. McKenna, Edward Joseph, M.B., B.Ch., R.U.I., Assistant Medical

Officer, Carlow District Asylum.

1911. Mackenzie, John Cosserat, M.B., Ch.B.Edin., County Mental Hospital,
Burutwood, 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.

1914. Macleod, Jan R„ L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 7, Mayfield
Gardens, Edinburgh.

1917. McMaster, Albert Victor, B.A., M.R.C.S.Eng., “ The Mount," Hills Road,

Cambridge.

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

Harley Street, London, W. 1.

1914. Macneill, Celia Mary Colquhoun. M.B., Ch.B.Edin. (Pathologist, North-
field, Prestonpans); Leith War Hospital, Seafield, Leith.

1910. MacPhail, Hector Duncan, M.A., M.D., Ch.B.Edin. (Assistant Medical
Officer, City Asylum, Gosforth, Newcastle-on-Tyne); Northumber¬
land War Hospital, Newcastle.

1882. Macpbnil, S. Rutherford, M.l)., C.M.Edin., Derby Borough Asylum,
Rowditch, Derby.

1896. Macplierson, Charles, M.D.Glas., L.R.C.P.&S., D.P.H.Edin., Deputy
Commissioner in Lunacy, 25, Palmerston Place, Edinburgh.

1901. McRae, G. Douglas, M.D., C.M.Edin., F.R.C.P.Ed., Medical Super¬

intendent, District Asylum, Ayr, N.B. (Assistant Editor of the
Journal since 1916).

1902. Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin. (Bangour Village,

Dechmont, Linlithgowshire); M.E.F.

1894. McWilliam, Alexander, M.A., M.B., C.M.Aber., Waterval, Odihara,
Winchfield, Hants.

1916. Manifold, Robert Fenton, M.B., D.Ch.Dub., Senior Assistant Medical
Officer, Denbigh Asylum, North Wales.

1908. Mapother, Edward, M.D., B.S.Lond., F.R.C.S.Eng., Assistant Medical
Officer, Loudon County Mental Hospital, Long-Grove, Epsom.

1903. Marnan, 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.&S.Glasg., M.P.C., Commis¬
sioner in Lunacy (10, Succoth Avenue, Edinburgh). (Hon. Sec.
Scottish Division, 1907-1910).

1913. Marshall, Robert, M.B., Ch.B.Glas. (Assistant Medical Officer, Gartloch

Mental Hospital, Gartcosh, N.B.) ; 19tli General Hospital, British
Expeditionary Force.

1905. Marshall. Robert Macnab, 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. & P.I., 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, Long-
Grove, Epsom.

1907. Martin, Mary Edith, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., L.S.A.Lond.,
M.P.C.Lond., Bailbrook House, Bath.

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

Assistant Medical Officer, St. Andrew’s Hospital, Northampton) ;
British Mediterranean Expeditionary Force.

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XX

Members of the Association.

1911. Martin, William Lewis, M.A., B.Sc., M.B., G.M.Edin., D.P.H., M.P.C.,
Dipl. Psych. ( Certifying Physician in Lunacy, Edinburgh Parish
Council), 56, Bruntsfield Place, Edinburgh.

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

Wndsley Asylum, Sheffield) ; The Wharncliffe War Hospital,
Sheffield.

1904. May, George Francis, M.D., C.M.McGill, L.S.A., Winterton Asylum,
Ferryhill, Durham."

1912. Melville, William Spence, M.B., Ch.B.Glas., Woodilee Mental Hospital,

Lenzie, Glasgow.

1890. Menzies, William F., M.D.,B.Sc.Edin., M.B.C.P.Lond., Medical Superin¬

tendent, Stafford County Asylum, Cheddlcton, near Leek.

1891. Mercicr, Charles A., M.D.Lond., F.R.C.P., F.R.C.S.Eng., late Lecturer

on Insanity, Westminster Hospital; Moorcroft, Parkstone, Dorset.
(Secretary Educational Committee, 1893-1905. Chairman do. from
1905-12.) (President, 1908-9.)

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

1893. Middlemass, James, M.A., M.D., C.M., B.Sc.Edin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, llyhope, Sunderland.

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

Street, Leeds.

1883. Miles, George E., M.R.C.S., L.R.C.P.Lond., D Block, Royal Victoria
Hospital, Netley, Hants; British Empire Club, St. James’ Square,
London, S.W. 1.

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

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

1893. Mills, John, M.B., B.Ch., Dipl. Ment. Dis., R.U.I., Medical Superinten¬
dent, District Asylum, Ballinasloe, Ireland.

1913. Milner, Ernest Arthur, M.B., C.M.Edin., Assistant Medical Officer, Royal

Albert Institution, Lancaster.

1911. Moll, Jan. Marins, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A.

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

1913. Molyneux, Benjamin Arthur, B.A., M.D., B.Ch.Dubl., St. Helens

House, St. Helens, Hastings.

1910. Monnington, Richard Caldicott, M.D., Ch.B., D.l’.H.Edin. (Daronth
Industrial Colony, Hartford, Kent) ; c/o Rev. T. P. Monnington,
Lowick Green, Ulverston, Lancs.

1915. Monrad-Krohn, G. II., M.B., B.S., M.R.C.P.Lond., M.R.C.S.Eng.,
Assistant Medical Officer, Rikshospitalet, Christiauia.

1914. Montgomery, Edwin, F.R.C.S.I., L.R.C.l’.l. Dipl. Psych. Mancli.

(Prestwich Asylum, Lancs.); 77th Field Ambulance, British
Expeditionary Force.

1899. Moore, Win. D., M.D., M.Ch.R.U.I., Medical Superintendent, Holloway
Sanatorium, Virginia Water, Surrey.

1914. Morres, Frederick, M.R.C.S.Eng., L.R.C.P.Lond. (Assistant Medical
Officer, Cane Hill Mental Hospital, Coulsdon, Surrey); Lord
Warden Hotel, Dover.

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

1896. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Wonford House, Exeter.

1896. Mott, F. W., M.D., B.S., F.R.C.P.Lond., LL.D.Edin., F.R.S., 25.
Nottingham Place, Marylehone, London, W. 1.

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

Yorks.

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

Manchester.

1914. Moyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Crichton Royal
Institution. Dumfries.

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

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Mevibers of the Association.

1011. Muneaster, Anna Lilian, M.H., B.Ch.Edin. (County Asylum, Ciiester);

Lome address, 8, Craylockliail Terrace, Edinburgh; at present
serving with Serbian Red Cross Society.

1917. Munro, Robert, M.B., Ch.B.Aberd., Assistant Medical Officer, Dorset

County Asylum, Dorchester.

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

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

L.R.C.P.Lond., Great Shelford, Cambridgeshire.

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

1910. Neill, Alexander W., M.D., Ch.B.Edin., Warneford Mental Hospital,

Oxford.

1903. Nelis, William F..M.D.Durh.,I,.R.C.P.Edin.,L.R.F.P.&S.Glasg.,Medical
Superintendent, Newport Borough Asylum, Caerleon, Mon.

1869. Nieolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, London, W.C. 2. (Pbksidhnt,
1895-6.)

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

1913. Nolan, James Noel Green, M.B., B.Cli., A.B.Dub., The Hospital, Hel-

lingly Asylum, Sussex.

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

Officer, Camberwell House Asylum, Peckhain Road, London, S.E. 5.
(Home address: 61, Crystal Palace Park Road, Sydenham, London,
S.E. 26.)

1916. O’Carroll, Joseph, M.D., F.R.C.P., Physician Richmond and Whitworth
Hospitals; Lord Chancellor’s Medical Visitor in Lunacy; 43,
Merrion Square, Dublin.

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.I)., IS.Ch.Dub., Medical Superintendent, London

County Asylum, Long Grove, Epsom, Surrey.

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

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

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

1902. Orr, David, M.I)., C.M.Edin., M.P.C., Pathologist, County Asylum,

Prestwick, Lancs.

1910. Orr, James H. C., M.D., Ch.B.Edin., Rosslynlee Asylum, Midlothian.
1899. Osburne, Cecil A. P., F.It.C.S., L.lt.C.P.Edin., The Grove, Old Catton,

Norwich.

1914. Osburne, John C., M.B., B.Ch.Dubl., Assistant Medical Officer, Lindville,

Cork.

1890. Oswald, Landel R., M.B., C.M.Glasg., M.P.C., Physician Superin¬
tendent, Royal Asylum, Gartnavel, Glasgow.

1916. Overbeck-Wright, Alexander William, M.I)., Ch.B., M.P.C., D.P.H.,
Superintendent, Lunatic Asylum, Agra, U. P., India (at present on
military duty); Lecturer on Mental Diseases, King George’s Hos¬
pital, Lucknow, and Agra Medical School, Agra. 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-
iutendent, Gartloch Asylum, Gartcosh, N.B.

1898. Pasmore, Edwin Stephen, M.D., M.Il.C.P.Lond., Chelslmm House,
Chelsbam, Surrey.

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PRINCETON UNIVERSITY

Digitized by

xxii Members of the Association.

1916. Patch, Charles James Lodge, L.R.C.P.&S.Edin., Assistant Medical
Officer, Renfrew District Asylum, Dykehar, Paisley.

1899. Patrick, Jolm, M.B., Cli.B., R.U.I., Medical Superintendent, Tyrone
Asylum, Omagh, Ireland.

1907. Peacheli. George Ernest, M.D., B.S.Lond., M.H.C.S., L.R.C.P.Lond.,

M.P.C.. Medical Superintendent, Dorset County Asylum, Herrison,
Dorchester.

1910. Pearu, Oscar Phillips Napier, M.R.C.S., L.R.C.P., L.S.A.Loud., (Assis¬

tant Medical Officer, London County Mental Hospital, Horton,
Epsom) ; Lord Derby’s War Hospital, Warrington, Lancs.

1915. Pennant, Dyfrig Huws, D.S.O., M.R.C.S., L.R.C.P.Lond., Barn wood

House, Gloucester.

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

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

1911. Petrie, Alfred Alexander Webster, M.D., B.S.Lond., Cli.B., F.R.C.S.

Edin., Assistant Medical Officer, Epileptic Colony, Ensom.

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., Bredon, Fisher
Street, I’aignton.

1908. Phillips. Joiin George Porter, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond,,

M.P.C., Resident Physician and Superintendent, Bethleui Royal
Hospital, Lambeth, London, S.E. 1. {Secretary of Educational
Committee tine* 1912.)

1910. Phillips, John Robert Parry, M.R.C.S., L.R.C.P.Lond. (Assistant Medical
Officer, City Asylum, Bristol); Beaufort War Hospital, Bristol.
1906. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬
tant Medical Officer, Couuty Asylum, Abergavenny, Monmouthshire.
1905. Phillips, Norman Routh, M.D.Brux., M.R.C.S., L.R.C.P.Lond., 67,
Billing Road, Northampton.

1891. Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The
Retreat, York. {Hon. Secretary N. and M. Division 1900-8.)
( Preside n t-Elbot. )

1888. Pietersen, J. F. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-

ford, near Dudley, Stafford.

1896. Planck. Charles, M.A.Caiub., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Brighton County and Borough Asylum, Haywards
Heath.

1912. Plummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond. (Medical Superin¬

tendent, Laverstock House. Salisbury); British Expeditionary Force.

1889. Pope, George Stevens, L.R.C.P.AS.Edin., L.lt.F.P.&S.Glasg., Medical

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

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
Lunatic Asylum, Nottingham.

1910. Powell, James Farqulmrson, M.R.C.S., L.R.C.P., D.P.H.Lond., M.P.C.,
Assistant Medical Officer, The Asylum, Caterliam, Surrey.

1916. Power, Patrick William, L.R.C.P., L.R.C.S., Senior Assistant Medical

Officer, County Asylum, Chester.

1908. Prentice, Reginald Wickham, L.M.S.S.A.Lond., Beauworth Manor,
Airesford, Hunts.

1918. Prideaux, John J >seph Francis Engledtie, M.R.C.S., L.R.C.P.Lond.,
Resident Medi' al Officer, GraylingweR War Hospital, Chichester.
1901. Pugh, Robert, M.D., Cli.B.Edin., Medical Superintendent, Brecon and
Radnor Asylum, Talgarth, S. Wales.

191)4. Race, John Percy, M.R.C.S., L.R.C.P., L.S.A.Loud., Journals and
notices to Winterton Asylum, Ferryhill, Durham (IVheatley Hill,
Doncaster).

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Members of the Association. xxiii

1890. Ruinsford, F. E., M.D., B.A.Dubl., L.R.C.P.I., L.R.C.P.&S.E., Resident
Physiciau, Stewart Institute, Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.A., M.D., B.Ch.Dub., Medical Superintendent,

St. Andrew’s Hospital, Northampton.

1910. Raukinc, Surg. Roger Aiken, R.N., M.B., B.S., M.R.C.S.,L.R.C.P.Lond.,

M.P.C.

1889. Raw, Nathan, M.P., M.D., B.S.Durh., L.S.Sc., F.R.C.S.Edin., M.R.C.P,
Lond., M.P.C. (66, Rodney Street, Liverpool) ; Liverpool Merchants’
Hospital, A.P.O.S. 11, British Exped. Force, France.

1870. Rayner, Henry, M.D.Aberd., M.R.C.P.Edin., Upper Terrace House,
Hampstead, Loudon, N.W. 3. (President, 1884.) ( General

Secretary, 1887-89.) ( Co-Editor of Journal 1895-1911.)

1913. Read, Charles Stanford, M.B.Lond., M.R.C.S.. L.R.C.P.Lond. (Assistant

Medical Officer, Fisherton House, Salisbury); Royal Victoria
Hospital, Netley.

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

1899. Redington, John, F.R.C.S.&L.R.C.P.I., Portrane Asylum, Donabate,
Co. Dublin.

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., Royal Asylum, 'Gartnavel,
Glasgow.

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

Officer. Burntwood Asylum, Liclifiold.

1886. Revington, George T„ M.A.. M.D., B.Ch.Dubl., M.P.C., Medical Superin¬

tendent, Central Criminal Asylum, Dundrnm, Ireland.

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.,Merryflats,Govnn, Glasgow.

1899. Richards, John, M.B., C.M.Edin., K.H.C.S.E., Medical Superintendent,

Joint Counties Asylum, Carmarthen.

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

Haddington, Scotland.

1914. Roberts, Ernest Theophilus, M.D., C.M.Edin., D.P.H.Camb., M.P.C.,

Hawkstone, 58, South Brae Drive, Jordanhill, Glasgow.

1903. Roberts, Norcliffe, M.D., B.S.Durh. (Senior Assistant Medical Officer,
Horton Mental Hospital, Epsom, Surrey); Horton County of
Loudon War Hospital, Epsom.

1887. Robertson, Geo. M„ M.D., C.M., F.R.C.P.Ediu., M.P.C., Physician-Super¬

intendent, Royal Asylum, Morningsidc, Edinburgh.

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

1916. Robertson, Jane I., M.B., Ch.B.Glasg., Gartnavel Asylum, Glasgow.

1895. Robertson, William Ford, M.D., C.M.Edin., 60, Northumberland Street,

Edinburgh.

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

1911. Robson, Cupt. Hubert Alan Hirst, M.R.C.S., L.R.C.P.Lond., Puujaub

Asylum, India.

1914. Rodger, Murdoch Mann, M.D.. Ch.B.Glas., The Rowans, Bothwell,
Scotland.

1908. Rodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.H. (Senior Medical
Officer, County Asylum, Wimviek, Lancs.); Lord Derby’s War
Hospital, Winwick.

1908. Rolleston, Charles Frank, B.A., M.B., Ch.B.Dub., Assistant Medical
Officer, County of London Manor Mental Hospital, Epsom.

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

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

Sydney, New South Wales.

1913. Ross, Derind Maxwell, M.B., Ch.B.Edin., Morningside Asylum, Edinburgh.

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XXIV

Members of the Association.

1910. Ross, Donald, M.B , Ch.B.Edin., Argyll and Bute Asylum, Lochgilphead.

1905. Ross, Sheila Margaret, M.D., Ch.B.Edin., 83 a, Friar Oate, Derby.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Commissioner under

Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬
minster, London, S.W. 1.

1906. Rowan, Marriott Logan, B.A., M.D.R.U.I., Medical Superintendent,

Derby County Asylum, Miekleover.

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

1902. Rows, Richard Gundry, M.D.Lond., M.R.C.S., L.R.C.P.Lond. (Patho¬
logist, County Asylum, Lancaster), British Red Cross Military
Hospital, Maghull, Liverpool.

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

1912. Russell, John Ivisou, M.B., Ch.B.Glasg., Jean ft eld, 18, Woodend Drive,
Jordan Hill, Glasgow.

1915. Russell, William, M.B., Ch.B.Kdin., Dip.Psych.Edin., D.T.M.Edin.,
Assistant Physician, Pretoria Mental Hospital, S. Africa.

1912. Rutherford, Cecil, M.B., B.Ch.Dubl. (Assistant Medical Officer, Holloway

Sanatorium, Virginia Water, Surrey); No. 16 Standard Hospital,
Mediterranean Expeditionary Force.

1907. Rutherford, Henry Richard Charles, F.R.C.S.I., L.R.C.P.I., D.P.H., St.

Patrick’s Hospital, James’s St., Dublin.

1896. Rutherford, James Mair, M.B., C.M.,F.It.C.P.Edin., M.P.C., Brislington
House, Bristol.

1913. Ryan, Ernest Noel, B.A., M.D., B.Ch.Dub., 6th London Field

Ambulance (T.).

1902. Sail, ErneBt Frederick, M.R.C.S., L.R.C.P.Lond., Medical Superinten¬
dent, Borough Asylum, Canterbury.

1908. Samuels, William Frederick, L.M.&L.S.Dubl., Medical Superintendent,

Central Asylum,Tangong, Rambutan,Perak,Federated Malay States.
1894. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medicnl
Licensee, Boreal ton Park Licensed House, Bnschurch, Salop.
Sankey, It. II. Heurtlev, M.R.C.S.Eng., 3, Marston Ferry Road, Oxford.
1873. Savage, Sir Geo. H., M.D., F.lt.C. P.Lond., 26, Devonshire Place,
London. W. 1. {Late Editor of Journal.) (President, 1886.)
1906.^Scanlan, John J., L.It.C.P.&S.Edin., L.R.F.P.&S.Gl»sg.,D.P.H. (1 Castle
Court, Coruhill, London, E.C. 3) ; 5th London Field Ambulance,
47th (Loudon) Division, British Expeditionary Force.

1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Road, West Kensing¬
ton, London, W. 14.

1915. Scott, James McAlpine, M.D., Ch.B.Glasg., Junior Assistant Medical
Officer, Stirling District Asylum, Larbert.

1889. Scowcroft, \Valt3r, M.lt.C.S., L.R.C.P.I., Medical Superintendent, Royal
Lunatic Hospital, Cheadle, near Manchester.

1911. Scroope, Geoffrey, M.B., B.Ch.Dub., Assistant Medicnl Officer, Central

Asylum, Dundrnm.

1880. Seccombe, George S., M.Il.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King
and Co., 65, Coruhill, 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.)

1913. Shand, George Ernest, M.D., Ch.B.Aberdeen ; (Senior Assistant Medicnl

Officer, City Mental Hospital, Winsou Green, Birmingham). Tem¬
porary address: 4, Odessa Road, Harlesdcn, London, N.W. 10.
Permanent address : 307, Gilottt Road, Edgbaston, Birmingham.
1901. Shaw, B. Henry, M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Stafford.

1909. Shaw, William Samuel J., M.B., B.Ch.R.U.I., Superintendent, North

Veravola, Poona, India.

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.E., Medical Superintendent,
. Royal Asylum, Montrose.

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Members of the Association.

xxv

1916. Shaw, Huel) Kirkland, M.B., Ch.B.Edin., Assistant Medical Officer,

Stirling District Asylum, Larbert.

1917. Shaw, John Cnstance, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬

tendent, West Ham Borough Asylum, Goodmnyes, Essex.

1904. Slrnw, Patrick, L.R.C.P.&S.Ediu., Senior Medical Officer (Hospital for

tlie Insane, Kew, Victoria, Australia); “ Lingerwocd,” Wills Street,
Kew, Victoria, Australia. On active service.

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

Terrace, South Shields.

1900. Sliera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Somerset County Asylum,

Wells, Somerset.

1912. Sheridan, Gerald Brinsley, M.B., B.Ch.R.U.I., Assistant Medical

Officer, Portrane Asylum, Donabate, Co. Dublin.

1914. Sherlock, Edward Burhall, M.D., B.Sc., D.P.H.Lond., Medical Superin¬
tendent, Dareuth Industrial Colony, Dartford.

1914. Shield, Hubert, M.B., B.S.Durli. (Assistant Medical Officer, Gateshead
Borough Asylum, Stannington.Newcastle-on-Tyne); 1st Nottingham
Field Ambulance, British Expeditionary Force, France.

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

Loud., 25, New Cavendish Street, London, W. 1; 36, Lambolle
Roud, Hampstead, London, N.W. 3.

1901. Simpson, Alexander, M.A., M.D., C.M.Aber. (Medical Superintendent,

County Asylum, Winwick, Newton-le-Willows, Lancashire); Lord
Derby War Hospital, Warrington.

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

Beverley, Yorks.

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

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

1900. Skinner, Ernest W., M.D., C.M.Edin., J.P., Mountstield, Rye, Sussex.
1914. Slaney, Clrns. Newnlinm, 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 Asylum, Breutwood.

1914. Smith, Charles Kelrnan, M.B., Ch.B.Abcrd., Assistant Medical Officer,
Parkside Asylum, Macclesfield.

1910. Smith, Gayton Warwick, M.D.Lond., B.S.Durli., D.P. II.Cantab.,

M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, Middlesex
County Asylum, Tooting, Loudon, S.W. 17.

1905. Smith, George William, M.B., Ch.B.Edin. (Assistant Medical Officer,
Holloway Sanatorium, Virginia Water, Surrey).

1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintendent,
Lebanon Hospital for the Insane, Asfurujeb, near Beyrout,
Syria.

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

1885. Smith, R. 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, 1899-1903.) (Phksi-
dent, 1904-5.)

1913. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester.

1911. Smith, Thomas Waddelow, F.R.C.S., L.R.C.P.Lond., M.P.C., Assistant

Medical Officer, City Asylum, Mappcrloy Hill, Nottingham.

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

1914. Smith, Walter II., B.A., M.D., B.Ch.Dub., Seuior Assistant Medical

Officer, County Asylum, Shrewsbury.

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,
Sharnbrook, Bedfordshire.

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xxvi Members of the Association.

1885. Soutar, James Greig, M.B., C.M.Ediu., M.P.C., Barn wood House, Glou¬
cester. (President, 1912-13.)

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

London County Asylum, Banstead, Surrey.

1876. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burnt-
wood Asylum, near Lichfield. {First Registrar, 1892-1899; Chair¬
man Parliamentary Committee, 1910-12.) (President, 1899-1900.)
1891. Stansfield, T. E. K., M.B.. C.M.Ediu., Medical Superintendent, London
County Mental Hospital, Bexley, Kent.

1901. Starkey, William, M.B., B.Ch.R.U.I., Medical Superintendent, Borough
Asylum, Blackadon, Ivybridge, S. Devon.

1907. Steele, Patrick, M.D., Ch.B., M.R.C.P.Edin., Assistant Medical Officer,

District Asylum, Melrose.

1898. Steen, Robert H., M.D.Lond., M.R.C.P.Lond., Medical Superintendent,

City of London Mental Hospital, Stone, Dartford. {Hon. Sec. S.E.
Division, 1905-10; Acting Oen. Sec. and Oen. Sec. since 1915.)
1914. Stephens, Harold Freize, M.R.C.S. Lond., L.R.C.P.Eng., 9, Belmont
Avenue, Palmer’s Green, Middlesex.

1914. Stevenson, George Henderson, M.B., Ch.B.Edin., D.P.H.Lond., Joyce

Green Hospital, Dartford, Kent.

1912. Stevenson, William Edward, M.B., B.S.Durh., Winncell Down Camp,

Winchester.

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

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

1915. Stewart, A. H. L., M.R.C.S., 72, Wimpole Street, London, W. 1.

1868. Stewart, James, B.A.Belf., F.R.C.P.Ed., L.R.C.S.I., “Donegal,” 32,
Kingsmead Road, Tulse Hill, Londou, S.W. 2.

1913. Stewart, Ronald, M.B., Ch.B.Glasg. (Gartlocb Asylum, Gartcosh,

Glasgow) ; No. 38 Hospital, Mediterranean Expeditionary Force.
1887. Stewart, Rotbsay C., M.R.C.S.Eng., L.S.A.Lond., Medical Superinten¬
dent, County Asylum, Narborough, near Leicester.

1914. Stewart, Roy M., M.B., Ch.B.Edin. (Assistant Medical Officer, County

Asylum,Prestwich); Mediterranean Expeditionary Force, c/o G.P.O.,
E.C. 1.

1905. Stiiwell, Henry Francis, L.R.C.P.&S.E., Hayes Park, Hayes, Middlesex.

1899. Stiiwell, 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., Harconrt House, Cavendish Square, London, W. 1.
{Hon. Sec. Educational Committee, 1908-1912.)

1909. Stokes, Frederick Ernest, M.B., Ch.B.Glasg., D.P.H.Cantab. (Assistant
Medical Officer, Borough Asylum, Portsmouth); 2/3 Wessex Field
Ambulance.

1905. Strathearn, John, M.D., Ch.B.Glasg., F.R.C.S.E., 23, Magdalen Yard
Road, Dundee.

1903. Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, London, W. 1.

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

Newton-le-Willows, Lancashire.

1909. Stuart, Frederick J., M.R.C.S., L.R.C.P.Lond. (Senior Assistant Medical
Officer, Northampton County Asylum, Berrywood); War Hospital,
Dunston, Northampton.

1900. Sturrock, James Prain, M.ASt.And., M.D., C.M.Edin., 25, Palmerston

Place, Edinburgh.

1886. Sufferu, Alex. C., M.D., M.Ch.R.U.I. (Medical Superintendent, Rubery

Hill Asylum, near Bromsgrove, Worcestershire); 1st Birmingham
War Hospital, Rubery Hill, Worcestershire.

1894. Sullivan, William C., M.D., B.Ch.R.U.I., Hampton Criminal Lunatic
Asylum, Retford, Notts.

1918. Sutherland, Francis, M.B., Ch.B.Ed., Senior Assistant Physician, Royal
Asylum, Aberdeen.

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Members of the Association. xx\ii

1910. Sutherland, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.

Loud., D.P.H., County Sanatorium, Stonehouse, Lanarkshire.

1908. Swift, Eric W. 1)., M.B.Lond., Medical Superiutendent, Government
Asylum, Bloemfontein.

1908. Tattersall, John, M.D.Lond., M.R.C.S., M R.C.P.Lond., Assistant
Medical Officer, London County Asylum, Hanwell, London, W. 7.

1910. Taylor, Arthur Loudoun, B.Sc., M.B., Ch.B., M.R.C. P.Edin., 30,

Hartiugtou Place, Edinburgh.

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

Loud., Medical Superintendent, East Sussex Asylum, Hellingly.
1918. Thienpont, Rudolph, M.D., Temporary Assistant Medical Officer, Cane
Hill Mental Hospital, Coulsdon, Surrey.

1908. Thomas, Joseph D., B.A., M.B., B.C.Cantab., 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. (Mosside, Maghull, near Liverpool) ; British Red Cross War
Hospital, Maghull, near Liverpool.

1880. Thomson, David G., M.D., C.M.Edin. (Medical Superintendent, County

Asylum, Thorpe, Norfolk); Norfolk War Hospital, Thorpe,
Norwich. (Prksidbnt, 1914-18.)

1903. Thomson, Herbert Campbell, M.D., F.R.C.P.Lond., Assist. Physician
Middlesex Hospital, 34, Queen Anne Street, London, W. 1.

1905. Tidbury, Robert, M.D., M.CIi. R.U.I., Heathlands, Foxhall Road,Ipswich.
1901. Tighe, 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., Crichton Royal Institution, Dumfries.

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

Asylum, Chartlmm, Kent.

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

1904. Treadwell, Oliver Fereira Naylor, M.R.C.S.Eng., L.S.A.Lond., 90, St.

George’s Square, London, S.W.l.

1903. Tredgold, Alfred F., M.R.C.S., L.R.C.P.Lond. (6, Dapdune Crescent,

Guildford, Surrey).

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

Royal and District Asylums, Dundee.

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

1888. Tuke, John Batty, M.I)., C.M., F. ICC.P.Edin., Resident Physician,

New Saughton Hall. Polton, Midlothian.

1916. Tulloch, William John, M.I).St. Andrews, Director Western Asylums

Research Institute, 10, Claython Road, Glasgow.

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

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 Asylum, Colchester.

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

Officer, Royal Eastern Counties Institution, Colchester.

1890. Turner, John, M.B., C.M.Aberd., Medical Superintendent, Essex County

Asylum, Brentwood.

1917. Vevers, Oswald Henry, M.R.C.S., L.R.C.P.Lond., Acting Medical Superin¬

tendent, Laverstock House, Salisbury.

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., M.B., B.S.Durh., M.R.C.S„ L.R.C.P.Lond.

(Medical Superiutendent, Wadsley Asylum, near Sheffield); Wliarn-
cliffe War Hospital, Sheffield.

1914. Vining, Charles Wilfred, M.D., B.S.Lond., M.R.C.P.Lond., D.P.H.,
M.P.C., Assistant Physician, Leeds General Infirmary, 40, Park
Square, Leeds.

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Digitized by

xxviii Members of the Association.

1913. VVull'oril, Harold U. S., M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent Comity Asylum, Barmins: Heath, Maidstone.

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. & S.I., Assistant Medical Officer, Mullingar

District Asylum, Mullingar.

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

1895. Waterston, Jane Elizabeth, M.D.Brux., L.R.C.P.I.,L.R.C.S.Edin., M.P.C.,
85, Parliament Street, Box 78, Cape Town, South Africa.

1902. Watson, Frederick, M.B., C.M.Edin., Elm Lodge, Clay Hill, Enfield.
1891 Watson, George A., M.B., C.M.Edin., M.P.C., Lyons House, Rainhill,

Liverpool.

1908. Watson,H. Ferguson,M.D..Ch.B.G!as., L.R.C.P.&S.E., L.R.F.P.&S.Glas.,
D.P.H., Northcote, Edinburgh Rond, Perth.

1911. Webber, Leonard Mortis, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Netherne, Merstliam, Surrey.!

1911. White, Edward Barton C., M.R.C.S., L.R.C.P.Lond. (Senior Assistant

Medical Officer, Cardiff City Mental Hospital, Whitchurch) ; Welsh
Metropolitan War Hospital, Whitchurch.

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond., Betley House, nr.

Shrewsbury. {lion. Sec. South-Eastern Division, 1897-1900.)
{Chairman Parliamentary Committee, 1904-7.) (President
1903-4.)

1905. Whittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
(Downford, Montpelier Road, Brighton); 2nd East General
Hospital, Brighton.

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

1903. Wigan, Charles Arthur, M.D.Durh., M.R.C.S.Eng., L.S.A.Lond., Deep-

dene, Portisliead, Somerset.

1883. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Springfield House, Wins-
cornbe, Somerset. (President, 1902-3.)

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., Bethnal House,
Cambridge Road, London, N.E. 1.

1914. Williams, Chnrles, L.R.C.P. &. S.Edin., L.S.A.Lond., Assistant Medical

Officer, The Warneford, Oxford.

1907. Williams, Charles E. C., M.A., M.D., B.Cb.Dubl.; Greystones, Caruford
Cliffs, Bournemouth; No. 12 General Hospital, British Expedi¬
tionary Force, France.

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

1915. Williams, Gwilym Ambrose, L.R.C.P.Lond., M.R.C.S.Eng. (Pathologist

and Assistant Medical Officer, 1 East Sussex County Asylum,
Helliugly) ; 27th General Hospital, Mediterranean Expeditionary
Force.

1916. Wilson, Marguerite, M.B., Cli.B.Glasg., c/o Messrs. Wilson and Baird,

372, Scotland Street, Glasgow.

1912. Wilson, Samuel Alexander Kinnier, M.A., M.D., B.Sc.Edin., F.R.C.P.

Lond., Registrar, National Hospital, Queen’s Square, 14, Harley
Street, London, W. 1.

1897. Winder, W. H., M.R.C.S., L.R.C.P.Lond., D.P.H.Cautab., Deputy
Medical Officer, H.M. Borstal Institution, Borstal, Kent.

1899. Wolseley-Lewis, Herbert. M.D.Brux., F.R.C.S.Eng., L.R.C.P.Lond.,
Medical Superintendent, Kent County Asylum, Banning Heath,
Maidstone. {Secretary Parliamentary Committee, 1907-12. Chair¬
man of same since 1912.)

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XXIX

Members of the Association.

1869. Wood,^ T. Outtersou, M.D.Durli., M.R.C.P.Lond., F.R.C.P., F.R.C.S.

Edin., 7, Abbey Crescent, Torquay. (President, 1905-6.)

1912. Woods, James Cowan, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
10, Palace Green, Kensington, London, W. 8 .

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.Eng., L.R.C.P.Lond., Havdoek Lodze
Newton-le-Willows, Lancs.

1900. Worth, Reginald, M.B., B.S.Durli., M.R.C.S., L.R.C.PL.ond., Medical
Superintendent, Middlesex Asylum, Tooting, London, S.W.17.
1917. Wright, Maurice Beresford, M.l)., C.M. (118, Harley Street, London,
W. 1) ; 10, Palace Green, Keusington, London, W. 8 .

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

1914. Yellowlees, Henry, M.B..Ch.B.Glas., 6 , Albert Gate Dowan Hill, Glasgow ;

26th British General Hospital, British Expeditionary Force.

1910. Younger, Edward George, M.D.Brux., M.R.C.P., M.R.C.S., L.S.A.Lond.,
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh
Square, London, W.C. 1 .

Oedinary Members . 626

Honorary Members . 32

Corresponding Members . 17

Total. (575

Members are particularly requested to send changes of address, etc to The
General Secretary, 11 , Chandos Street,' Cavendish Square London
W. 1, and in duplicate to the Printers of the Journal, Messrs Adlard
& Son S' West Newman, Ltd., 23, Bartholomew Close, London EC 1

OBITUARY.

Honorary Members.

1887. Chapin, John B., M.D., Canandnigna, N.Y., U.S.A.

1912. Maudsley, Henry, LL.D.Edin. (Hon.), M.D.Lond., F.R.C.P.Lond,
Heathboumo, Bushey Heath, Herts. (President, 1871.) (Formerly
Editor, Journal of Mental Science.) y

Corresponding Member.

1890. R 6 gis, Dr. E., 54, Rue Huguerie, Bordeaux.

Members.

1894. Baily, Percy J., M.B., C.M.Edin., 24, Barrack Road, Bexhill-on-Sea.

1914. Gettiugs,Harold Salter, L.R.C.P. & S.Edin.,L.R.F.P.&S.G., D.P.H.Birin.,

Inoculation Dept., St. Mary’s Hospital, Paddington.

1915. Griffith, Alfred Hume, M.D.Edin., D.P.H.Camh., Medical Superinten¬

dent, Lingfleld Epileptic School Colony, The Homestead, Lingfield,
Surrey.

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

1903. Logau, Thomas Stratford, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., D.P.H.,
Stone Asylum, Aylesbury, Bucks.

1914. O’Flynn, Dominick Thomas, L.R.C.P. & S.I., Assistant Medical Officer,
London County Asylum, Hanwell, Middlesex.

1875. Philipson,Sir George Hare, M.A., M.D.Cantab., D.C.L., LL.D., F.R.C.P.
Loud., 7, Eldon Square, Ncwcastle-ou-Tyne.

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xxx Obituary.

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

1882. SewArd, William J., M.B.Lond., M.R.C.S.Eng., 15, Chandoa Avenue,
Oakleigh Park, London, N. 11.

1913. Spensley, Prank Oswold, M.R.C.S.. L.R.C.P.Lond., Senior Medical
Officer, Darenth Asylum, Dartford, Kent.

1875. Winslow, Henry Forbes, M.D.Lond., M.R.C.P.Lond., M.R.C.S.Eng.,
164, Marine Parade, Brighton.

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PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

[.Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.~\

No. 268 [ToTU] JANUARY, 1919. Vol. LXV.

Part I.—Original Articles.

Presidential Address.Q) By James V. Angun, M.D., Medical Super-
tendent, the Provincial Hospital, St. John, New Brunswick.

[The following address has reached us through the kindness of
I)r. Brush, Managing Editor of the American Journal of Insanity.

The American Medico-Psychological Association includes members
from both the United States and from Canada, and Dr. Anglin’s address
is an indication of the cordial feeling which exists between the members
of the specialty in the old Dominion and in the great Republic of the
West.

That Dr. Anglin is worthy of the honour no one who reads the
address can possibly doubt, which in literary vigour and freshness,
patriotic spirit and cheery optimism it would be difficult to match. Of
Dr. Anglin Dr. Brush writes :

“ Dr. Anglin is a most loyal subject of Great Britain. He lost a son
last spring, who died leading his men in a charge at Vimy Ridge;
another son has been invalided home a permanent cripple from gunshot
wounds received in the trenches; a third son is now in the ranks in
France with the Canadian forces, and a fourth is just getting prepared
to leave for overseas’ military service.

“ The address reflects the spirit which has animated the whole of
Canada, with the exception of some of the French-Canadians in the
province of Quebec, who, curiously, are not interested in the fate of the
land of their French ancestors.

“ I make the following quotation from a letter received from Dr. Anglin
when sending me proof-slips for the Journal of Insanity : 1 It (referring to
the address) was put together under very trying circumstances. There
were uppermost the anxieties about my boys. Then, I had to work on
a military tribunal for months past. Help was so scarce I was worried
LXV. I

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to death, and scarcity of coal through an unusually severe winter
deprived me of sleep. Everything seemed to militate against the
preparation of an address.’

“ The address awoke an enthusiastic response from the Association,
and will, it seems to me, be appreciated on your side of the ocean.”

With this anticipation on the part of Dr. Brush we cordially agree.
—Eds., J.M.S .]

To this, the seventy-fourth annual meeting of our Association, opened
so auspiciously, it is my privilege to welcome you officially.

It was with trepidation that preparations for it were proceeded with
in this year of stress, but its carrying on will be justified if our coming
together enlarges the common store of useful knowledge ; increases our
mutual understanding; helps to sweep away obstacles to the advance
of the healing art, and quickens us to do our bit in freedom’s cause,
whose battle-line reaches to our homes, our gardens, and our pockets.

Last year at the closing of the meeting, I took opportunity to thank
the members there for selecting me for the presidency of this venerable
body, and I now repeat how sincere is my appreciation of this distinc¬
tion. It is most gratifying to have bestowed on one your best gift, as it
expresses what all men covet earnestly—the goodwill of one’s associates.
And yet there wells up in mind the thought that when in the sunny
south I was placed in line for the chair I may now occupy, it was—in
part at least—because I was a citizen of no mean country, and the
majority of you, holding allegiance to another, sought in some measure
to show your younger brother of the north that your heart was with him
when he rushed into the fray to fight for the liberty championed by
Great Britain, and thrilled that fond mother who had thrown her pro¬
tecting arms about him from his tenderest years, without other return
than his loyalty and love.

Fifty years ago Canada had her first Dominion Day, when from the
position of a group of provinces lying on the banks of a magnificent
waterway she stepped into self-conscious nationhood, embracing a
territory which now stretches from sea to sea, and from the river,
St. Lawrence, to the end of the earth. Britain’s tenure of Canada
depends neither on the strength of her battalions nor on the might of
her fleets. Within her borders there has not been stationed since my
earliest recollection a single soldier nor a single cannon over which
Britain claimed control. Yet her influence in her great colony has grown
more and more powerful. The Canadian people are animated by the
same sentiments of loyalty as are found in the isles of their fathers,
and British interests are as secure in their keeping as in the very core of
the Empire.

I need not recount Canada’s contribution to the present conflict.

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BY JAMES V. ANGLIN, M.D.

I9I9.]

3

Everywhere in this country you have been generous in the extreme in
expressing admiration of the spirit of the Dominion.

Germany did not believe that the lion would be able to obtain effec¬
tive assistance from its whelps in the event of a European war. This
opinion must have been derived from the Victorian era, when knowledge
of the colonies was vague.

It is only within recent years that British statesmen have shown any
real understanding of their dominions beyond the seas. There was a
day when one can imagine their welcoming the news that every colony
of the Empire had issued a declaration of independence, fashioned on
the model of that with which Washington confounded the politicians
who surrounded the King.

Canada got on the British map during the Boer War, appealingly and
permanently. Over in England they sat up and took notice then, though
many who are fighting with us now were not quite sure we were doing
the right or chivalrous thing. But most people outside of Germany
and Britain did not realise that the Kaiser’s cable to Kruger was the
formal shying of his helmet into the ring, and the existence of the
British Empire was at stake in South Africa. In the darkest period of
the Boer War Canada had sprung to arms, which should have been an
augury to Germany of what the colonies would do when their mother
was in trouble.

It is a part of our national creed that what the nineteenth century
was to this great neighbouring republic the twentieth will be to my
country. Canada’s soil is destined to support teeming millions. With
boundless acres, enriched by wastefulness while the lone Indian scoured
the plains, capable of providing the world with the finest of the wheat,
with mineral stores of wonders untold, with unrivalled natural forces
and virgin forests, with a stern yet invigorating climate, one would
indeed be bold who would picture the meridian splendour of the nation
which possesses such an heritage.

The most important purpose of such an Association as ours is the
mutual improvement of its members by advancement in knowledge.
No class stands in greater need of getting together frequently than do
men of our profession. We are called on to decide complicated
problems involving the well-being—yea, the very lives of our fellows.
The experience of the greatest is limited. It is easy to stray from the
narrow path. There is no corrective equal to discussions with others.
In this matter our Association has accomplished much. We have a
journal to link us together through the year. It gives an account of
our meetings, which is a boon for those who cannot attend. Experi¬
menters through this medium can convey information as to their hopes,
aims, and accomplishments directly, without filtering through foreign
publications. That man deceives himself, however, who fancies he can

1*

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derive the same benefit from a perusal of the journal as he would from
coming to our meetings. He misses the second object to be attained
in a society like this—the binding together of its members by means of
social intercourse.

Ample time should be allowed for interchange of opinion over the
tea-cups, or any place as congenial. While there is room for reminis¬
cences not purely scientific, mental stimulus is to be derived from
contact one with another, quietly discussing problems about our life-work.

" Our discords, quenched by meeting harmonies,

Die in the large and charitable air.”

The present time is for all of us one of deepest anxiety, with a great
sense of unrest. The angry clouds of war have hung heavily over us
for nearly four years, and show no signs of lifting. Many friends are
overseas, to mitigate suffering, liable and ready to give their lives, if
need be, in behalf of country, liberty, and our ideals of honour, truth,
and justice. Some dearer to us than tongue can tell are in the fighting
ranks, in jeopardy every hour.

With such distraction it was impossible to focus the mind on such
an address as you have usually had from the long line of my forerunners,
even were such timely, and I capable of keeping to the beaten path.
The constitution says your President shall prepare an inaugural. He is
not to come here, open his mouth, and expect the Lord to fill it. In
an effort to obey I shall occupy further time while you become accli¬
mated to this lake region with an endeavour to discover some silver
lining to the leaden clouds on which Mars is riding so recklessly. For
myself, I was born beside these waters after they had laved Chicago,
and so am quite at home. The horrors of war are so constantly present
that there may be some consolation in looking for another side.

I remember how in the first days of the war we stood aghast and said
it could not endure more than a few weeks; how David Starr Jordan
proved conclusively, we thought, that the bankers would never permit
a world war to begin; how Samuel Gompers said that Labour would
prevent the rupture of international peace; and how that brilliant
wielder of the pen, Goldwin Smith, had declared that Canadians would
never face a bayonet for England’s sake. We have lived to see how far
astray were such surmises. The greatest conflict in history not only
began but has extended over weary years. Labouring men, who had
pledged their word to protect their alien brothers, flew to the colours
of the greatest autocrat of all time, and the best of Canadian youth are
over there, where they have proved themselves of such stuff that no
troops have put greater fear into the hearts of the foe. They have
shown invaluable initiative, innate to the new world, and your boys will
do the same.

So, though the future may not bear one out in taking the optimist’s

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PRINCETON UNIVERSITY

BY JAMES V. ANGLIN, M.D.

1919]

5

view-point, no harm can follow “reaching a hand through time to catch
the far-off interest of tears.”

Every evil thing is followed by some good, and every achievement of
good only uncovers some further ill for men to combat. Early in the
war, in nearly all the belligerent countries, there was a sudden decrease
of crime due to the absorption of many lawbreakers into the armies and
fewer idle hands for Satan to get busy with. A few months later, how¬
ever, juvenile crime increased from lack of parental control, the fathers
having gone to war, the mothers to work.

Likewise, war found work for everybody. Thousands of families
who were never far from the starvation line now earn wages they never
dreamed they could command. That is a good thing, but it, too, has
its demoralising side. Money thus unexpectedly possessed threw men
and women off their moral balance, and the saloon has flourished.

It is in these contradictory elements in our progress that ammunition
is found for optimists and pessimists. The pessimists claim that the
evil counterbalances the good. The optimists take the opposite view,
and history seems to favour the latter.

Medicine itself is likely to gain little from the experience of war. It
has taught the surgeons much about the proper application of Listerian
principles; physicians, the efficacy of inoculations against diseases which
formerly decimated armies; alienists, the effects of shell-shock. But
such advances in knowledge, valuable as they are in themselves, have
comparatively little application to ordinary life. The practical humanity
of the medical officers, shown in so many ways, is indeed a relief to a
contest in which angry nations use every means of destruction to exter¬
minate each other. But the blast of war that blows on our ears makes
the still small voice of science inaudible.

Some comfort comes from learning that there is no evidence, in
Great Britain at least, that since the outbreak of the war the amount of
insanity has increased. There has actually been a decrease in hospital
admissions, due mainly to the absence of so many men in the Army,
who are dealt with by the military if they become insane. Among
women, the higher wages earned, and the separation allowances
regularly received, have relieved domestic uncertainties. Many who
had nothing to do previous to the war have forgotten self by throwing
their energies into active work for others. Rich and poor alike are now
busy all the time. The result is a vast improvement in the nation’s
mental stability. People whose lives were empty are interested from
morning till night. Work is the surest consolation for the grievous
sorrow of war.

Even among the soldiers mental disorders have not been as prevalent
as expected. The French conclude that with a few exceptions, in
which a pre-existent organic taint was always to be found, the war has

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not been productive of insanity. It were well, quoth the observer, if
the opposite could be said, namely, that insanity has not produced the
war. What was chiefly feared was mental disorder among men worn
out by the fatigue of the campaign, but such cases have been rare.
The circumstances of service in the field react on the mind in so many
ways and so differently from the influences of peace that new forms of
mental trouble may result.

The experience of the war is certain to lead to better lunacy laws.
There has long been complaint that mental disorders have been
regarded on a different basis from physical. Though in no department
of medicine is the need greater for the earliest treatment, yet the
tendency of existing laws is to cause remedial treatment to lie post¬
poned. The trouble arises from the fact that the laws governing these
matters were framed by lawyers who are concerned in arranging how
people are to be protected. But public health asks how mental sufferers
are to be best treated so that they may be cured. The lawyers’ view¬
point, though important, has been allowed to outweigh all others. The
war has made it necessary to deal with the problem in a fresh, untram¬
melled way. Hitherto the law 7 has hindered early treatment in many
cases by making certification necessary for admission to an institution,
by inflicting the stigma of pauperism, and by branding the recent case
with insanity with all the disastrous consequences that flow therefrom,
unjust though they be. The Army has brushed these difficulties aside.
Numerous cases of recent mental disturbance among the soldiers have
been dealt with in special hospitals without being certified insane in
the usual way. Out of nearly 4,000 such cases among the British
troops less than 200 had to be transferred to an insane institution.
The soldiers suffer from the stigma neither of insanity nor of pauperism,
and there is no obstacle to the earliest and best treatment. A civilian
should have the same advantages when a mental breakdown threatens.
There is no essential difference between the case of the soldier who
becomes insane in the defence of his country, and that of a woman who
suffers from mental symptoms brought on by producing her country’s
defenders.

The maxim that medical science knows no national boundaries has
been rudely shaken by the war. The Fatherland has been preparing
for isolation from the medical world without its confines. Just as,
years ago, the Kaiser laid his ban on French words in table menus, so,
as early as 1914, German scientists embarked on a campaign against
all words which had been borrowed from an enemy country. A purely
German medical nomenclature was the end in view. The rest of the
world need not grieve much if they show their puerile hate in this way.
It will only help to stop the tendency to Pan-Germanism in medicine
which has for some years past been gaining headway.

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PRINCETON UNIVERSITY

1 9 1 9*1

BY JAMES V. ANGLIN, M.D.

7

The Germans excel all other nations in their genius for advertising
themselves. They have proved true the French proverb that one is
given the standing he claims. On a slender basis of achievement they
have contrived to impress themselves as the most scientific nation.
Never was there greater imposture. They display the same cleverness
in foisting on a gullible world their scientific achievements as their
shoddy commercial wares. The two are of much the same value,
made for show rather than endurance—in short, made in Germany.

While they were preparing men and munitions for their intended
onslaught for world dominion, they were spending millions of dollars to
win the admiration of both the working classes and the intellectuals of
other nations, extolling the superior conditions of the Fatherland,
picturing it a paradise, with model homes, short hours and high wages.
This was but a cloak for the sinister plans of Prussian autocracy.
But how great has been the disillusionment 1 The facts are its working
classes laboured longer hours than in any other country and for
starvation wages, the women and children toiled like beasts of burden
in most strenuous trades, sweat-shops abounded, many suffered from
lack of fuel and food, farmers were oppressed with a rigid caste system
so arranged that a peasant child could never become other than a
peasant. Instead of the villas embowered with flowers, the general
mass of workers lived in barrack tenements, gloomy and foul, lacking
baths and heat, but with gaudy exteriors as camouflage.

In the earliest months of the war it was pointed out that there are
tendencies in the evolution of medicine as a pure science as it is
developed in Germany which are contributing to the increase of
charlatanism of which we should be warned. A medical school has
two duties—one to medical science, the other to the public. The
latter function is the greater, for out of every graduating class 90 percent.
are practitioners and less than 10 per cent, are scientists. The conditions
in Germany are reversed. There, there were ninety physicians dawdling
with science to every ten in practice. Of these 90, fully 75 per cent.
were wasting their time. In Germany the scientific side is over-done,
and they have little to show for it all, while the human side is neglected.
Even in their new institutions, splendid as they are in a material sense,
it is easy to be seen that the improved conditions were not for the
comfort of the patients.

Out of this war some modicum of good may come if it leads to a
revision of the exaggerated estimate that has prevailed in English-
speaking countries of the achievements of the Germans in science. We
had apparently forgotten the race that had given the world Newton,
Faraday, Stephenson, Lister, Hunter, Jenner, Fulton, Morse, Bell,
Edison, and others of equal worth. German scientists wait till a
Pasteur has made the great discovery, on which it is easy for her

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trained men to work. She shirks getting for herself a child through
the gates of sacrifice and pain ; but steals a babe, and as it grows
bigger under her care, boasts herself as more than equal to the mother
who bore it. Realising her mental sterility, drunk with self-adoration,
she makes insane war on the nations who still have the power of creative
thought.

Alienists have been infatuated with German pseudo-discoveries.
Novelty of terminology has been taken for originality of thought, and
their works on insanity have been accorded undue authority. We
ignored the substance in our own and the Motherland, and chased the
mirage on the Continent.

Since the German army was successful in 1870, it has since been
idolised, and the admiration bestowed on it has extended, so that in
spite of the fact that the Germans themselves have gone to other
countries for their ideas, we have cultivated a superstition of German
pre-eminence in everything, but especially in science. There might be
some excuse for this if they had made any discoveries comparable with
those of the circulation of the blood, of vaccination, of asepsis—all
made by men who speak our language ; or if German names were
identified with important lesions or diseases as are those of Colles, Pott,
Bright, Addison, Hughlings Jackson, Hutchinson, Argyll-Robertson,
and others.

But it is especially in mental science that the reputation of the
Germans is most exalted and is least deserved. For every philosopher
of the first rank that Germany has produced, the English can show at
least three. And in psychiatry, while we have classical writings in the
English tongue, and men of our own gifted with clinical insight, we need
seek no foreign guides, and can afford to let the abounding nonsense
of Teutonic origin perish from neglect of cultivation.

The Germans are shelling Paris from their Gothas and their new gun.
Murdering innocents, to create a panic in the heart of France ! With
what effect ? The French army cries the louder, “They shall not pass ” ;
Paris glows with pride to be sharing the soldiers’ dangers, and increases
its output of war material ; and the American army sees why it is in
France, and is filled with righteous hatred. Panic nowhere. Vengeance
everywhere. What does the Hun know of psychology ? His most
stupid, thick-witted performance was his brutal defiance of the United
States with its wealth, resources, and energy. That revealed a mental
condition both grotesque and pitiable.

After the war a centre of medical activity will be found on this side
the Atlantic, and those who have watched the progress medical science
has made in the United States will have no misgivings as to your
qualifications for leadership. If we learn to know ourselves, great good
will come out of this war.

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PRINCETON UNIVERSITY

1 9 1 9-]

BY JAMES V. ANGLIN, M.D.

9

Since 1914 there has been an awakening of the public conscience
regarding health. An impetus has been given by the wonderful results
of sanitation in the armies. In this we are interested because bodily
disorder often foreruns mental, and many cases we treat are due to an
infectious disease usually avoidable. Long ago Disraeli declared that
public health is the foundation on which rests the happiness of the
people and the strength of the nation. Statesmen generally are only
now recognising that not only is the well-being of many millions of
workers involved, but that the development of a country is checked if
due attention is not given to the many problems associated with the
maintenance of health.

In my home province this spring the Government has created a
health department to give at least as much attention to human beings
as it has done to domestic animals or the moose that attracts sportsmen
to the wilderness. The more grave the situation in France becomes,
the more vigorously should we strive to shield those who can assist in
greater protection from preventable disease and lessened efficiency.
The war has impressed us with the fact that the childhood of the nation
is the second great line of defence, and every child must be saved not
alone for its own sake or its parents, but for the continuance of the
nation.

This war has shown us the value of developing the bodies of our
young people. Wherever soldiers have been in the making there has
been demonstrated what a change military training brings about in the
recruits, converting youths of poor physique into erect, strapping, ruddy
athletes. It is hard to realise they are the same human material, but
for the first time in the lives of most of them they learned how to
live. When compelled to endure hardships such as they never knew
before, or lie in hospital recovering from wounds, the fitness secured by
training is a decided factor in their favour. When the cruel war is over
and welcome peace has stilled the stirring drum, shall the call for this
physical fitness be no longer made ? The need of it will not pass
away. The demands of peace make it necessary that every youth be
made as perfect as possible. And this applies equally to girls. The
country which would produce a hardy race must have strong women as
well as strong men.

Nationally, we had almost completely ignored the cultivation of the
body. We make it compulsory for every child to submit to years at
school for the sake of intellectual training. But its physical develop¬
ment has been left largely to chance and nature, and then when we
call for soldiers we find a third of our youth unfit. It must be the
State’s business to attempt in every possible way to develop the physical
life of our young people. Even if it meant the taking of a whole year
for necessary training it would be a national boon, adding as it would

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five or ten years to the life of the individual. The time for trusting to
luck and letting things slide has surely passed. Benjamin Franklin said
wars are not paid for in war time. The bill comes later. This
is the sad truth, but the bill will be settled the sooner if we make the
most of the rising race.

The war will hasten some scheme to provide all who need it with
medical care. Often among the working classes disease leads to
distress, and distress to disease, and charity in some form has been
obliged to assist in destroying this vicious circle. Free hospitals have
arisen, but this condition is not ideal, yet the man with meagre income
must accept this charity. A better plan appears to be that of an
insurance under which all wage-earners are compelled while well to
accumulate a reserve which will defray part, at least, of the expense
during periods of disability. Some such plan has just been pressed on
the British to provide in case of illness or injury adequate care for
all persons whose income is less than $800 a year. Nine-tenths of
the general practitioners in the British Isles have entered into the
scheme.

On this Continent little attention has been given to a measure of
this kind, but it seems probable that, whether medical men like it or
not, a similar one will become law on this side of the Atlantic.

The war has brought about a curtailment in the abuse of alcoholic
drinks. For some years past there has been a revolution going on in
regard to intoxicants. T he world-wide attack on liquor at the outbreak
of the war was simply the crystallisation of an antagonistic sentiment
which had been slowly forming, based on scientific evidence of the
physiological and social effects of alcohol drinking.

There is no reason to suppose that the great temperance wave is
a passing thing which will ebb when the excitement of the war is
over. Unless all signs fail, it represents a permanent gain, whose far-
reaching benefits members of this Association will be the first to
appreciate. It is not the moral reformers who have brought prohibition
to pass. There is now a solid body of educated sentiment behind the
law. Business corporations are roused against the liquor traffic as they
certainly were not twenty-five years ago, because they now recognise
that whiskey and efficiency make a poor team. The world has travelled
a long way since that first teetotaler applied for life insurance, and was
charged an extra premium because total abstinence was so dangerous
to health.

Social standards even in England, which still retains a bad pre¬
eminence in drunkenness, have marvellously changed since the days of
Charles Dickens, who was quite unconscious that intemperance was
anything more than an amiable weakness of generous and convivial
hearts.

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PRINCETON UNIVERSITY

1919-] BY JAMES V. ANGLIN, M.D. II

We are abolishing the bar. We still have the bottle. The quack-
me dicinevendor is busier than ever. Money is plenty and he wants
some of it. He uses mental suggestion and interests us. He is a
specialist in distortion who probes into the ordinary sensations of
healthy people and perverts them into symptoms. Every bill-board,
newspaper, fence-rail, barn and rock thrusts out a suggestion of sickness
as never before. The only vulnerable point to attack the vicious traffic
is the advertising. If governments forbid that as they should, the next
generation will be healthier and richer. If we are going to let imagina¬
tion play, let us exercise it on suggestions and symptoms of health.

The world is moving rapidly in these days, and to women is being
granted their rightful place. They are being given the ballot, not as a
reward for what they had done in the war, but because they possessed
the patriotism and the intelligence which entitle them to share in the
conduct of public affairs.

We have been struck by the readiness with which our boys have
responded to the country’s call, and have admired their cheerfulness,
but more impressive has been the heroism of the mothers, the wives,
the sweethearts, and the sisters, who have sent forth the best we breed
without a murmur. Theirs is the harder task to go quietly on with the
daily routine while the heart is in France with the boys they love.
While many talented ones have been prominent in public service,
behind them lies a great army of women who are not known outside
of their own small circle, and who are yet the nation’s richest possession,
its most sacred trust, who make life attractive, and freedom possible and
worth while. We would never have had such valiant armies in France
if it had not been for the brave women at home. The advent of
women into political life means purer government, and the coming
of long overdue reforms in the laws of the land.

Even our religion will be a better brand because of the war. Creeds
count for little over there, and will never again divide men as they have
done. Less and less emphasis is put on the sweet by-and-bye, and
men’s thoughts are turning to the service of their fellows here and now.
They are recognising the practical unity of religion, and the square
deal all round.

And so it will come to pass,

" That mind and soul, according well
May make one music as before,

But vaster.”

The war is teaching us the value of thrift—that exceedingly useful virtue
which most men practise only when they must. But unpopular as it has
been, stern national necessity is now helping to restore it to its rightful
place. On this continent we have not as yet gone far in this direction.

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But in the Motherland there is another story. For over two years not
a single new pleasure auto has been manufactured. Big social functions
are not merely bad form—they have ceased altogether.

The traffic in luxuries in certain cases has been entirely wiped out.
Everybody is wearing old clothes and saving the wool for the boys in
the trenches, and saving the food that the Army may be properly fed.
England is practising economy such as she never did before, and the
strange thing is that apparently business is better than it was in the days
of more luxurious living. One reason for this condition is undoubtedly
the fact that everybody is working. The scale of living for the rich has
been lowered, but the scale of living for the poor has been raised.
This is probably a help to both classes. The pinch really comes, how¬
ever, on the middle classes, whose salaries have not increased, but
whose expenses have gone up by leaps and bounds. And yet there is no
grumbling. The men who grumbled at everything in pre-war times are
now silent when they have really something to grumble about. England
in prosperity may sometimes be hard to put up with, but England in
adversity is magnificent.

The war has done much for us if it has done nothing more than to
reveal men to us. Before the war we judged them by their petty virtues
or petty faults, and we thought we judged correctly ; but now we see that
under it all lay a capacity and a willingness for self-denial and cheerful
self-sacrifice that we had never suspected. The real nature of men has
come to the surface, and we stand amazed at the goodness and grandeur
of it. On this side the Atlantic we have not yet seriously tackled the
luxury question, but we shall have to deal with it in radical fashion
before our war debts are paid. Luxuries, whether they be costly, or the
smaller ones in which poorer men indulge, are not a necessity to national
development or to individual happiness, and their abolition does not
either ruin trade or make men discontented and unhappy. If the war
teaches us this it will mean much for our future national and individual
well-being.

Hospital superintendents, who are responsible for maintaining
hundreds of lives and the operation of many acres, may be vital factors
in both saving and producing, and thus play the game. It may be the
only war service some of us can render.

With France all the time within a few days of starving; with Great
Britain relying on us for 65 per cent, of her essential foods ; with the
wheat of Argentina and Australia too distant to be available, Northern
America must step into the breach to avert famine for a warring world,
and the fate that has overwhelmed the greatest empires of the past.
A time of food shortage is at the door. It is hard to take it to heart
while money is plenty. But money will not take the place of bread.
By eating no more than we need, and by stopping waste, a good deal

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can be done to relieve the situation. At any rate, a good habit will
have been formed.

But the common-sense way of undertaking to prevent famine is to
increase the food supply. This cannot be done in every land. Some
nations are cultivating every foot that has not a building on it. But
on this Continent the case is different. Here there are yet countless
acres waiting for the breaking plough. In Great Britain they are
tilling every available plot, and it is of just as vital importance to us
that we increase production here as there. We are equally concerned
in the outcome of the war.

Recently governments passed a law enacting that every able-bodied
adult must be engaged in some useful occupation. If enforced without
fear or favour it would set to work the tramp and the pampered son of
the foolish rich man alike. Everyone would become a producer of
wealth. It would be good for the country, and still better for the idler
himself. Idleness, whether of the rich or poor, is a crime against the
State, and is also the fruitful parent of vice and degeneracy. Ideals
are changing : the gentleman is now a respectable citizen who toils in
his country’s service.

Distant though we be from the din and smoke of the battlefields,
there is opportunity for us to prove ourselves heroes in the strife.
These stars must not be left to do it all.( 2 ) Each should take to heart
that—

“ It isn’t the task of the few—

The pick of the brave and the strong ;

It’s he and it’s I and it's you
Must drive the good vessel along.

Will you save ? Will you work ? Will you fight?

Are you ready to take off your coat ?

Are you serving the State ?

Are you pulling your weight—

Are you pulling your weight in the boat?"

There are not a few who, over three years ago, were almost wishing
that they had never lived to see such a dire day as was then dawning,
but who have come to see through the years that the dark day of
tragedy was also a day glorious with opportunity and destiny. It is
even now said that had the war been won two years ago, it would have
been the worst thing for our nation, as its lessons had not been learned.

A new and better day is coming for this war-wrecked world. The
sea before us is uncharted, and there may be much that differs radically
from the past, but we can only do as Columbus did—sail on.

A new spirit is moving in the masses of society. Men’s ways of
thinking are changing more rapidly than at any other time in history.
Before the war it was said that to spend twenty-five millions yearly on

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social reforms in Great Britain would mean national bankruptcy. Now
it is found that more than that can be spent in a day to ensure the
national safety. It will be found after the war that great expenditures
to improve social conditions will come as a matter of course.

The soldiers will return with enlarged views of democracy and social
justice. The rich and the poor, the learned and the ignorant, have
together looked death in the face. The sense of brotherhood and
comradeship has been immensely strengthened. Those who were less
favoured under the old social system will be inclined to demand justice
and equality. Those who were more favoured will be inclined to concede
the demand. Artificial distinctions of rank, and even distinctions
founded on superior capacity and learning, fade away before the proof
of the common virtues of manhood. The equality that is sought is the
equality of brotherhood and of rights.

Just as in war time, so it must be in time of peace—the good of the
country, the well-being of the many, must prevail against the privileges
and over the rights of few. This is good politics. It is true patriotism
The world is going to be a better place for the great masses of men.
If we can but keep up the habit that we are to-day learning of being
world-citizens, interested in great enterprises outside of ourselves, then
we would be helping to build the democracy of the future, which must
more and more become a society in wdiich duties are greater than
rights, and to serve a finer thing than to get.

If in these introductory remarks I have not been able to detach
myself from the world’s most serious business at the present time,
perhaps on reflection they may not have gone very far afield from the
subject which binds us together in an association. If there is to be a
change in the conditions under which we live this must have its effect
on the minds of men ; whether for good or ill, I will not stop to specu¬
late. We are intensely concerned with environment. This war itself
is entangled with it.

England’s greatness, her devotion to honour, truth, and fidelity, is
due to the environment in which her children are trained and grow to
manhood.

The ivy-grown wall, the vine-clad hills and the rose-covered bowers
constitute the birth-place of English character.

Gerard tells us the cause of the war is the uncongenial environment
in which the German youth is cradled and reared. The leaden skies
for which Prussia is noted, its bleak Baltic winds, the continuous cold,
dreary rains, the low-lying land, and the absence of flowers have tended
to harden the spirit and rob it of its virtue, produce a sullen and morose
character, curdling the milk of human kindness.

It is a greater pleasure than usual for Canadians to meet with their
American cousins in this year, when our two countries are joined in the

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15

grim but glorious comradeship of war in defence of the heritage and
aspirations that belong to us both. Our fathers came from common
soil, their veins flow common blood. For over a century we have lived
as good neighbours in the friendly rivalries of peace. Through proximity
we have adopted more and more your ways without becoming a whit
less true to the British flag.

After this war we will be still better friends. We will have been in a
fight together and on the same side. We will carry flowers across the
seas to lay on mounds in the same clime. The boys who come back
will have the same stories to tell of struggles and triumphs. Let us
hope that the present is the dark hour that precedes the dawn, and that
ere long the sky may be fired with the red glow of the rushing morn ;
that soon the shot that brings victory—the last one—may be heard, and
if it come from an American gun, no Canadian will begrudge you the
lucky honour.

The war has achieved much in cementing the two great English-
speaking nations of the world as nothing else could possibly have done.

Great Britain and the United States have never before fought shoulder
to shoulder, but they are doing it now, and the fact is one ominous to
their enemies. A common peril has united them, and a common aim
will perpetuate the union. To no group of people will success in the
war mean more than to the Anglo-Saxons, and the fact that this great
family will in future dwell together in undisguised confidence and good¬
will is worth in itself all that the war has cost.

The Allies are depending on this land for food and men, for ships
and guns, for ammunition and aeroplanes, and this is leading Britain to
recast its views of the United States, and is leading the latter to regard
Britain in a more favourable light than ever before. The old suspicions
and the ancient grudges are being melted away. Years of misunder¬
standing were trodden underfoot when American boys marched through
the streets of an amazed and admiring London.

It had long been a reproach that on this Continent men cared for
nothing but the almighty dollar and made gold their hope, but when
the call came to sacrifice for the good of the Allies no nation ever
responded more gladly or liberally. Britain asked for meat, all you
could spare, and you answered with meatless days, with the result that
the United States has been able to supply millions of pounds more of
bacon and beef than were expected. To-day the British workman has
his normal supply of meat, thanks to America’s response.

Germany never played more clearly into the hands of her foes than
when she scornfully defied the world’s greatest republic, in the mistaken
conviction that while the United States was of great potential strength,
she would not dare to challenge the mightiest military machine that
ever cursed the world. But Germany’s blunder will prove the world’s

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salvation if it succeeds in binding together in friendship the two great,
peace-loving, freedom-cherishing, English-speaking democracies—Great
Britain and America.

In 1493, a tiny barque, frail and scarred by many a storm, the first
craft from America, returned to the shores of Europe. She bore what
was then termed the richest freight that ever lay upon the bosom of the
deep—the tidings of a new world beyond that vast waste of w-ater which
rolled in untamed majesty to the west. That was a year of good news
for the people of Europe. The thirst for gold was as keen in the
15th century as it is to-day, and the discovery of Columbus disclosed
to monarchs and adventurers alike visions of wealth.

Little could they reck that in this year infinitely more precious freight
would be borne across the same pathway, when ship after ship, leviathans
of the deep, would bring from that new world to somewhere in Europe
offspring of the sturdy pioneers from the old land, who in braving the
savage forces of Nature had found liberty, legions of brave and noble men,
in martial array, with the star-spangled banner at the mast-head, to reveal
to the war-bound nations visions of something with which those of the
wealth of the boundless West or the gorgeous East could not compare—
visions of freedom for all mankind.

Thank God ! “ Our fathers’ God, to whom they came in every storm
and stress,” America did not turn a deaf ear to the laureate’s apostrophe :

“ Gigantic daughter of the West,

We drink to thee across the flood;

We know thee most, we love thee best, •

For art not thou of British blood ?

Should War’s mad blast again be blown,

Permit not thou the Tyrant Powers
To fight thy mother here alone,

But let thy broadsides roar with ours.”

(') Delivered at the Seventy-fourth Annual Meeting of the American Medico-
Psychological Association, Chicago, Ill., June 4th~7th, 1918.—( ! ) Referring to the
"service flag” behind the speaker's desk with more than ninety stars, representing
members of the Association in the Army Medical Service.

The Infective Factors in Some Types of Neurasthenia. By W.

Ford Robertson, M.D., Pathologist to the Scottish Asylums.

The distinctive signs and symptoms of neurasthenia are capable of
fairly precise definition, and there need rarely be any doubt, or difference
of opinion, as to whether a particular case is to be classed as of this
nature or not. The chief symptoms are a constant feeling of fatigue,
not relieved by rest, and the occurrence of various forms of hyper-
resthesia, parsesthesia, and localised pain. Two important physical
signs constantly occur—exaggeration of the patellar reflex and tremor

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17

of the eyelids when the eyes are half closed. Added to these, there are,
in greater or less degree, characteristic mental features which constitute
the picture of psychasthenia, namely, incoercible ideas, obsessions, and
monophobias.

Predisposing to the occurrence of neurasthenia there is a particular
type of constitution—the neurasthenic diathesis. Under the same
adverse conditions some persons will develop neurasthenia, while
others will not. Slight degrees of the malady are extremely common.
Indeed, to have the signs of neurasthenia in its mild form is a distinction,
for it is certain that it is chiefly the people who have a neurasthenic
constitution who are the most brilliant, original, energetic,and influential.
It is they who do the intellectual work of the world.

The severe and distinctly pathological manifestations of neurasthenia
are those alone with which I have to deal. It is important to recognise
that neurasthenia may be a prelude of serious organic disease, such as
general paralysis, dementia praecox, other forms of insanity, pernicious
anaemia, rheumatoid arthritis, and tuberculosis, the onset of which may
obscure, but rarely obliterates, the characteristic features of the less
serious malady.

With regard to the causation of neurasthenia, the evidence has
hitherto been lacking in precision, or altogether defective. The only
assigned cause having any definiteness is traumatism, and this, at
most, accounts for only a small proportion of the cases. Nevertheless,
this factor is of special interest at the present time. The trauma may
be physical, or it may operate by vivid and painful mental impressions
as shock. It is my purpose to-day to endeavour to show that the
importance of this traumatic factor is being much exaggerated, and that
many of the morbid conditions universally attributed to it can be proved
to be due to chronic bacterial infections, which have been aggravated
by the physical and mental stress, and other conditions inimical to
health, to which the soldier on active service is inevitably subjected.

The number of cases of neurasthenia that I have investigated
bacteriologically is sixty-six. It is necessary that I should make it clear
that these sixty-six cases form a mere fraction of the total number
studied by similar methods. Indeed, I have never made any special
investigation of cases of neurasthenia. My object has been to gain
accurate knowledge of the relationship of mental diseases to infections.
In order to make the basis for conclusions sufficiently broad, I have
studied all sorts of cases, not only in asylums, but among the general
public. I have simply picked out the cases of neurasthenia, as it seemed
to me that this subject was the one that was most likely to prove of
interest on the present occasion.

The areas of the body investigated have been chiefly the nasal
passages, lower respiratory tract, nasopharynx, mouth, fauces, and the

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intestinal and genito-urinary tracts. The nature and importance of
acute and chronic infections of the nasal passages and lower respiratory
tract are fairly well understood. It does not seem, however, to be
realised that the nasopharynx is the part of the body more liable than
any other to bacterial attack, and that various important chronic
maladies are commonly dependent upon infections of this region.
Infections of the genito-urinary tract are somewhat better understood,
but in regard to them, also, it is possible to show that the present
teaching is defective. The region that has suffered the most serious
neglect in respect of the possible relation of chronic infections to
common diseases is, however, the alimentary tract. That more attention
should not have been given to it is probably due partly to the special
difficulties of investigation and partly to lack of scientific imagination,
which ought to have attracted bacteriologists to this region long ago,
and led them far beyond the mere study of typhoid and paratyphoid
fevers, dysentery, and cholera.

Most advances in pathological knowledge have been dependent
upon one or other of two things—the application of new methods of
investigation, and the recognition of why certain important facts have
previously eluded observation. In regard to our knowledge of the
relationship of common diseases to chronic bacterial infections, both of
these essentials to progress are in dire need of being brought into
operation at the present time. As an example of the importance of
recognising why certain facts have previously eluded observation, I would
mention a discovery of fundamental importance that we have exploited
at the Laboratory of the Scottish Asylums for over two years. It is that
many pathogenic bacteria which in orthodox teaching are regarded as
aerobes are liable to occur as anaerobes, and to refuse to grow unless
fairly strict anaerobic conditions are provided for them. This applies
to such common pathogenic species as Micrococcus catarrhaiis, the three
highly important and distinct pathogenic varieties of pneumococci,
Streptococcus fcecalis, Streptococcus pyogenes , and neurotoxic diphtheroid
bacilli. It is therefore essential to use anaerobic methods as a matter
of routine in the bacteriological investigation of cases. Those who do
not use them in such work must continually miss facts of primary
importance for the successful treatment of the patient’s malady. An
equally necessary requirement in regard to methods of investigation is
the constant use of haemoglobin agar. Tire value of a culture medium
of this kind was maintained by my colleagues and myself more than
sixteen years ago, but as far as I can gather it is still little used—at
least in a proper way. For the differentiation of the many distinct
streptococci, and for the growth of pneumococci and of the bacilli of
the influenza group, it is essential. It is also the basis of the only
anaerobic method suitable for systematic case investigations.

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There is a rather important point that requires to be alluded to and
put aside before I describe the chronic infective conditions that I have
found in my cases of neurasthenia. Most persons afflicted with this
malady suffer from intestinal stasis and its consequent toxasmia. The
toxins absorbed from the colon in these cases are no doubt varied in
nature and origin, but they are chiefly formed by the action of sapro¬
phytic bacteria upon the food residues. Absorbed in excess of the
amount that can be destroyed, they produce lassitude, mental depression,
slight degrees of mental confusion, more or less severe headache, and
sleeplessness or drowsiness. All cases of neurasthenia accompanied by
intestinal stasis are aggravated by absorption of these toxins. It is, I
believe, an error to regard any case of neurasthenia as dependent upon
intestinal stasis alone. There are always pathogenic factors of much
greater moment.

There is still one more preliminary point that it is necessary I should
try to make clear. We need rarely, nowadays, remain in the dark as
to whether a particular organism isolated from a case is acting as a
pathogenic agent or not. We do not require to resort to experiments
upon animals ; indeed, such experiments could not give us the infor¬
mation we want. The methods of focal reaction and therapeutic immu
nisation furnish trustworthy evidence of the kind desired in almost
every instance. Applied in a long series of cases, they permit of
important practical generalisations regarding the bacterial causation of
many chronic maladies. I believe it is chiefly to Dr. R. W. Allen that
we are indebted for directing attention to the importance of focal
reactions, both as evidence of the pathogenic character of a particular
bacterium and as guides to correct dosage. I have endeavoured to
follow and to extend his work. A focal reaction is specific. It is an
active congestion at the seat of infection induced by the hypodermic
injection of a minute dose of an emulsion of the corresponding bacterial
toxin. It is almost always revealed by characteristic disturbances,
which generally simulate certain symptoms of the malady. Sometimes
the active congestion can be seen, as, for example, in the course ot
therapeutic immunisation for infections of the conjunctiva. In many
other instances it is manifested by signs scarcely less distinct.
Frequently we have to rely, however, only upon symptoms experienced
by the patient. If, after we have induced a series of such reactions, all
symptoms disappear, there is added the evidence of therapeutic immu¬
nisation in support of the conclusion that the bacterium used in the
preparation of the vaccine was the cause of the malady. By such
methods the pathogenic character of various types of bacteria has been
established, and the particular kinds of disorder to which they give rise
have been clearly recognised. For instance, it has been possible in in¬
numerable instances to confirm the fairly well-known relation of pneumo-

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coccus infections to various forms of chronic catarrh of the respiratory
tract, and to go further and to show that many cases of chronic intes¬
tinal catarrh are due to the same micro-organism, and to separate out
two other distinct species of pneumococcus and to prove that they are
respectively the primary causes of rheumatoid arthritis and pernicious
anaemia. I well know that the subject is endless, and that we are yet at
the very beginnings of the application of bacteriology and therapeutic
immunisation to common maladies.

I have now, I hope, sufficiently prepared the way for an analysis of
the sixty-six cases of neurasthenia in which I have made a bacterio¬
logical examination.

In all of these cases chronic infections were discovered, and their
relationship to the malady, as either the chief, or a very important
contributory cause, was established by the methods I have indicated.
In most instances the infections were complex. In seven of the cases
the neurasthenia seemed to depend essentially upon a chronic infection
by the bacillus of influenza. Under therapeutic immunisation all of
the cases made complete recoveries, with the single exception of one in
which treatment is not yet finished, but in which also there is every
prospect of a good result. I would here remark that acute and chronic
infections by the bacillus of influenza yield to correct therapeutic immu¬
nisation with a readiness unsurpassed in any other form of bacterial
infection, and that protective inoculation is simple, rapid and effective.
It must not be thought that chronic infection by the bacillus of
influenza is constantly associated with neurasthenia. These seven
cases in which this form of infection could be regarded as of axiological
importance represent not more than one-tenth of the cases of the same
infection that I have investigated and treated.

There were ten cases in the series in which a pneumococcus was the
only, or the leading, chronic infective agent. In eight of these cases
the intestine was the seat of invasion ; in the remaining two it was the
nasopharynx. Again, it is to be said that similar pneumococcus infec¬
tions occur without neurasthenia. These ten cases constitute only a
very small fraction of the number of cases of chronic pneumococcus
infection that have come under observation.

Another bacterium that may induce the neurasthenic syndrome is
Streptococcus pyogenes. Its frequent action as a neurotoxic agent when
it occurs as an acute infection is well known ; the best examples are
seen in cases of puerperal endometritis aud erysipelas. It is not yet
generally recognised that as a chronic infection it may, though only
exceptionally, produce important neurotoxic effects. Ten cases
occurred in which invasion by this streptococcus was at least an
important factor in the production of the patient’s malady. In five of
the cases the seat of the infection was the nasopharynx, in two the

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1919.] BY W. FORD ROBERTSON, M.D.

gums, in two the intestine, and in one the organism was found only in
the urine.

Another streptococcus which some cases of simple infection have
proved to possess important neurotoxic powers in susceptible persons
is the Streptococcus fcrcalis in its haemolytic form. It was found under
such conditions as to warrant the conclusion that it was acting as an
infecting agent in eleven of the cases. The most common seats of
infection were the nasopharynx and intestinal tract; examples of infec¬
tion of the urinary tract also occurred. This streptococcus is a very
common infecting agent, and it is certainly the exception for its
invasion to be associated with nervous symptoms.

I have left to the last the most important neurotoxic infective agent
that these researches have revealed. By methods as rigid as any that
science can require, it has been established that certain bacilli of the
diphtheroid group are neurotoxic agents of great potency, and that they
are operative in a wide range of nervous disorders. I cannot here
adduce more than a fraction of the evidence I have collected. It will
be given in some detail in a future publication. It is important it
should be understood that the investigation of this subject is beset by
a special difficulty that has rendered the collection of satisfactory
evidence a very slow and laborious task. In the case of almost every
other group of bacteria we can apply cultural, morphological and
biochemical tests that serve to differentiate important species and
varieties. In the diphtheroid group alone every criterion that has yet
been suggested as a means of distinguishing one species from another,
and pathogenic forms from non-pathogenic ones, has been found on
extensive trial to be devoid of practical value. YVe can but take the
forms that we find and test their power to produce focal reactions and
their therapeutic value. By this means the relationship of some species
of diphtheroid bacilli to cases of neurasthenia, exophthalmic goitre,
dementia praecox and several other nervous disorders has been rendered
evident. For many years I have been aware that in most cases of fully
developed neurasthenia the urine is loaded with diphtheroid bacilli.
The same feature is observable in a large proportion of asylum
patients. In many of these cases of diphtheroiduria the presence of the
bacilli can be readily recognised only by a direct examination of the
centrifuge deposit; the organisms will not grow under the ordinary
conditions of culture. At one time I interpreted this fact as indicating
that the bacilli were dead. It has, however, now transpired that this
is rarely, if ever, the case. The reason that the organisms will not grow
under the usual conditions of cultivation is that, in these instancesi
they are anaerobes. Under anaerobic conditions upon haemoglobin
agar they will generally grow quite well. In the wide group of the
diphtheroid bacilli there are several species that either temporarily

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«

acquire, or essentially possess, an anaerobic habit of growth. The
fact is one of great practical importance.

The systematic application of anaerobic methods to the investigation
of the intestinal flora has shown that intestinal infections by anaerobic
diphtheroid bacilli occur with considerable frequency, and that they
are almost always associated with severe nervous disturbances. The
types of cases in which there occur such infections by anaerobic
diphtheroid bacilli include neurasthenia, mucous colitis, exophthalmic
goitre, disseminated sclerosis, and various forms of acute and chronic
insanity. That the presence of such anaerobic diphtheroid bacilli in
the intestine is quite abnormal is borne out by the study of nearly two
hundred other cases by similar methods, which serve as controls. In
some cases the number of these anaerobic diphtheroids is almost
incredible. Although Bacillus coli communis grows quite well under
anaerobic conditions, I have obtained cultures in which its colonies
appeared in the proportion of only one to about three hundred of
those of the diphtheroid bacillus. I have a culture of this kind to show
from a case of agitated melancholia.

My statistics of the sixty-six cases of neurasthenia show that forty-nine
had diphtheroiduria. Six were ascertained to have aerobic diphtheroid
bacillus infections of the intestine and twenty-five to have similar
anaerobic infections. Some of the earlier cases were not investigated
by anaerobic methods, and this figure is therefore probably below the
actual mark. Aerobic diphtheroid bacillus infections of the nasal
passages, nasopharynx and gums are also exceedingly common, and
may be either of little or of great pathological importance. A proved
cause of recurrent cold is a bacillus of this kind, which is quite different
from the Bacillus septus and from Hoffmann’s bacillus. In striking
contrast to the non-neurotoxic character of this catarrhal diphtheroid
bacillus is the intensely neurotoxic action of other strains which may be
found in great abundance in the same region in many cases of dementia
praecox.

I regard the aetiological relation of anaerobic diphtheroid bacillus
infection of the intestine to mucous colitis as established. I have
been able to make a close study of four cases. The focal react ions
are distinct, and the value of prolonged therapeutic immunisation has
been clearly proved. There is, however, in this malady another funda¬
mental factor not amenable to treatment of this kind, namely intestinal
displacement, which, in proportion to its severity, permanently impairs
the health of the patient.

Five cases of neurasthenia complicated by exophthalmic goitre
showed severe intestinal infections by anaerobic or aerobic (one) diph¬
theroid bacilli. In four of the cases there was also intestinal infection
by Streptococcus ftecalis hcemolyticus, and in one by a pneumococcus.

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* *919-]

BY W. FORD ROBERTSON, M.D.

23

All of the five cases showed an extreme degree of diphtheroiduria,
as also did two earlier cases in which no bacteriological examination
was made of the stools. One of the cases was complicated by subacute
Bright’s disease, but all of the remaining six have done well under
therapeutic immunisation.

Another disease that begins as neurasthenia is disseminated sclerosis
I have had an opportunity of investigating only one case by the methods
now employed. It is that of a lady teacher. Less than a year ago she
had all the signs and symptoms of this grave malady, and had to con¬
template giving up her work, upon which she depended for her living.
I found that both the urine and the stools were loaded with a purely
anaerobic diphtheroid bacillus of unusual morphological characters.
Therapeutic immunisation has now been continued for eight months.
Focal reactions, manifested by severe nervous disturbances, occurred on
several occasions, necessitating a diminution in the dose. Steady
improvement in the patient’s condition has taken place. All signs of
disseminated sclerosis have disappeared, and she is again feeling quite
fit for her work.

Included in the sixty-six cases of neurasthenia investigated bacterio-
logically there were nine of patients in the Army or Navy who had
seen active service. None of them had suffered from shell-shock, but
all of them had endured severe physical and mental strain, and some
of them also exposure to cold and wet, and privation. They were cases
typical of those that fill the military hospitals for neurasthenics. All
of them on investigation proved to be suffering from severe chronic
infections incompatible with health, and every one of them has either
recovered, or is now improving under therapeutic immunisation directed
against the infections from which he was ascertained to be suffering.
Each case has had its point of interest.

A naval officer, after severe strain, suffered from depression, lack of
confidence in himself, and neurasthenic symptoms. Various remedies
were tried, including a period of rest, but without avail. The real
cause of his illness was never even suspected. He was sent to me for
bacteriological investigation. I found he was suffering from a chronic
infection by the bacillus of influenza, with some other infections of
minor importance. Under therapeutic immunisation he speedily re¬
covered, and has remained well and fit for the discharge of his important
duties.

Three of the cases suffered from chronic infections by a pneumo¬
coccus, intestinal in two of them, and nasopharyngeal in the remaining
one. In each instance the illness was severe and disabling. All
recovered under therapeutic immunisation, and were able to return to
active service.

Three of the cases were typical examples of diphtheroid bacillus

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infection of the intestinal tract, with the usually accompanying extreme
diphtheroiduria. Two other cases had similar diphtheroiduria, but
came under observation before the importance of anaerobic intestinal
cultures was fully realised. I have been able to keep four of these
cases of diphtheroidosis under observation, and they have all done
well. The three with intestinal infection have shown great sensitive¬
ness to minute doses of the diphtheroid bacillus vaccines, abdominal
pain and discomfort and general malaise being the chief symptoms
of focal reaction. Improvement under therapeutic immunisation in
this form of infection is always slow, and treatment has generally to
be continued for at least six months.

The moral of these cases is obvious. I do not deny the importance
of traumatism and strain, physical and mental, as factors in the causa¬
tion of neurasthenia, but after a period of rest the symptoms due to
such causes should either subside, or leave residues that are distinguish¬
able from the phenomena of true neurasthenia. If neurasthenic
symptoms continue they must have a toxic basis, and the cases should
be investigated and treated accordingly.

Communications from the Lunatic Asylum at Nykobing, Seel and.
Fr. Ivrarup, Chief Physician.

Some Experiments on Treatment of Dementia Paralytica with
Subdural Injections of Neosalvarsan. By George E. Schrpder,
Assistant Physician, Communal Hospital, Copenhagen, and Hj.
Helweg, Assistant Physician, St. Hans’ Hospital.

The demonstration by Noguchi and many other investigators after
him of spirochaetes in the nervous texture in tabes dorsalis and in
dementia paralytica has, as is well known, quite subverted the old
conception of these diseases as para- or metasyphilitic in nature. They
are just as syphilitic as other diseases caused by Spirochceta pallida are.
It is quite a different thing, however, that in certain respects they occupy
a peculiar position ; as a rule they do not manifest themselves till ten
to fifteen years after the primary affection, and they are very little
affected by antisyphilitic treatment. It is well known that it was
especially this last fact which caused thtm to be considered as not
syphilitic in the common sense.

The said proof of spirochaetes has not made it less difficult to
understand why the results of the ordinary antisyphilitic cure, also
the salvarsan and neosalvarsan treatment, are so defective. The total
outcome of the experiences so far obtained is the but little encouraging
fact that in reality we have never, or very seldom, succeeded in stoppin

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the progress of the disease effectively and for ever. We have quite
often heard of temporary recoveries or cures, but, the said diseases in
themselves showing a tendency to remissions, we have here in this
country generally been most inclined to explain the achieved results as
spontaneous remissions, or perhaps as results from the influence of the
ordinary hospital hygiene.

However, the rational basis for the treatment—the presence of the
spirochaetes—having now been substantiated, we purposed, although
without any great expectations, to attempt a treatment which the
Norwegian-English alienist Monrad-Kiohn has proposed.

Monrad-Krohn has in the Nonvegian Magazine for Physicians ,
No. 5, 1914, published an article concerning “The Treatment of
Syphilis of the Nervous System Spec., Tabes and Paralysis Generalis.”
It contained an account of rational treatment with salvarsanised serum,
and the rational point consisted in taking serum from a patient who
had been under the salvarsan treatment half or one hour after the
intravenous injection of salvarsan and injecting it into the spinal canal.
Thereby both salvarsan and anti-substance were injected at one time,
and through the perivascular lymphatic channels these make their way
to the parasites. On the contrary, after a mere intravenous injection
of salvarsan no salvarsan passes into the cerebrospinal fluid, and, as
far as can be judged, no anti-substance either.

Monrad-Krohn has achieved good results in tabes, but no results in
dementia paralytica. But he observes in a supplement to his essay
that in three cases of dementia paralytica he has injected 20-30 c.cm.
salvarsanised serum directly into the cranium—that is to say, through
a trephine opening into the subarachnoid space. In two of the cases
the result was satisfactory, and in the third one a temporary deterioration
occurred, which was followed by some convalescence. In a later
article in the Journal of Mental Science, April, 1935, “Remarks on
the Intracranial Injection of Salvarsanised Serum,” Dr. Krohn touches
upon his technique and on theoretical considerations which underlie the
treatment. Here it has only to be observed that as a result of different
experiments it was proved that a subdural injection of fluid was able
to extend itself to rather a high degree over the surface of the brain,
even over both hemispheres, but first to the left frontal lobe when the
injection was made on the left side.

As to the technique, it shall also be only briefly mentioned. A
trephine opening with a trephine of 1^-2 cm. diameter was made
10-12 cm. above the temporal end of arcus zygomaticus under the
usual anti- and aseptic measures. The dura, which was not opened,
was then pierced aslope from behind forwards with a fine cannula, and
25-30 c.cm. salvarsanised serum was slowly injected. The operation
was undertaken under local anaesthesia.

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Unfortunately the essay was not accompanied by accounts of the
illness, and a direct written application to Dr. Monrad-Krohn only
elicited that the method had been tried a few times with good results,
but that the war had to such a degree increased the work at that
English hospital to which he was appointed that further experiments
had to be suspended.

Others, and especially English authors, have occupied themselves
with the subject. However, we shall not enter into details, but only
refer to articles by Swift and Ellis, Mapother and Beaton ( Journal of
Mental Science, October, 1914), and in this country Carl With {Hospital
Magazine, Nos. 40 and 41, 1917, and Medical Weekly Paper, No. 39,
1917). They are expecting more or less from these methods, which,
however, have not got beyond the stage of experiment.

Although absolutely convincing communications were not forth¬
coming, we yet resolved to attempt this treatment, partly on account of
the principle being supposed to be rational, and partly and not least
on account of dementia paralytica being in itself such a hopeless
disease that it is simply a duty to attempt any new and “rational”
therapy. It ought here to be observed that previous experiments with
subcutaneous injections of natr. nuclein and other fever-producing
means have now and then proved to be of some effect, yet not in such
a way that real power over the disease was obtained (Hallager, Medical
Weekly Paper). Of course we did not expect the new method to be
able to cure the disease, but we had the hope of possibly stopping its
progress—that is, of making it effectively stationary, and that at so early
a period in its course that the working ability of the patient would be
in part retained. We seize this opportunity to thank Mr. Krarup, the
chief physician, for permission to make these experiments, and the then
assistant physician, Mr. v. Thun, for his aid at the first trephine
operation.

The technique of the treatment used by us was at the beginning
quite like that indicated by Monrad-Krohn, for which reason we refer
to this. We gave intravenous injections of salvarsan, took some blood
from the patient one hour after, had it coagulated under aseptic
measures, and took 20 c.cm. of the exuded serum for the injection.
However, through different difficulties presenting themselves, we were
obliged to alter our technique somewhat. I shall shortly give an account
of it for the use of eventual later experiments. For, in spite of our
experiments not being specially encouraging, we still think that they
ought to be carried on.

The operation itself presents no difficulty. It may be undertaken by
any physician in a lunatic asylum, provided a small operating-room can
be adapted for the purpose. It is always done under general narcosis.

The situation of the trephine opening in the temporal region at the

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2 7

line of the hair was such that there was no danger of injuring the sinus
sagittalis or the temporal artery. In some cases, however, a small
branch of A. mening. passed across the visible part of the dura. In
such cases the opening was prolonged to one of the sides with a small
curvature, so as to have a place where you could make sure of not
injuring the vessel when injections through the skin were to be under¬
taken later on. This little alteration was most easily executed by biting
off the edge of the bone with an ordinary gouge-tong. Tlie injection
through the dura caused no difficulty either; on the other hand the
later injections through the healed-up flap of the skin and dura were
sometimes difficult. They were always made in such a way that the
skin was first congealed with ethyl-chloride ; then the cannula was pierced
through the skin so deeply that the dura was supposed to have been
pierced also. The last part of this penetration was quite free from pain,
neither the dura nor the brain reacting painfully to the introduction of
a fine cannula. It was no doubt unavoidable that now and then you
happened to thrust the cannula a little way into the cortex, but when
nothing was injected it did not cause the patient any inconvenience. In
the case of brain-punctures, which were formerly used, small pieces of
tissue were even removed without inconvenience to the patient. When
making these injections it is, however, for other reasons absolutely
necessary to make sure that you are within the subdural space, and
this is done by letting the cerebrospinal fluid run out or be sucked
through the cannula.

If you are not on your guard in this way you may happen to inject
fluid into the cortex itself, which is thereby destroyed to a greater or
less extent—a lesion which may possibly result in a paresis of the arm or
the leg on the opposite side of the opening for the place of introduction.
It sometimes occurred that we injected a solution of fluid without the
cerebrospinal fluid being evacuated, trusting that the needle had really
only been subdurally placed, and the consequence was as described.

Later on sections from some of these cases were examined, and
there appeared to be an extensive leptomeningitis, which had probably
hindered the outflow of the cerebrospinal fluid. Therefore you may
certainly take it for granted that in all cases where you are unable to
drain out the fluid through the cannula it is owing to such a chronic
leptomeningitis, and this negative result of the puncture, and this disease
ought then to be considered a counter-indication for continuing the
treatment.

Moreover, it is most likely that a needle formed at the point like a
catheter could more easily be passed subdurally, and an injection could
be made without thereby injuring the cerebrum, but we did not get so
far as to use such a one. However, we modified somewhat the injection-
fluid, which was of more vital importance. There appeared, namely, to be

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various inconveniences in using neosalvarsanised serum. Firstly, it was
rather difficult to obtain sufficient sterilised serum for the injection with¬
out making the venesection comparatively large. Of course this diffi¬
culty could be overcome. But secondly—and this was of greater
importance—you could not prove that the neosalvarsanised serum
contained arsenic, or at best traces thereof, and that only when very
large doses of neosalvarsan had been given intravenously, and of
course it is arsenic which is the effective substance. After injections
of 45-60 cgrm. neosalvarsan we submitted various samples of blood of
20 c.cm. to Stein’s laboratory. These could not be proved to contain
the least arsenic. Traces were only found in a sample of blood after
an injection of 75 cgrm. neosalvarsan. The blood sample was supplied
by Dr. C. E. Jensen, who treated a syphilitic patient with these large
doses.

After that we resolved to inject neosalvarsan subdurally dissolved in
fresh, distilled, sterilised water. The doses varied from 2^ to 15 mgrm.
neosalvarsan in the following solution : neosalvarsan o - 45~o'6o cgrm.
in 20 c.cm. distilled water—a somewhat weaker solution than Ravault
has used for his intraspinal injections. The injections were repeated
after an interval of two to four weeks. The largest number of injections
given to any patient were five subdural injections, and in no case
whatever has infection occurred from these injections.

In the following we shall state the achieved results. They are, as
may be noticed by the shortly quoted accounts of the cases, not
especially excellent.

But before coming to any conclusion from these attempts it will be
fair to examine whether the results are a consequence of a wrong
treatment, or whether the problem must be considered as altogether
insoluble.

Case i. —M. S—, set. 34, workman. Syphilis treated with fifty
salving-cures when *et. 24. Taken to the lunatic asylum at Nykdbing,
S., January 10th, 1916. The disease commenced at the age of 32 with
an initial phase of depression. \\ hen taken to the hospital there was
pupil diff. Left pupil insensitive. Slight paralytic disorder of speech.
Spinal fluid, cells, 7 ; Nonne-Appelt, 0-35 ; Wm. in the cerebro¬
spinal fluid, o - 3-2o. 0.2-T00 ; in blood, o’2~5o, o - i-roo.

Trephining was done on April 17th, T9T6. Neosalvarsan was
injected intravenously, and to c.cm. neosalvarsanised serum subdurally.

May 13th, 1916: Injection of neosalvarsan, 0^003 grm. subdur.
through the skin : o'3 grm. intravenous.

May 24th : Injection of neosalvarsan, o - oo6 grm. subdur.; o'6 grm.
intravenous.

June 16th : Injection of neosalvarsan, o'T2 grm. subdur,; o - 6 grm.
intravenous.

July 7th : The patient is much better; able to work part of the day.

November 29th ; o’oo6 grm. subdur.; 0 6 grm. intravenous.

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November 21st: The patient is dull and without interests.

December 21st : The patient does not want to work. Feels unwell.

February 14th, 1917 : 0 0025 8 rm - subdur. ; 0^45 grm. intravenous.

February 17th: In spinal fluid, Nonne-Appelt 2-35; in cerebral
fluid, Nonne-Appelt 3-35 after a respite of twenty-four hours.

February 20th : The patient lost his comb yesterday which he had
in his left hand. He explains that his left hand and arm a few times
have been as if they were dead, but quite temporarily. No paresis of
muscles, but a somewhat reduced sensibility of the left hand.

February 25th: In the course of the last twenty-lour hours has had
seven times some contortions of the face. Had injection of sulph.
mag. 5 c.cm. of a 10 per cent, solution.

February 26th : Some slight attacks of contortions.

March 5th : Irritable and discontented.

May 25th : Works a little.

July 1 st: Working better.

August 8th : Discharged, after having paid a visit to his home.

Case 2.—C. L. J—, set. 36, unmarried, assistant. Taken to the
lunatic asylum at Nykffbing, S., on November 17th, 1915.

The patient contracted syphilis when 22, and when 35 he became
nervous, tired and restless.

In the Frederiksberg Hospital, where the patient was first quartered,
pleocytosis and positive Nonne-Appelt reaction and positive Wasser-
mann reaction in blood and spinal fluid had been demonstrated.

When the patient was taken to the lunatic asylum at Nyk^bing, S.,
and for a long time after, he was over-excited, but quite brisk and
comparatively little demented. However, after a period of six months
he began to pilfer, which he had never done before; he also evidently
became more dull and had to cease working at the hospital.

In the spinal fluid there were then—cells, 40, and Nonne-Appelt
reaction 5-20.

Wm. in the spinal fluid, o - i5-2o, 0 075-80; Wm. in blood, o - 2~4o,

O’l-IOO.

Trephining was performed on May 23rd, 1916, followed by injection
of neosalvarsan, 0 006 grm. subdurally ; o'45 grm. intravenous.

June 10th : Is again more brisk. Goes to work. Yet he is some¬
what low-spirited. Complains of a feeling of strain in the masticatory
muscles on both sides.

June 15th: Neosalvarsan was injected, o’oi2 grm. subdur.; o’6o
grm. intravenous.

Six hours after the injection there was difficulty of speech and paresis
of the left arm and leg. Slight facial paresis and Babinski’s reflex in
the left foot.

However, in the course of a fortnight the patient was again able to
walk about and was relatively well, but could not at all times move the
left arm. The difficulty has later on improved somewhat, but there is
still a slight paresis left.

The dementia of the patient has become rather stationary. Bodily
the patient is getting on well.

November 7th, 1917: Spinal fluid, cells, 7 ; Nonne-Appelt, 2-10;
Wm. in spinal fluid, o - 2o-2o, o'i-ioo; Wm. in blood, o - oi-o.

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Case 3.—C. A. W. J—, policeman, jet. 42. The patient was
infected with syphilis when jet. 20, and was treated with many salving-
cures and injections.

The disease commenced when the patient was set. 40 with depression
and irritability.

There was then strong pleocytosis in the spinal fluid. Nonne-Appelt,
1-50. Wm. in spinal fluid, 0-05-0.

November 23rd: Was taken to the Frederiksberg Hospital, treated
with strong antiluetic cure and had tuberculin treatment. The patient
was discharged with — Wm. in blood.

May 3rd-May 22nd, 1915 : Renewed treatment.

August 4th : Again at the Frederiksberg Hospital, with disorder of
speech, facial paresis, and strong depressive unrest. Wm. -f- in blood.

March 25th, 1916 : Taken to the lunatic asylum at Nyk^bing, S.: far
advanced dulness.

April 25th: In spinal fluid, cells, 112, and of these many extra¬
ordinary polymorphonuclear-formed lymphocytes. Nonne-Appelt, 7-25.
Wm. in spinal fluid, 0-07-60 ; o'oo3-ioo ; in blood, o - i-6o ; 0-05-100.

May 9th: Trephined. Injection of neosalvarsan, 0-015 grin . sub-
durally; 0-309 grm. intravenous; 0009 grm. subdur. ; 0-45 grm. intra¬
venous.

June 16th : Attempt at injection in vain.

August 29th : o 01 grm. subdur. ; o'6o grm. intravenous.

February 10th, 1917 : Attempt at injection in vain. Lumbar punc¬
ture. In the spinal fluid there are now 450 cells, about £ of them,
polymorphonuclear formed.

February 18th : Incision above the place of trephining, then injection
of neosalvarsan, 0-0025 grm. subdur.; o 60 grm. intravenous.

March 1st and March 3rd : Spasms in the right arm.

November 3rd : His psychical condition is unaltered.

Spinal fluid, cells, 7. Nonne-Appelt 2-10. Wm. in spinal fluid,
0-1-20,0 05-100; in blood, 0-025-60,0 05-100.

In the following three cases a temporary recovery in response to the
treatment occurred, but after the lapse of some time the disease
progressed and the patients died.

Case 4.—M. P. P—, blacksmith, jet. 45.

When the patient was 22 years of age he contracted syphilis,
which was treated at the Communal Hospital, fourth ward ; later on a
fresh outbreak occurred, which was treated ambulant. At forty-three
years of age he became irritable, capricious, and got megalomania.

June 19th, 1914-February 13th, 1915, at the Frederiksberg Hospital.
Wm. in the spinal fluid was weakly positive. He was treated at the
Frederiksberg Hospital with tuberculin, salvarsan, and hydrargyrum.

Discharged recovered with negative Wm. in blood.

November 14th, 1915-April 5th, 1916, again at the Frederiksberg
Hospital, treated with injections of sublimate and salving-cures. When
taken to the hospital he was a typical dementia paralytica, and was
discharged unchanged. There was a considerable increase of the
quantity of albumen and positive Wm. in the spinal fluid.

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1919-] iJY GEORGE E. SCHR0DER AND HJ. HELVVEG. 3 1

June 14th, 19x6 : Taken to the lunatic asylum at Nyk0bing, S.,
with rather advanced dementia. In the spinal fluid, cells, 13 ; Nonne-
Appelt, 5-30. Wm. in spinal fluid, 1-20; in blood negative, o'6-ioo.

July nth: Trephined, with injection-of neosalvarsan, o'oo6 grm.
subdurally; o'45 grm. intravenous.

August 29th : 0 006 grm. subdurally ; C45 grm. intravenous.

October 6th : The patient is getting better; is working in the work¬
shop and the garden. Has had an attack of unconsciousness.

February 14th, 1917: Injection of neosalvarsan, o - oo25 subdur.;
intravenous failed. -•

In the spinal fluid 24 lymphocytes, and in the cerebral fluid 21
lymphocytes.

February 20th : Has attacks of convulsion in arms and legs, mostly
in the left side.

February 22nd: Numerous attacks of convulsion, mostly in the
left side.

February 26th : Increasing attacks of convulsion. Mors.

Section; Under the trephine opening on the left side a small,
yellowish-grey softening is to be seen quite superficial in cortex;
ependymitis granularis ; myocardial degeneration; bronchopneumonia.

On the right side on inner surface of dura flat fibrinous deposits and
slight bleedings ; pachymeningitis hsemorrhag. interna.

Cask 5.—O. V. P—, dairy manager, aet. 24.

Nothing known about syphilis. Patient was taken ill during his
military service, and was at once treated with potassic iodide and
salving cure. Wm. positive in the blood. He was taken to the lunatic
asylum at Nykpbing, S., on November 15th, 1915. He presented a
typical paralysis with megalomania and disorder of speech.

February 6th, 1916: The spinal fluid showed cells, 23. Nonne-
Appelt,3-2o. Wm. in spinal fluid, o'1-60 ; o'05-ioo; in blood, 0025-60;

O'OI-IOO.

March 22nd: Trephined. Injection of neosalvarsanised serum,
io'oo grm. subdur. ; neosalvarsan, o - 6o grm. intravenous.

April nth: io'oo grm. subdur. ; neosalvarsan, 060 grm. intravenous.

May 8th : Injection of neosalvarsan, o'oo3 grm. subdur. ; neo¬
salvarsan, o'6o grm. intravenous.

May 18th: The patient has written a letter, which, compared with
previous letters, was excellent.

May 25th : Injection of neosalvarsan, 0 009 grm. subdur. ; o'6o grm.
intravenous.

June 8th : More clever at assisting in the garden and in the ward.

June 17th: Neosalvarsan, o'ox 2 grm. subdur.; o'6o grm. intravenous.

July 14th : In the spinal fluid, cells, o. Nonne-Appelt, 3-75. Wm.
in spinal fluid, o'2-6o, o - oo25-ioo ; in blood, o'o5~6o, o'l-ioo.

August 20th : The patient is getting more restless and dirty, evil-
tempered and obscene, then steady psychical and somatical descent to
Mors. On November 16th, 1916, sections examined : Leptomeningitis,
ependymitis, aortitis luica. Dura a little adherent at the trephine-
opening, but no local alterations in front of this.

Case 6. —V. C. C—, butcher’s journeyman, act. 37. The date of
infection is unknown. When 32. years of age he received antiluetic

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treatment, because Wm. was positive. He was able to work after
the treatment.

He was taken to the lunatic asylum at Nyktfbing, S., on November
29th, 1916. Dementia paralytica with far advanced dementia. Spinal
fluid, cells, i2 - o; Nonne-Appelt, 5-40. Wm. in spinal fluid, o'3~4o,
o - 2-ioo ; in blood, o’i-2o, 0 005-100.

He was trephined, and was then altogether twice injected with
neosalvarsan o - oo6 grm. subdurally, and at the same time 0^45 grm.
intravenous. There was a quite transitory convalescence after the last
injection, but from that on Iris paralysis advanced sttadily. At a later
spinal puncture his spinal fluid was found not to contain more cells.

Section-diagnosis : Diffuse inspissation of the soft membranes.
Ependymitis granularis. No softenings. Aortitis luica ; bronchitis chr.

In the following four cases the patients died without the injections
having influenced them at all. Sections showed nothing but the usual
and characteristic appearances seen in cases of dementia paralytica.
We had no impression of these injections having influenced the
paralysis in any way. In any case, three of these patients, when taken
to the lunatic asylum, had reached such an advanced condition of
dementia that it would have been a doubtful advantage even if we had
really been able to retard their disease.

The disease was in all four cases quite typical and well substantiated,
also as to the cerebrospinal fluid. We shall only give a short account
of them.

Case 7.—G. K—, aet. 55. Far advanced paralysis. The patient
had previously had paralytic attacks with temporary paresis of the
left arm.

The spinal fluid showed—cells, 6; Wm. in spinal fluid, o’3-8o;
in blood, o - 2~3o.

August 20th, 1916: Trephining, with injection of neosalvarsan,
o - oo6 and 0 045 grm.

August 30th : Spasms in the left arm with continuing paresis, which
in the following months partly improved.

February 15th, 1917 : Thirteen cells in the spinal fluid. Juneist: Mors.

Section: A small superficial softening in front of the trephine opening.
Extensive paralytic alterations in the brain. Aneurysma aortse.

Case 8.—O. S—, set. 41. Taken to the hospital on December 28th,

I 9 I S-

On October 13th, 1914, there was found in the spinal fluid a consider¬
able increase of cells and albumen reaction and positive Wm. reaction.

When taken to the hospital the patient presented the picture of far-
advanced paralysis with typical attacks, after which there was for a time
some paresis of the left arm.

February 9th, 1916: Spifial fluid, cells, 16; Nonne-Appelt, 2-60;
Wm. in spinal fluid, o'i-6o, o - ©5-ioo; in blood, ©‘2-30, o'i-ioo.

April 10th : Trephined. After that there was injected subdurally
o'oo3, o'oi2 and C015 and o’oo6 grm., and intravenous, o - 6o grm., four
times. A few days after the third subdural injection there w»as a temporary

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paresis ot the left hand, and later on attacks of convulsion in the
left side.

Section: Strong diffuse pia-inspissations. No softening.

Case 9.—C. P. C. C—, set. 36. Taken to the hospital on July 13th,
1916. The patient contracted syphilis when 23 years of age. After
he had been taken to the hospital a lumbar puncture was performed.
The spinal fluid showed—cells, 97; Nonne-Appelt, 5-40; Wm. in
spinal fluid, o‘3~2o, o‘2-ioo; in blood, o'i-6o, 00 5-100.

Trephined with subdur. injection of neosalvarsan 0 01 and 0^45 grm.
intravenous was given. The injection was made without succeeding
in evacuating fluid first. The day after there was a slight paresis of
the left arm and the left side of the face.

Section : Leptomeningitis chr. Cortical softening of cerebrum. Aorlit.
luica.

Case 10.—N. M—, aet. 37. Taken to the lunatic asylum at Nykpbing,
S., on July 7th, 1916. The patient presented a typical paralysis.

August 20th, 1916: Trephining with injection of neosalvarsan, 0 006
and 0 45 grm. respectively subdur. and intraven.

September 2nd: Slight paresis of the left arm.

September 4th : Evident paresis of the arm, which, however, got
somewhat better in the course of a month. In the course of six months
the patient began to fall away, and then died.

Section: Dura was adherent to the cranium and to pia in front of the
trephine opening. No softenings.

All these very concise extracts from records do not, as already
mentioned, present any very encouraging remits from the treatment,
yet, before denouncing such an apparently rational treatment as the
one in question, you ought, as also observed, first to examine whether
“primary mistakes” should impair this issue, as is generally the case
as regards recently evolved methods of treatment, at d to ascertain
whether these mistakes were avoidable, so that in time the treatment
might become of advantage.

Therefore it will be necessary to consider the groups previously
mentioned a little more closely—first of all the one where the treatment
was ineffective. It presents two features which may partly explain
the bad result. One of them is that at any rate three of the cases
mentioned showed far-advanced paralysis; the fourth case was also
rather advanced, but the dementia was somewhat less than in the
other cases. Consequently these were cases where it was conceivable
that the disease was too far advanced for the treatment to be of effect.
To this must be added the other not less important point that the
complication which frightened us from further treatment occurred so
quickly, namely after the first or the second injection, that, in fact,
a systematic treatment of three of the cases, including the one less
advanced, was out of the question. The only one which got a series
of four injections was already, when taken to the hospital, so lar

LXV. 3

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TREATMENT OF DEMENTIA PARALYTICA, [Jan.,

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advanced that, as indicated, it would be beyond all expectation that
the treatment would be effectual.

Therefore these bad results can hardly be chargeable against the
method. There are hardly any other methods, which, under similar
circumstances, would have given a better result.

The next group, in which the patients died, but where, however,
there was a temporary improvement in response to the treatment, also
proves, but certainly less obviously, that similar circumstances have
influenced the result. At any rate in two of the cases the dementia was
far advanced before the treatment, and the treatment was not resumed
because of the improvement having subsided, and the dementia again
being in advance. Here the remissions occurred after the second
injection.

The two cases had also previously had remissions after antiluetic
treatment, but in the third no such treatment had been attempted, and
this is therefore the most interesting. The remission was here quite
beyond doubt: the patient did not quite recover before he' got a
relapse; he consequently presented a somewhat childish behaviour,
which, however, was possibly constitutional with him.

Here five injections were given, but two of them being of neo-
salvarsanised serum, which, as proved, did not contain arsenic, only
three injections may be reckoned with.

Finally, there is the last group, the three cases in which for the
present the paralysis seemed to have become stationary or improved.
In one there were given four double injections, in the other two, and
finally in the third were given five double injections.

All three cases have been amongst the less seriously attacked; in one
of them—the slightest—the patient has been discharged.

However, before regarding these results as being in favour of the
treatment, there is no doubt a circumstance which must be taken
into consideration—the very essential one that paralyses also present
remissions spontaneously. If we examine how our ten patients have
got on, it appears, including the previous quarterings at the hospital,
that four of the patients have previously had antiluetic treatment—that
is, with Hg. and neosalvarsan—and all four had undoubted remissions,
and in this hospital the seven have, as mentioned, had remissions of
shorter or longer duration—altogether a number which surely is
somewhat more than the number of spontaneous remissions would
be in the case of ten other paralytics which had not been treated
Consequently it really appears as if a more energetic antiluetic treatment
than a mere salving-cure is able to exercise a temporary effect on the
paralysis. And other investigators, who have greater material at their
disposal, have come to the same conclusion. Here I shall only refer
to the statements of Leredde.

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Leredde insists that the reason of failure to cure the paralysis is, that
the treatment is not sufficiently energetic. And Nonne (‘), surely the
investigator who has the best knowledge of lues cerebrospinalis in
all its shades, has also commenced to esteem the energetic salvarsan
treatment more highly than before. Formerly he warned against it,
and was of opinion that the treatment consisting of increasing the
leucocytes was the best one—the tuberculin and natrium nucleinicum
treatment—but now, having become acquainted with the remedy along
with Gennerich in Kiel, he thinks that you may expect something from
intraspinal injections of neosalvarsan.

Here it would be of importance if you could prove that the treatment
had any influence on the pathological processes discovered in the
cerebrospinal fluid and the blood, as it has now and then been proved
by other investigators both as regards the ordinary antiluetic and the
fever treatment. But in this domain the mateiial is doubtless very
deficient. There ought to have been many more re-punctures than has
been the case. Only in six cases have cells been repeatedly counted,
and in four of them the number of these has, after the treatment,
become nought, and in two it has increased. As known beforehand,
you are to a certain degree able to influence the pathological process in
the spinal fluid.

Finally, just a few words on the complication which prevented us
from carrying through so energetic a treatment as we should other¬
wise have considered ourselves bound to do. As seen from the records,
in several of the cases—altogether four—an unfortunate consequence of
the injections appeared. There was a continuing paresis of the arm—
sometimes, but more seldom, of the leg also—on the opposite side to
where the injections had been made. At first we supposed that it was
owing to a local cortical softening produced by the needle, and through
injection of the concentrated fluid. The first sections, namely, showed
such a small softening, but the section in Case 10 showed that also
without softening a paresis might come—probably a consequence of the
local irritation of leptorneninges. Such an acute partial leptomeningitis
also explains the paresis in the other cases better than the said small
softenings, it seeming strange that so superficial and limited a softening
could cause so great disturbances. Therefore in all cases it is to be
supposed that the acute local leptomeningitis has been the cause, and
this you will be able to avoid in the future if neosalvarsan in more
dilute solutions is used—for instance, an injection made with 10 or
20 c.cm. sterilised salt water.

In the preceding remarks we have tried as objectively as possible to
weigh what is in favour of and what is against the treatment described-
We have not reached convincingly good results, but perhaps useful ones;
and that this has not been done to a greater extent by the proceeding

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used by us cannot, as we have proved, be unjustly charged as altogether
against the method. On comparing it with so many others we must
recollect that not seldom has it occurred that methods, which at the
beginning have had difficulties to encounter, have proved useful in the
long run. Before passing a final sentence there is still an important
question to be settled.

For the present the question may be stated thus : Is it altogether
worth the trouble to treat paralytics, and especially in the way indicated,
which consequently should be given preference over the mere intra¬
venous injection in that it affects the spirochaetes in the cortex directly?
However, this must be answered in the affirmative. We know that the
paralysis in itself is such a hopeless disease that any chance, be it ever
so inconsiderable, of being able to make the disease stationary would
be an advantage. If we succeed in this, it will surely also be possible
to do it at so early a stage of the disease that the working ability of the
individual may be wholly or partly retained.

As therefore the method, with suitable alterations and limits as indi¬
cated by us, seems to give a faint hope, the experiments ought to be
carried on. For instance, it is possible that a continued series of
examinations of the spinal fluid in the case of the same patients will
prove that there are certain forms of paralysis which can be more
influenced than others.

( ! ) Nonne, “ Ueber die Frage der Heilbark. der Dem. paralyt.,” D.e.f.Nhlk.
Bd. 58 , H. 1 and 2 .

Medico-Psychological Association of Great Britain and Ireland:
Report of English Lunacy Legislation Sub-Committee.

A Sub-Committee of the Parliamentary Committee of the Association
was appointed in January, 1918, the terms of the reference being “to
consider the amendment of the existing Lunacy Laws.”

The Committee was composed as follows :

H. Wolseley Lewis, Esq., M.D., F.R.C.S. (Chairman).

Robert H. Cole, Esq., M.D., F.R.C.P. (Secretary).

Lieut.-Col. Sir Robert Armstrong-Jones, M.D., F.R.C.P.

Miss A. Helen Boyle, M.D.

James Chambers, Esq., M.A., M.I).

Lieut.-Col. Maurice Craig, M l)., F.R.C.P.

Reginald L. Langdon-Down, Esq., M.B., M.R.C.P.

Bedford Pierce, Esq., M.D., F.R.C.P.

George E. Shuttleworth, Esq., B.A., M.I).

Lieut.-Col. T. E. K. Stansfield, M.B., C.M.

Robert H. Steen, Esq., M.D., M.R.C.P.

Lieut.-Col. David G. Thomson, M.D., C.M.

J. G. Soutap, Esq., M.B., C.M. (co-opted at a later stage).

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I 9 19-] REPORT OF LUNACY LEGISLATION SUB-COMMITTEE. 37

Introductory.

The terms of the reference were so wide that it was agreed to invite
opinions from medical men and others as to what, in their experience,
were the defects in the present Lunacy Laws, and a large amount of
evidence was thus collected.

From this it was obvious that there is a pressing need for some better
method of dealing with cases of unconfirmed mental disease. The
importance of this matter is further indicated by the facts that much
has appeared recently on the subject both in the Medical and General
Press, that books dealing with it have had a wide circulation, and that
Bills providing for better treatment of unconfirmed mental disease have
been presented to Parliament in recent years, notably in 1914 and 1915.

These facts, and other evidence of dissatisfaction with the operation
of the existing Lunacy Laws, have impressed upon us that it has become
urgent to secure such amendments of the Law as will give effect to some
of the recommendations made in the Report on the Status of British
Psychiatry issued by the Medico-Psychological Association in i9i4.( 1 )
That report established the pressing claim, which further experience
has accentuated, for better facilities for the treatment of cases of mental
disorder in the early stages. How that purpose may be accomplished
has been the subject of careful consideration by this Committee.

It has been definitely ascertained that:

1. There are very few facilities for patients who are threatened

with mental breakdown obtaining skilled treatment until they
are certified. The early symptoms of disorder often occur
long before certification is possible.

2. Owing to efficient treatment being delayed the most valuable

time for adopting measures to secure early recovery is lost.

3. There is strong objection to certification in itself on the part of

the public, which is alive to the material and moral damage
which it so often inflicts on the patient and his relatives, so
that even when certification has become possible they refuse
to resort to it and thus still further postpone the adoption of
efficient treatment.

4. In cases where certification has to be resorted to the subsequent

course of events often shows that this might have been
avoided with advantage if there had been facilities for treatment
under other conditions.

5. The experience gathered as the result of the war has opened

the eyes of the public and the medical profession in a fresh
way to the difficulties and needs of these cases.

6. Many medical practitioners, having had no opportunity of

gaining knowledge of the manifestations and treatment of
mental disorders in their early stages, fail to recognise the

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38 REPORT OF LUNACY LEGISLATION SUB-COMMITTEE. [Jan.,

seriousness of the condition and to secure for their patients
efficient treatment. They are also often deterred, by the
necessity of certifying the patient, from advising suitable
treatment. This unwillingness may be due to a genuine and
proper doubt whether the condition is sufficiently definite to
justify this procedure or to a natural reluctance to cause distress
to the patient and his friends. In some cases direct evidence
of insanity cannot be obtained at occasional interviews, and
certification and treatment are thus delayed.

7. In many early cases advantage would be taken of the oppor¬

tunity for treatment in Asylums were the Voluntary Boarder
system, with some modification of procedure, extended to all
Institutions for the insane.

8. Many persons of the well-to-do classes, who are the subjects

of mental disorder and are certifiable, are now placed in
private houses without an order having been obtained for their
reception. No intimation of their admission is given to the
Board of Control. No precautions are necessarily taken to
ascertain that the conditions are favourable for the patient or
that efficient treatment is thus being obtained for him. It is
felt that while many cases may be treated in private houses
quite properly, provision should be made to give a competent
authority the opportunity of ascertaining that houses in which
such patients are received are suitable for the purpose, and
that the persons in charge are competent to treat cases of
mental disorder.

Although some desire to see the Lunacy Laws entirely re-cast and re¬
named, with abolition of the Magistrate's order and other legal
formalities, the majority are satisfied that such far-reaching changes are
not necessary, and it appears that all the reforms most urgently needed
could be obtained by a short Amending Bill. It is certain that at the
present time such a Bill would be more likely to secure the early con¬
sideration of Parliament, and would meet with less difficulty in its
passage than a wider measure.

The Commit Zee therefore rccommetids :—

1. That the Medico-Psychological Association take no steps at
present to obtain a complete revision of the Lunacy Acts,
but seek to obtain amendments only to those Acts.

As the Committee cannot but think that all, with experience of the
subject, agree that the Law now presses hardly on certain cases, pauper
and private' alike, is not abreast of modern requirements and aspira¬
tions, and is not working in the best interests of the State, it has
endeavoured to frame proposals to meet these defects.

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In doing so, it has kept in mind on the one hand the practical con¬
venience and view-point and possible prejudice of those for whose
benefit the measures suggested are intended, and on the other the
necessity of winning the support of instructed lay opinion, the medical
profession and the constituted authorities.

These proposals fall under four heads :

Clinics.

Voluntary Boarders.

Further Provision for Private Patients.

Supplementary.

Clinics.

These aim at providing facilities for treatment of which ailing
members of the public will be ready to avail themselves at the earliest
possible moment, even when the condition is merely what is commonly
described as one of “disordered nerves.” This necessitates as com¬
plete a dissociation as possible from the existing statutory requirements
for dealing with the insarte.

It also necessitates the provision of facilities similar in character and
equal in completeness to those available for purely physical ailments—
that is, a thoroughly well-found and well-staffed Clinic for both in- and
out-patients. These facilities must be brought as near to the homes of
the people as possible. They should therefore be established all over
the country in large centres of population, so that the people may
easily seek advice and so be encouraged to get instruction in mental
hygiene at a stage when preventive measures are possible, and thus
escape in many cases a serious breakdown, to the advantage both of
themselves and the community; for thus would be retained as workers
those who otherwise become a burden to their fellows.

No mere extension of the Voluntary Boarder system in Asylums
(which is much to be desired on other grounds) would appear to meet
these requirements. Nor is it probable that any arrangements that
might be made at the General Hospitals throughout the country would
alone be sufficient.

The Clinic should be called by some name which will clearly indicate
its purpose as a place to which patients suffering from any of the early
indications of nervous disorder may resort.

Just as in ordinary Hospitals some cases of delirium and excitement
with loss of control occasionally occur and are there dealt with without
special powers or any great difficulties, so similarly cases of mental
disease in their early stages where the symptoms are likely to subside
under proper treatment would be received and suitably provided for in
the proposed Clinics.

The decision whether a case is or is not suitable for further treat-

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40 REPORT OF LUNACY LEGISLATION SUB-COMMITTEE. [Jan.,

ment in such a Clinic would depend upon practical convenience and
the nature and duration of the symptoms.

It is thought that the special character which it is hoped will attach
to these Clinics will be more certainly secured if no formal powers of
detention therein on the ground of mental disease are asked for, at all
events in the first instance, until some experience has been gained
of the practical working of the scheme.

By keeping the proposed Clinics free from any formal powers of
detention they will be given distinction in fact as well as in name
from the existing Institutions : they are intended to cover a different
* field from that covered by the Asylums, and it is hoped that the
confines of this field will be extended to a far earlier period of the
disorder than could possibly be the case in connection with the Asylums.

In large towns Clinics should be affiliated to the General Hospitals,
in oider that students may have opportunities of studying those early
stages of mental disorder which as practitioners they will be called
upon to treat. For this purpose either special wards might be set
aside or special buildings used with assistance from public funds.
Clinics would also provide a valuable field for post-graduate work and
for scientific research with the necessary laboratory accommodation. If
the recommendations of the Local Government Committee on Transfer
of Functions of Poor-Law Authorities 1918 are adopted many existing
buildings or parts of buildings might be adapted for use as Clinics,
and in other cases the provision of buildings for Clinics should save
expenditure which would otherwise be incurred in enlarging existing
Asylums or erecting new ones.

The Committee therefore recommends:

2. That Clinics be established by local authorities for the treatment

of nervous and mental diseases in their early stages; and that
in the organisation of Clinics special provision be made for
children.

3. That the first resolution, re Legal Changes, Appendix 7, of the

Status Committee’s Report, 1914, be amended by the sub¬
stitution of the word “reception” for the word “detention.”( 2 )

4. That a Clinic should be housed in a special building or in an

annexe to a General Hospital.

5. That a Clinic should be staffed by a special staff trained for the

work.

6. That it should be the duty of Local Authorities to provide and

maintain Clinics either themselves or by arrangement with
voluntary organisations for the purpose.

7. That the Committee of Management of a Clinic should be a

special Committee appointed for the purpose.

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8. That the inspection and approval of the buildings used for

Clinics should be the duty of a Central Government Depart¬
ment.

Voluntary Boarders.

Under the present Lunacy Laws patients may be received as Voluntary
Boarders in Registered Hospitals and Licensed Houses. This facility
should be extended to suitable persons, whether of the private or rate-
aided class, desirous of placing themselves under treatment in County
or Borough Asylums. The Board of Control in its third Annual Report
has expressed its approval of this change.

Many patients who have recovered from a previous attack in an
Asylum, and are on the verge of a relapse, wish to place themselves
under Asylum care again, but are, at present, unable to do so until they
become certifiably insane, and then they must be referred to the Relieving
Officer.

There will no doubt be other cases unable to afford the expense of a
Registered Hospital or Licensed House who will prefer to go direct to the
Asylum for treatment in the first instance, if they can do so under the
conditions attaching to Voluntary Boarders, and this should be per¬
mitted and encouraged.

The Board of Control should be informed of all persons received as
Voluntary Boarders into Institutions for the Insane, but their previous
consent thereto, or that of the Justices in the case of Licensed Houses,
seems unnecessary and interferes with the utility of the plan, as many
patients object to making written application to the Board of Control or
the Justices for permission, as at present required; moreover, no such
requirement obtains in the case of Registered Hospitals.

Further, there appears to be no good reason why this mode of admis¬
sion should be reserved for persons who cannot be certified as insane,
as it conflicts with the fundamental principle that treatment should be
begun at the earliest possible moment. It should be sufficient for any¬
one, being aware of his mental illness, voluntarily to sign a document
expressing his desire to be admitted as a boarder for purposes of treatment.

For practical convenience it is much to be desired that the notice
required to be given by Voluntary Boarders of their intention to leave
should be increased from 24 to 48 hours.

The reform suggested has long been advocated, and has met with
practically no opposition.

The Committee therefore recommends ;

9. That all Institutions for the Insane should be encouraged to

admit patients as Voluntary Boarders on their signing an
application to that effect addressed to the Medical Officer of
the Institution, provided :

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42 REPORT OF LUNACY LEGISLATION SUB-COMMITTEE. [Jatl.,

(а) That there is suitable accommodation and the appli¬
cants are suitable persons.

( б ) That they should be required to give 48 hours’ notice
in writing of their desire to leave the Institution, after the
expiry of which period they must cease to reside as such ;
further provided that, before the Notice expires, the Boarder
does not intimate in writing his desire to withdraw the Notice.

10. That Regulations should be made setting out the conditions on
which the Medical Officer may admit Voluntary Boarders, and
as to the provision for the maintenance of those unable to
support themselves.

Further Provision for Private Patients.

It lias to be recognised that the objection to certification in the early
and curable stages of mental disorder is strongly felt by all classes, and
the temptation, for those who can afford it, to send patients to un¬
recognised places of treatment is very great both for the patient’s
friends and their medical advisers. Those who receive such patients
knowingly run the risk of prosecution, and there is no guarantee that
they can or do give suitable care or treatment to the patients. The
treatment of certain cases of mental disorder in suitable private houses
is undoubtedly desirable, and the true interests of the patients should
be obtainable in conformity with the law.

Where residential treatment is conducted for payment in the case
of patients suffering from mental disorder which is deemed to be
temporary, but who may be considered certifiable, it is desirable that
the fact of their reception should be brought to the cognizance of
some central authority. It is hoped that with this safeguard facilities
may be granted for the treatment for payment by private persons or
voluntary associations of early, undeveloped and recoverable cases of
mental disease without the drawbacks attaching to certification.

It is suggested that the Board of Control should be empowered to
give legal sanction to the treatment of this group of cases without
certification. This can only be done by provisions limiting the
application of Section 315 of the Lunacy Act, which imposes penalties
on those receiving persons of unsound mind for payment without
certification. It is not proposed to do away with this Section, and as
its enforcement is in the hands of the Board of Control it is practically
necessary to give any powers over-riding its application to the same
body.

Any facilities for treatment of cases granted under this section should
be equally applicable to such cases in Asylums, Registered Hospitals
and Licensed Houses.

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The Committee therefore recommends:

11. That the Board of Control should have power (a) to approve
Homes which are supported wholly or partly by voluntary
contributions or which are privately owned, as also Asylums,
Registered Hospitals and Licensed Houses, in which it shall
be lawful to receive without certification more than one
patient suffering from mental disease in its early stages, and
(h) to give legal sanction to the reception without certification
of such patients as single patients in houses not so approved,
provided that a medical practitioner gives a written recom¬
mendation in each case, stating that suitable treatment can
be obtained for the patient in the proposed house.

12. That on any such patient being received into or ceasing to
reside in any Approved (or Recognised) Home, Asylum,
Registered Hospital or Licensed House, or as a single patient
in a house not so approved, the fact shall be intimated to the
Board of Control.

Supplementary.

The Committee is further of opinion :

13. That it is undesirable that patients alleged to be of unsound
mind should be removed to a workhouse or pauper infirmary
before their reception in an Asylum. If an intermediary stage
is desirable it would be better supplied by the proposed
Clinics. Practical convenience such as a motor service should
be available for the transfer of patients to Asylums and Clinics
on lines similar to those adopted in the Public Health Service.

14. That where no criminal offence is charged it is undesirable
that Justices should in Court conduct the examination of
mental cases for the purpose of making reception orders.

15. That it should be made possible for rate-aided patients as well
as private patients to be admitted to Asylums under an
“ Urgency Order.”

16. That it is desirable that neighbouring Asylums should be
enabled to establish and maintain joint laboratories for
research.

17. ( a ) That the words “ Lunacy ” and “ Lunatics” be discontinued
and the words “ Mental Diseases ” and “ Persons of Unsound
Mind ” be substituted.

( b ) That instead of the word “ Asylum ” the words “ Mental
Hospital” or “Hospital for Mental Diseases” be used,
County, City, or Borough as may be.

(c) That the words “rate-aided” be used instead of the word
“ pauper.”

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18. (a) That there is much need of simplification of forms under
the existing Lunacy Act.

(b) That some of the legal phraseology is cumbrous and involves
needless repetitions, and is at times objectionable, e.g., “ Take
Notice,” etc.

(c) That intervals in time require uniformity, e.g., “ clear days,”
“ within 14 days,” “not more than 7 days,” etc.

(d) That in particular the duration and lapsing of Reception
Orders require radical amendment.

19. (a) That the administration of the estate under Sect. 116
should be simplified, expedited and rendered less expensive;
and—

(b) That the endorsement on the Summons should be re drafted.

20. That patients and voluntary boarders should be permitted
reception direct to Branch Establishments of Asylums,
Registered Hospitals or Licensed Houses.

21. That it should be possible to transfer the jurisdiction for
licensing a house (or “hospital”) from one authority to
another on good reason being shown.

22. That it should be permissible for patients transferred from
an asylum to a workhouse to be transferred back without
re-certification.

23. That the existing Lunacy Act—which should be called the
Mental Diseases Act—is framed more to protect society and
safeguard the liberty of the subject than to treat and cure
the patient.

24. That the amending Bill be called “The Mental Treatment

Bill,” 1919.

(’) Journal of Mental Science, October, 1914, p. 667 et seq. —(*) The resolution
referred to is as follows: “That it is desirable that provision be made for the
detention of patients in Psychiatric Clinics for ajlimited time without certification.”

Part II.—Epitome of Current Literature.

The So-called Lucid Interval in Manic-Depressive Psychosis: Its
Medico-Legal Value. (.American Journal of Insanity, April, 1918.)
Gordon , A.

In this paper the question is considered as to how far the mentality
of an individual can be regarded as normal during the intervallary
periods of a manic depressive psychosis. The writer has carefully
studied the reaction of two patients during a prolonged so-called lucid
period. In each case a superficial judgment would have failed to
reveal any mental disorder, and from the point of view of the friends of

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the patients they were regarded as quite normal. A careful analysis of
the entire life of the patients, however, reveals a different picture of their
mentality, and indicates that while the characteristic elements of the
psychosis are no more in action, the disease, nevertheless, produces
such a disturbance in the power of judgment, affectivity, sense of
morality, and attitude towards others that the patients could not be
considered normal.

Such individuals obviously do not require commitment, but they
should, nevertheless, be kept under observation. In spite of apparent
lucidity there are such fundamental deviations of mentality that they
may seriously compromise themselves or their family. The civil
capacity is, therefore, more than questionable, and proper administrators
should be appointed to safeguard their interests. An individual with
a previous history of manic depressive periods possesses an underlying
morbidity, of which the psychosis is an expression, and the morbid
characteristics cannot naturally disappear during a so-called lucid
interval, no matter how protracted its duration may be.

H. Devine.

Part III.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at 11, Chandos Street,
London W., on Tuesday, November 26th, 1918, Lieut.-Col. David G. Thomson,
M.D., R.A.M.C. (Acting-President), in the chair.

The following signed their names in the book as having been present at the
meeting or as having attended meetings of committees: Sir G. H. Savage, Lieut.-
Col. Sir Robert Armstrong-Jones, Drs. M. A. Archdale, H. T. S. Aveline, C. W.
Bower, David Bower, H. C. MacBryan, James Chambers, R. H. Cole, A. W.
Daniel, J. Francis Dixon, R. Langdon-Down, Richard Eager, C. F. Fothergill,
H. E. Haynes, David Hunter, H. Wolseley-Lewis, John Macarthur, S. E. Martin,
Alfred Miller, Jessie M. Murray, C. S. Myers, Alex. W. Neill, W. F. Nelis, H. J.
Norman, David Ogilvy, David Orr, L. R. Oswald, J. G. Porter Phillips, Bedford
Pierce, J. J. F. Prideaux, J. Noel Sergeant, J. C. Shaw, G. E. Shuttleworth, R.
Percy Smith, J. G. Soutar, T. E. K. Stansfield, R. C. Stewart, F. R. P. Taylor, R.
Worth, and R. H. Steen (General Secretary;.

Visitors : Drs. S. Lane, H. C. Maudsley, and F. W. Thurnam.

Present at Council Meeting .- Lieut-Col. D. G. Thomson, M.D , R.A.M.C.,
in the chair, and Drs. H. T. S. Aveline, David Bower, James Chambers, R. H.
Cole, A. W. Daniel, R. Eager, Alfred Miller, L. R. Oswald, J. G. Porter
Phillips, Bedford Pierce, [. N. Sergeant, G. E. Shuttleworth, H. Wolseley-Lewis,
and R. H. Steen.

Dr. J. G. Soutar and Lieut.-Col. M. A. Collins attended on the invitation of the
Acting President.

Apologies for unavoidable absence were received from : Drs. Thos. Drapes,
R. B. Campbell, T. Stewart Adair, Henry J. Mackenzie, A. Helen Boyle, Fletcher
Beach, J. H. Skeen, Francis Sutherland, William Tuach-MacKenzie.

The Chairman said the minutes of the May meeting had already appeared in
the Journal, July issue, therefore he assumed the meeting would agree to take
them as read.

The min-utes were approved and signed.

The Chairman said he had to ask the meeting to again tolerate him as Chair¬
man, as he regretted to say the President, Lieut.-Col. Keay, was compelled to be

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absent owing to illness. Dr. Keay underwent, after a serious illness, an operation
for appendicitis. He was glad to know that the patient was now doing fairly well,
though not yet fit for duty in his own hospital nor for transacting the work of this
Association. He was now recuperating in the south of England. He proposed
to the meeting a vote of sympathy with him in his illness, which, if approved,
would probably act as an encouragement to him in his convalescence. He was
sure such a vote would be much appreciated by the recipient.

The resolution was carried unanimously.

Obituary.

The Chairman said one of the first duties of the occupant of the chair at these
gatherings was to bring to the notice of the meeting the names of those members
who had died since the previous meeting. To-day he had to notify the death of
Dr. John Chapin, of New York. The American Journal of Insanity , referring to
the event, said : " Just as the Journal is about to go to press the sad news reaches
us of the death of Dr. Chapin, at his home in Canandaigua, New York, on Thursday
afternoon, January 17th, 1918. Dr. Chapin has been regarded, for many years, as
the Nestor of American psychiatry. He completed his 88th year on December 4th,
1917. In 1904, in Philadelphia, at the head of the Department for the Insane, he
rounded out fifty years of service in hospitals for mental disorders, and a dinner
given in his honour on December 1st of that year was attended by a noteworthy
gathering of friends. For seven years longer he continued at the head of the
hospital over which he had presided since 1884, retiring in the summer of 1911
and removing to Canandaigua, New York.” He had been an Honorary Member
of this Association since 1887.

The next name was that of Dr. William Reid, who, for twenty-five years, was
Superintendent of Aberdeen Royal Asylum. He died on September 3rd. After
a distinguished career at Aberdeen University, he became junior assistant to Dr.
Jamieson, who at that date was medical head of that Asylum, and on that gentle¬
man’s death, fifteen years later, he succeeded him. During his long term he saw
the great institution reconstructed at a cost of .£50,000, with the addition of a
branch asylum at Daviot. The success of the project owed much to Dr. Reid’s
able administration. Dr. Reid was responsible for the introduction of female
nursing on both sides of the Asylum, though he was severely criticised for it. Dr.
Reid also filled the post of lecturer on mental diseases at Aberdeen University.
He left a wife and two daughters.

Members would have the same feelings of regret, and desire to express them in
the proper way, concerning the late Captain Frank Oswald Spensley, who died of
pneumonia at Burden Military Hospital, Weymouth. Educated at St. Thomas’s
Hospital, he became Senior Assistant Officer of the Darenth Industrial Colony at
Dartford. After joining the R.A.M.C., he became Captain after a year's service.
He was invalided home from Salonica, and had latterly been attached to the
R.A.F. at Blandford.

He had also to notify the death of Dr. Logan, of the Bucks Asylum, Stone,
near Aylesbury ; that of Dr. Hume Griffith, Medical Superintendent, Lingfield
Epileptic Colony; and that of Dr. Herbert, Assistant Medical Officer of York City
Asylum.

He moved that votes of condolence and sympathy should be sent to the relatives
of all those he had mentioned.

The members signified their assent by rising in their places.

The Mental Hospital at Lebanon, Syria.

The Chairman called upon Dr. Percy SVnith to make a statement on this
subject.

Dr. Percy Smith said this subject did not appear on the agenda paper of the
meeting, but the Chairman had kindly said he might make a short statement to
the members.

His hearers would be aware that there existed a hospital called the Lebanon
Hospital for Mental Diseases in Syria. Some members were subscribers to it, and
some were on the English General Committee. It had now been open about
sixteen years. The present Medical Superintendent, Dr. Watson Smith, was a

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member of this Association. All through the war the question had arisen as to
what was the position of this hospital—it was a charitable institution, absolutely
international in scope, and it housed patients of every creed and nationality. It
had been equipped as a hospital for acute mental cases on the pavilion system and
on modern lines. So long as we were not at war with Turkey we did not feel
anxiety about the existence and well-being of the institution, but when Turkey
entered the war it became a subject of anxiety. Most of the subscribers were
English, but there was also a large amount of American help, and Turkey was
not at war with America, so that communication could be kept up indirectly
through America. Dr. Watson Smith had held the place throughout, and there
could be no doubt that during the last two and a half to three years he had been
through a very bad time. When Turkey entered the war, Dr. Smith's wife and
family had to return home to England and the hospital matron had to go to Egypt,
therefore he was left there with only native assistance, though the head attendant
was a German. The Turkish authorities recognised the institution as a charitable
one in the category of religious foundations, and he was glad to say the Turks had
absolutely kept to their principles in that way. Though the institution had been
used for Turkish insane soldiers and had been under the Red Crescent, yet all
along they had supplied the hospital with food at a time when there was frightful
starvation in the surrounding Syrian country. Though during this time Dr.
Watson Smith was really a prisoner in Turkish hands, he had remained in charge
of the hospital; he was not deported. During the recent advance through
Palestine, Syria and Mesopotamia there had been anxiety for news, and at last he
was in receipt of a letter, since the occupation of Beirut, saying that on October 13th
Dr. Watson Smith was all right, and, of course, free. He also said he was in a
position to send home the necessary documents.

The head attendant and his wife left the hospital when they knew the British
were arriving, and had now gone for ever, and the doctor was now working the
hospital with the head nurse and a young Roumanian student. The hospital had
suffered structurally, and life had been one of semi-starvation and at exorbitant
prices. He, Dr. and Mrs. Graham were the only English residents to meet the
British troops on their arrival. The letter went on to say it was impossible to
describe in a letter what their feelings were to see, after four years, the fine English
soldiers and sailors. They had been seeing thousands of people dying all round.

He said he thought it would be a graceful act if the General Secretary could be
induced to write a letter of congratulation to Dr. Watson Smith on the pluck in
carrying the management of the institution through during the war. Colonel
Dawson, of Dublin, had written to him (Dr. Percy Smith) saying he saw a note on
the matter in The Lancet, and, as he felt the hospital must be badly in need of
funds, he sent two guineas. If any other members should feel similarly, there
would be a grateful response.

The meeting duly authorised the sending of the letter.

The Report of the English Lunacy Legislation Sub-Committee, 1918.

The Chairman suggested that the document in question should be read to the
meeting. It was a lengthy document, but it had been impossible to circulate it as
a whole, owing to it being a question of urgency. The printed synopsis prac¬
tically embodied the essentials of the Report, but it was desirable that the meeting
should hear the full Report. After Dr. Steen had read it, he would ask Dr.
Wolseley Lewis, the Chairman of the Sub-Committee, to move its adoption.

Dr. Steen read the detailed Report (see p. 36).

Dr. "Wolseley Lewis: As Chairman of the Committee which was responsible
forthe Report you have just heard read, I rise to move its adoption. In the first
place you will notice that the Committee is a representative one; it is composed
of members who have had experience in public and in private asylums as well as
in consulting practice; it includes members of the Status Committee which drew
up the Report that received your approval in the year 1914. It also includes four
past Presidents of our Association. Since the beginning of the year we have held
monthly meetings, which have been very well attended, and in the intervals
between the meetings a good deal of work has been done by correspondence. I

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am very glad of this opportunity of expressing my indebtedness to various members
of the Committee for the large amount of work they have put in, and more
especially to our energetic Secretary, Dr. Cole, who, I know, has had a very hard
time over this Report.

From a review of the composition of the Committee you will realise that this
subject has been viewed from many different angles, and you may rest assured
that no paragraph has been allowed to stand in the Report without having received
its full meed of criticism.

From the complexity of the subject-, it strikes me, you may think the Report is
unduly short; in fact that we have perhaps produced a mole-hill rather than the
expected mountain. But I would remind you that in a report of this kind its merit
lies, perhaps, as much in what is left unsaid as in what has been said. The aim
has been to produce a workable scheme that may meet with general approval, and
though more Utopian schemes have, at times, held the attention of the Committee,
they have been rejected as being outside the scope of practical politics. 1 do not
propose to go—nor, probably, would you desire that I should go—into a detailed
analysis of the Report; it will be sufficient for me to say that our whole object
has been to offer, without any disabilities, as good facilities for the treatment of
early mental diseases as now exist for the treatment of bodily diseases, and to offer
those facilities without the assistance—I had almost said without the interference
—of the lawyer. It is for this reason, and because we felt that any form of
detention without full safeguards of certification would have no chance of receiving
the assent of Parliament, that we are convinced it is better not to seek any powers
of detention. For that reason we ask leave to amend the first resolution of the
Status Committee in that sense—that is to say, by placing the word " reception ”
in the stead of “detention.”

On October 29th we had a conference with the Board of Control; we spent a
very busy and very satisfactory morning with them, for our Report was very
sympathetically received by them. If we are unanimous in our adoption of this
Report we shall very materially strengthen the hands of the Board of Control in
securing legislation, because that body will then be in a position to say that expert
opinion, as represented by' this Association, advocated the course which this
Report lays down.

No doubt many of you—the majority perhaps—have seen the recommendations
in the last report of the Board of Control, and that their proposals and ours are in
general agreement. I understand their chief points are, firstly, that they should be
satisfied that the places where treatment is to take place are suitable ; and, secondly,
that there shall be no powers of detention.

After a very hurried luncheon on that day we went off to a conference at the
Guildhall. That conference was convened by the Bucks County Asylum, and was
largely attended by representatives of local authorities who were interested in the
matter. We found there a very strong body of public opinion in favour of reforms
similar to those which are laid down in this report. At that meeting I had an
opportunity of making a statement to the effect that our Report had been drafted
and would be submitted to this genera! meeting of the Association to-day. The
result, I am glad to say, was that the Committee, which was invited by that con¬
ference to draw up a report, have invited this Association to appoint three or more
members to assist them in that task. You will thus at once see that we have an
opportunity of influencing an important section of the public.

There can be very few of our members who are not aware, from their own
experience, of the immense amount of real hardship which results from this diffi¬
culty in obtaining treatment in early cases of mental disorder, as evidenced at the
conference and recently in the public Press. We find, too, that the public are
becoming alive to this fact. As the Board of Control put it in their last sentence,
in connection with the question of soldiers: ‘‘In order to meet the pronounced
opposition of the public to the certification of soldiers, certain institutions should
be set apart for their treatment without certification. The public prejudice against
the so-called ‘stigma of certification’ has, in no small degree, been the cause of,
and created the necessity for, this special arrangement. It is a prejudice which
has always existed, and has to be recognised and reckoned with in civilian life.
In the opinion of the Board, it has ever been a hindrance to the early treatment of
mental disease, with the result that in all asylums there are numbers of persons

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suffering from incurable insanity who, had they been the subjects of expert advice
and treatment when the premonitory symptoms manifested themselves, would not
improbably have recovered, and become useful members of the community.” In
my opinion, it is at once the duty and the privilege of this Association to take a
leading part in the reconstruction of the law on this subject, and I appeal to you
not only to approve this report, but to see that your views as represented by it
are circulated as widely as possible. In my opinion the times are ripe, and I
appeal to you to let the voice of this Association be heard in no uncertain way.

Dr. Cole : In rising to second the motion for the adoption of this Report, it is
not my wish to detain you very long, because it is probable that many speakers
will follow me.

I must say the Committee has worked extremely hard at this Report, and
although we did not all see eye to eye at the various meetings, we have now pro¬
duced a Report that we are unanimous in supporting. Some of us have had to
alter our preconceived opinions with regard to the principle of notification ; but
we feel it is expedient—at all events, for the present—to leave that, even if we
think well to ask for powers of temporary detention later on. To my mind, our
Report does not in any way put institutions for the insane on an inferior level.
We should all do our best to recognise that these are hospitals for mental diseases,
and that this matter of supposed stigma is one which must be continually fought
against. I do not like to think of asylums without blocks for acute cases ; I do
not like to think of their being deprived of acute cases to be treated. Neither do
I think there will be much difference with regard to the reception of such cases
in asylums in comparison with what obtains at the present day. But we should
like to see the laws amended so that a fair trial may be given to incipient cases of
insanity to recover outside an asylum without certification when prejudice is very
strong.

For many years there has been agitation for changes in the Lunacy Laws. In
1900 we had the Lord Chancellor’s Bill advocating voluntary boarders in asylums,
and seeking the provision of special treatment for incipient mental disease which
was framed largely on the lines of the Scotch Act. I will not say anything about
that section 13, because I think it is seldom made use of. The Bill contained many
other amendments and was dropped. In 1904-5 Sir Robert Finlay, who was then
the Attorney-General, brought forward another Bill, dealing with temporary care
in cases of incipient insanity. It also fell to the ground, though it was a Govern¬
ment measure, because Parliament was not sufficiently interested, and the medical
profession did not push its points sufficiently.

Since then the war has broken out, and soldiers and sailors are being treated for
mental disorder, and the public has been demanding that they shall not be
certified. We are all well aware that there is no necessity to certify them, because
the military law is in tvery way more stringent than is the law with regard to
lunacy.

An important point in our report, which is an addition to what we have advo¬
cated in the past, is the proposed establishment of clinics. The recommendation is
largely the outcome of the la!.ours of the Status Committee. For the work done
by that Committee our Sub-Committee feels very grateful. The proposition
means that we are asking that the local authorities should be compelled to provide
accommodation for incipient mental disease, just as they have to make accommo¬
dation for “pauper lunatics” as they are called now. This is to compel local
authorities to do so, not to give them the option, which might be evaded.

I would like to explain to you that the recommendations were circulated, but the
whole Report was not printed because, in the first place, it was going to receive
further amendment this morning, and secondly, because it had to receive the
approval of the Council before it could be printed. The printed recommendations
which you have, however, are really the gist of the Report, and the supplementary
opinions which deal with further amendments of the Act are not quite so pressing.
These, however, have been read out to you.

We hope very sincerely that you will adopt this Report. No member need feel
he is voting for something which has not received the fullest consideration. If
there are any points of a minor character which we can elucidate, we shall be glad
to try to do so if questions are put to us. It is most important we should get
something through forthwith. We have met the Board of Control; we attended the
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meeting at the Guildhall which you have already been told of ; there is reconstruction
going on everywhere, and we ought not to delay the matter longer. 1 therefore
strongly appeal to you to pass this Report and authorise it to be printed.

The Chairman : Does anyone desire to speak on any section or on the Report
as a whole ?

Dr. Bedford Pif.rce : Could we take the four sections separately?

The Chairman : Certainly. Do you accept the introductory portion ?

Agreed.

Clause 8.

The Chairman : We have not specified the Board of Control nor any other
department, because, in view of the possible introduction of a Ministry of
Health, these departments may be altered—at least in name.

Clause 7.

Lieut.-Col. Rows: I ask what we are to understand by the term “ local
authority ? ”

The Chairman : Just the same as boroughs and counties in the Lunacy Act.

Lieut.-Col. Rows: It is suggested they should be attached to Universities
and medical schools: would it not be better to have co-operation between the
University or the medical school staff, or their committees and any local authority ?

Dr. Wolseley Lewis: That was the intention. In cases where a voluntary
hospital takes these cases, it should take them for the local authority.

Dr. Cole : It was felt that the voluntary hospitals are already under some
control by the local authority ; for instance, we now have a Tuberculosis Depart¬
ment, a Venereal Diseases Department, and it has a voice in the management
to some extent. We think that in the case of an University town, the University
authorities will be represented on the Committee of Management, as well as the
local authority.

Lieut.-Col. Rows : I would like it to be so stated.

The Chairman : There is more in that Clause 7 than meets the eye. There
was a feeling on the part of certain members of the Committee that these clinics,
having been established, should not be managed by the same persons who manage
the asylums—the county and borough. That is the inner meaning of this clause.

I think Col. Rows’ point is rather raised under Clauses 2 and 6.

Dr. Wolseley Lewis : The idea is this : supposing the local authority were in
any way responsible for the payment for people in these places, then the local
authority would have to have representatives on the Committee; that is all.
Therefore it would be combined.

Lieut.-Col. Rows : But if the Universities decided to start a clinic before the local
authority came in ?

Dr. Wolseley Lewis : That would be a voluntary organisation.

Lieut.-Col. Rows: We understand that in Lancashire the Asylums’ Board feel
it is their duty, if the patients are treated in an University clinic, that they should
co-operate.

Lieut.-Col. M. A. Collins : Would it not be clearer if No. 7 were put more
fully—that the Committee of Management should not be the Asylum Committee,
but should be a special County Committee ?

The Chairman : That is an indirect censure on the Committees. We say the
same thing more politely.

Dr. Bedford Pierce : We do not know what will be the authority, and we
leave out the words “ local authority.” We say the Committee of Management
of the clinic should be a separate Committee appointed for the purpose.

Dr. Cole : That would be so.

Dr. Wolseley Lewis : Yes.

Lieut.-Col. Rows : That meets my point.

The Chairman : The clause sounds redundant, because, naturally, any public
place is managed by a committee ad hoc.

Lieut.-Col. Rows : Yes.

The Chairman : Yet it will not be considered redundant when you know what
the Committee had at the back of their minds : that if the same body of men who
now manage the asylums were to manage these, they would at once be associated
in the public mind with asylum administration.

Dr. Dixon : Do I understand the meaning of the last amendment is, that the

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local authorities who are asked to establish these clinics are, later on, to have no
say in the management of them ?

The Chairman : No.

Dr. Langdon-Down : Before we leave the clinics section, I would like to say it
seems to me proposals to establish clinics of this kind offer a convenient oppor¬
tunity for dealing with a class of case for which there is no proper provision, and
which we might definitely recognise in our representations. I refer to cases of
children who are subject to mental defects or disorders. I think it desirable we
should say that in the establishment of clinics the organisation should provide a
separate department for children. That would form a central clearing department
for consultation on cases occurring in the work of school doctors and others, also
it might develop into a psychological clinic where all children who become
chargeable before a court are first seen for examination. So 1 suggest we should
add a clause to the effect that it it is desirable, in organising clinics, that a separate
department for children should be included.

The Chairman : We must ask you to draft a clause and hand it up, as an
addition to or amendment of a certain clause.

Dr. Steen: It is moved by Dr. Langdon-Down—"That in the organisation of
clinics provision be made for a special department for children.”

Dr. Langdon-Down : As a separate clause.

Dr. Wolseley Lewis: Will Dr. Langdon-Down accept, instead of " a special
department,” “ special provision should be made for children”? Some of these
clinics may not be very big.

Dr. Langdon-Down : Yes, I agree.

Dr. Percy Smith : Would it not be better to have it under No. 2 ? It is better
as a continuation of that sentence.

Dr. Bower: Is it necessary to say anything about children at all ?

The Chairman : It appeals to sentiment. This is not a question of framing a
Bill now : we are not committed to these actual words.

It was agreed that in recommendation 2 the words “ and that in the organisation
of clinics special provision be made for children ” be added.

Clause 9.

The Chairman : Is the word " encourage ” necessary ?

Dr. Cole : That word was specially used after some discussion.

Dr. Wolseley Lewis: We did not want to use too strong a word. "En¬
couraged ” was put in at the urgent request of Sir Robert Armstrong-Jones,
because, he said, it is not a question of giving them power to do it; we want to
ask them to do it, not compel them.

The Chairman : It leaves it open for any institution for the insane—public,
private, or registered—to have nothing to do with boarders.

Dr. Percy Smith : This is giving paternal advice; otherwise, legally, it should
be that they should be permitted.

Dr. Wolseley Lewis : " Permitted ” was our word before.

The Chairman : I take it that Nos. 9 and 10 meet with approval.

Agreed.

The Chairman: Now " Further provision for private patients,” Nos. 11 and 12.
Do any licensees of private asylums consider their interests are affected by these
clauses ?

Dr. Sergeant called attention to the great dangers involved in giving legal
sanction to the reception of single uncertified patients in ordinary houses which
had not been specially approved merely on the authority of a medical certificate
from a medical practitioner.

The Chairman : This is certainly a very important point. I have heard
expressions in my district similar to those just uttered, and it is only fair to
licensed houses that this subject should be gone into at this open meeting.
Before I ask Dr. Wolseley Lewis to reply, is there any other member who wishes
to criticise this No. 1 1, or No. 12 ?

Dr. Percy Smith : I ask what this means : that "The Board of Control should
have power (a) to approve homes which are supported wholly or partly by volun¬
tary contributions,” etc., and then ( b ) “ to give legal sanction to the reception
without certification of such patients as single patients in houses not so approved ” ?
I gathered from the Chairman of the Committee that there is to be no notification

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of the case to the Board of Control, therefore how are they to start to give legal
sanction to the reception of such a patient ?

The Chairman : It is a very important part of the Committee’s Report.

Dr. Soutar : I agree this is a very important point, and I think it was carefully
considered by the Committee. It was specially brought up, and it was determined
that no privilege must be given to single houses or to approved houses which was
not given to existing institutions for the insane. One purpose which was before the
Committee was that patients and their friends should have free choice with
regard to the treatment of the patient, and that whatever advantage may be given
to approved houses should be extended to licensed houses, asylums, and hospitals
for the insane. In that way all are put under the same advantages and disadvan¬
tages. The great advantage which, I think, will accrue is that in future, instead
of cases being sent into private houses, no authority knowing anything about
them, they must be reported to the Board on admission and on discharge.
The Board of Control will have it in their power to make an investigation, and
take such action as may be necessary. At present many of those patients are
treated surreptitiously; nobody knows anything about them, and it is only by
accidental discovery of something amiss that a prosecution is instituted. If, in
the future, an endeavour is made to deal with these cases surreptitiously, the
person doing so will be in a worse position than he is to-day. Through the
proposals now made the interests of the existing institutions are carefully safe¬
guarded, and great advantage will accrue to patients generally, in that they will
not be treated in unsuitable places.

Dr. Norman : I would like to raise the point whether it would not be better to
see to that beforehand, whether you should not have a system whereby anybody
wishing to take patients should have their houses examined, as is general with
licensed houses at the present time. Under the present system the thing might
take place; the house might be carried on for some time unless the Board of
Control is greatly extended. Another suggestion would be that they should
appoint people in particular districts whose function it should be to supervise and
inspect such houses in which it was proposed that mental patients should be
taken.

Dr. Percy Smith : In any legislation the Board of Control will take powers to
see licensed houses before they approve of them.

Dr. Dixon: It says a medical practitioner appointed for the purpose or approved
by the Board of Control. But an ordinary general practitioner might not be in a
position to judge.

Dr. Bowf.r : That only gives the Board of Control power to approve and power
to give legal sanction; it does not say that, because the medical practitioner
gives a certificate, the Board of Control will give legal sanction. I think there is
sufficient power. I raised this question at the meeting of the Parliamentary
Committee and at the Council meeting this morning, and the explanation pointed
out to me seems clear enough.

Dr. Norman : Is no suggestion coming from the Association as to what is
meant by the early stages of mental disorder ? Is it a week, or two or three
months, or what ?

Dr. Wolseley Lewis : There is no time.

Dr. Sergeant: May not a case be an “ eaily case” for years?

Dr. Wolseley Lewis : All I have to say is, "that the intention of that clause was
to strengthen the hands of the Board of Control in doing away with all these
people who complained and who were unrecognised people and often gave unsuit¬
able treatment. And it was thought, if that clause were put in, they would be
much better able to prosecute under section 315 than they are now, and which
they are anxious to do. And it would take away the temptation to act against
section 315, because they would say, ” Here is a suitable place which the Board of
Control know of—I will send my patient there; there is no disability.” All it
means is that where a patient goes to has to be intimated, and the name of the
patient is not given. With regard to the question of the medical practitioner,
meaning any ordinary medical practitioner, that was the Board’s own idea, and I
thought it was rather a compliment to the medical profession. What Sir William
Byrne said to me was, “ Surely a doctor is a very responsible person, and we should
accept his word." If he writes that such and such a person as a patient is suitably

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treated that is enough for us, and if we doubt him we could refuse to accept his
word again.

Dr. Fothergill : It is to the advantage of the patient that he should be received
in this way, because it gives him great opportunities of getting well and without any
stigma, and the man who keeps the home would say, “ I shall be glad to have my
home known as an approved house." He would also say, "Any doubtful case I
shall now feel safe about.” At present certain cases are sent to him, and he has
to pass them on to some institution, whereas if they had only been able to remain
a little time longer in what would now be an approved home they could be cured
without having to go to an asylum. I do not understand the second part of
clause ( b ). I ask whether this refers to sending patients to the houses of non¬
medical men. Does it mean a patient can be sent to Mrs. B—’s house who is not
a doctor ?

The Chairman : Yes.

Dr. Cole : With regard to clauses (a) and (6), you can send a certified patient
to any house, a layman's or doctor’s. There are many houses suitable for
patients, but some which are unsuitable. It is too much to ask that every
house shall be approved ; you cannot ask that a house for a single patient
shall be approved, but the house of the kind Dr. Fothergill mentioned, for half a
dozen patients, should be approved. If there is a house with only one patient it
need not be approved, but it must be intimated to the Board of Control. The
suggestion is on the lines of approved homes under the Mental Deficiency Act,
and it would be better to call them “ recognised homes ’’ instead of " approved
homes ” by way of distinction.

Dr. Sergeant: I understand that the words " in its early stages ” in regard to
mental disease do not mean anything, because, as I have already said, I under¬
stand the “early stage" may go on for years. And if those words do not mean
anything why are they introduced ? It is undesirable to make use of words which
have no meaning. I think we should attach a meaning to them—make them mean
what they appear to mean—that is, early as opposed to prolonged and chronic. I
think the Board of Control have suggested six months in this connection.

Dr. Fothergill : There are some people who are eccentric all their lives but
yet are never insane, so they may remain during all their lives in the early stage
of mental disease without deserving to be certified. A time-limit does not come
into it at all, and I agree with the present wording.

Sir Robert Armstrong-Jo.nes : I wish to apologise, Mr. Chairman, for my
late arrival. The idea in the minds of the Committee was that this should be left
indefinite in our report to the Council, but that in a Bill a definite period should
be stated. The feeling was that nine months—the period held to apply to the case
of the soldier—should be held as that to which the word " early ” would apply.

The Chairman : Yes. As 1 say, this is not a Bill.

Supplementary.

The Chairman: Are there any criticisms on the supplementary part ? If not,
I put it that the Report, as a whole, be approved.

Dr. Langdon-Down : There is another point to which in times past criticism
has been directed, which might be corrected now. The form of certification
requires that the examination shall be made by one doctor separately from that
of any other medical practitioner. I notice it has been thought that it is a slur
on the medical profession, and that it is a handicap to people who desire to certify
cases where evidence of insanity is difficult to obtain. It is thought there would
be collusion between doctors in obtaining evidence on which they base their
certificates. If we could get those words deleted in any further forms I think it
would be to the credit of the medical profession.

Dr. Percy Smith : If that means that the examination of the patient separately
from that of any other medical practitioner should be eliminated, I think it would
be a great mistake to make the suggested alteration. The whole object is to safe¬
guard the individual, and for this there should be separate examinations. It is so
easy for two people talking together to get the same facts and put them down, and
to get the same impression of a case. The examination by two medical men
together is not sufficient protection to the patient. Whenever I go to a consulta¬
tion and the doctor says, “ I think this patient ought to be certified,” I say, “ One
must have a separate interview at once.” If you begin to talk together and arrange

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a separate interview afterwards, it is a difficult matter to forma separate jndgment.
I am sure the general public would look with suspicion on the removal of those
words.

Dr. Soutar: I agree with Dr. Percy Smith. There is no reflection in it; there
is no reason why the two doctors should not consult, but what they have to say is
what they found at the moment by separate examination. There is no interference
with the holding of a consultation at all.

The Chairman; I suppose you do not wish to press the point to a division,
Dr. Langdon-Down ?

Dr. Langdon-Down: No.

The Chairman : I put the Report as a whole. 1 put it with the one or two
amendments which have been passed.

Carried.

Dr. Soutar: Before we pass to another matter I would just like to say this
Report has required a tremendous amount of skill, care, and balanced consideration,
and it has received that from our Chairman, Dr. Wolseley Lewis, and from Dr.
Cole. The amount of work they have done in order to bring the Report to what
you see you may realise, because there were several points which arose upon which
great divergence of opinion must have existed and did exist. But they have suc¬
ceeded by the splendid way in which they have carried out their work in producing
an unanimous Report, and I think these gentlemen deserve the thanks of the Asso¬
ciation for what they have done.

The resolution was carried by acclamation.

Dr. Wolseley Lewis : I am very much obliged to you, gentlemen, for this vote
of thanks. What I am really pleased with is that you have been unanimous in
adopting this Report, because it strengthens the position very much.

Paper.

Dr. David Orr and Lieut.-Col. Rows, R.A.M.C.: ‘'The Interdependence of the
Sympathetic and Central Nervous Systems” (illustrated by slides).

(This paper, with the discussion on it, will, we hope, appear in the April issue
of the Journal.— Eds.

The Chairman said it only remained for him to thank, in the members’ name,
Dr. Orr and Col. Rows for their very interesting and suggestive paper. It was
hoped that the subject would be brought forward on a future occasion, when,
perhaps, the results of further investigations could be brought to light.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held, by
the kind invitation of Col. Rows, at the Military Hospital, Maghuil, near Liverpool,
on Thursday, October 24th, 1918.

Lieut.-Col. R. G. Rows presided.

The following eighteen members were present: Drs. R. Eager, Major, R.A.M.C.;
T. Benson Evans; E. S. Hayes Gill; Stanley A. Gill; G. Hamilton Grills;
E. G. Grove; Bernard Hart; D. Hunter; R. McD. Ladell; W. F. Menzies;

G. E. Mould; P. G. Mould; R. G. Rows, Lieut.-Col., R.A.M.C.; C. T. Street,
Major; J. B. Tighd, Lieut.-Col., R.A.M.C.; E. W. White, Lieut.-Col., R.A.M.C.;

H. Yellowlees; T. S. Adair; and twenty-nine visitors.

The Minutes of the last meeting were read and confirmed.

Reference was made to the illness of the President, Lieut.-Col. Keay, and it
was proposed by Col. White, and seconded by Major Eager, that a message of
sympathy be sent to him.

Dr. R. S. Macphail, Dr. Bedford Pierce and Major C. T. Street were
unanimously elected to form the Divisional Committee for the ensuing year.

Several short communications were then given on the work and scope of
the Hospital, with an account of the types of war neuroses as seen there.
Lieut.-Col. Rows gave a general outline of the conditions, and was followed by

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Major Hart, Capt. Bryce and Capt. Stewart, each of whom took up some special
point and discussed it. Many new and interesting points, theoretical and other¬
wise, were touched upon.

A pleasant visit was made round the wards and buildings of the Hospital in
the morning.

A hearty vote of thanks was accorded Col. Rows for his kind and generous
hospitality.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division of the Medico-Psycho¬
logical Association was held at n.Chandos Street, London, W. i, on Wednesday,
October 9th, 1918.

Present: Drs. Archdale, Bower, Chambers, Earls, Edwards, Haynes, Hughes,
Norman, Shuttleworth, Stewart, and Sergeant (Hon. Div. Sec.). Dr. Shuttleworth
in the Chair.

The Minutes of the last meeting were taken as read and confirmed.

The Members standing passed a vote of condolence to Mrs. Griffith, and in¬
structed the Secretary to write expressing the sorrow of the South-Eastern
Division.

Dr. Brend was unanimously elected a Member of the Association.

It was decided to leave the date and place of the Spring Meeting, 1919, to the
discretion of the Secretary.

Dr. Shuttleworth informed the meeting as to recent legislation in connection
with the amendment of the Asylum Workers' Superannuation Act, and the meeting
then closed.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the above Division was held at 17, Belmont, Bath,
by the kind permission of Dr. MacBryan, on Friday, October 25th, 1918, at
2.30 p.m.

The following members were present: Drs. Aveline, MacBryan, Mary Martin,
Mules, Nelis, King Turner, and Bartlett (Hon. Div. Secretary). Dr. C. E. S.
Flemming was welcomed as a visitor.

Dr. Nelis was voted to the Chair.

Letters of regret for non-attendance from Drs. Macdonald and Devine were
read.

The minutes of the last meeting were read and confirmed.

Dr. Bartlett was nominated as Hon. Div. Secretary.

Drs. Aveline and MacBryan were nominated as representative members of
Council.

The place of the Spring Meeting was provisionally fixed as Fisherton House,
Dr. King Turner having kindly extended an invitation

An interesting discussion on the Cardiff leaflet followed, and the meeting
expressed agreement with the reforms suggested therein, and viewed with favour
the concerted effort to advance the treatment of mental disorders. The following
recommendations were approved: (1) The establishment of clinics attached to
general hospital, mental hospitals, and special institutions by local authorities for
the treatment of early cases ; (2) the approval of homes for borderland cases
without certificate, to apply also to special institutions; (3) the extension of a
system of voluntary boarders ; (4) the more extensive employment of the services
of the medical officers attached to mental hospitals in consultative work with
medical practitioners ; (5) the granting of power to medical practitioners to send
cases for treatment and observation to approved institutions pending certificate.

Dr. C. E. S. Flemming expressed the difficulties experienced by general prac-

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titioners in dealing with early and doubtful cases of mental disease under the
following headings: (i) The stigma of certification; (2) the lack of approved
homes for observation and treatment without certification; (3) the lack of facilities
for obtaining expert advice ; (4) the lack of facilities for general practitioners to
gain expert knowledge.

SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Royal College of Physicians, Queen Street, Edinburgh, on Friday,
November 15th, 191S.

Present: Major Buchanan, Capt. Yellowlees, Lieut. Gostwyck, R.A.M.C,
Drs. Carswell, Crichlow, Easterbrook, Carlyle Johnstone, Kerr, T. C. Mackenzie,
Tuach Mackenzie, Orr, Ford Robertson, and Surgeon-Commander R. B. Campbell,
R.N, Divisional Secretary, Dr. T. Murray Lyon being present as guest.

Dr. Carlyle Johnstone occupied the chair.

Before taking up the ordinary business of the meeting the Chairman referred
in appropriate terms to the loss which the Association had sustained since last
meeting by the death of Dr. William Reid, Medical Superintendent, Aberdeen
Royal Asylum. He stated that Dr. Reid was one of the oldest members of the
Scottish Division, and that he had had a long association with asylum administra¬
tion, having acted as Medical Superintendent of Aberdeen Royal Asylum for
thirty-three years. The Chairman also referred to Dr. Reid’s fine personal
qualities. It was unanimously resolved that it be recorded in the minutes that the
members of the Scottish Division of the Medico-Psychological Association desire
to express their deep sense of the loss sustained by the death of Dr. Reid, and
their sympathy with his relatives in their bereavement, and the Secretary was
instructed to transmit an excerpt of the minutes to Mrs. Reid.

The minutes of the last Divisional meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary intimated an apology from Lieut.-Col. Keay, President of the
Association, who was unable to be present on account of illness. It was the
unanimous wish of the Division that the Secretary should convey to the President
an expression of regret on learning of the reason for his absence and best wishes
for a speedy and complete recovery.

Apologies were also intimated from Drs. David Yellowlees, Oswald, Hotchkis,
Skeen, Carre, McRae, Steele and Sutherland.

The Business Committee was appointed, consisting of the nominated member
of Council, the two representative members of Council, Drs. Carlyle Johnstone,
Maxwell Ross, and the Divisional Secretary..

Drs. J. H. •Skeen and T. C. Mackenzie were nominated by the Division for the
position of Representative Members of Council, and Dr. R. B. Campbell was
nominated for the position of Divisional Secretary.

The following candidate after ballot was admitted to membership of the Associa¬
tion : Madeline Archibald, L.R.C.P. & L.R.C.S., Assistant Medical Officer, Argyll
and Bute District Asylum, Lochgilphead. Proposed by Drs. Kerr, Dunlop
Robertson, and R. B. Campbell.

Dr. G. M. Robertson's paper on “ The Freudian Interpretation of some Clinical
Symptoms ” was in his absence read by Dr. Carlyle Johnstone. A short discus¬
sion followed, in which several members took part.

The Secretary reported that the Sub-committee appointed by the Division to
consider amendments to the existing lunacy laws had met that afternoon and
considered the report of the English Lunacy Legislation Sub-committee, whose
recommendations had already been circulated to the Members of the Association,
and the Sub-committee expressed general approval of the recommendations con¬
tained in the report. After some little discussion the Secretary was instructed to
inform the Secretary of the Parliamentary Committee of the Association that the
Division approved of the recommendations contained in the Report of the English
Lunacy Legislation Sub-committee.

A vote of thanks to the Chairman for presiding concluded the business of the
meeting.

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OBITUARY.

John B. Chapin, M.D.

In the fulness of years, in quiet retirement after more than a half century's
active professional toil, amid scenes endeared to him by early years of association
and work, surrounded by his children, having the admiration and love of the
members of his profession, and the affectionate gratitude of unnumbered persons
to whom or to whose friends he had been physician, guide, counsellor and friend,
Dr. Chapin died at his home in Canandaigua, N.Y., on January 17th, 1918.

" Life’s work well done,

Life’s race well run,

Then comes rest.”

These words form the opening passage in an appreciative and sympathetic
obituary notice of the late Dr. Chapin in the American Journal of Insanity lor
April last from the pen of Dr. Brush. It occupies some seventeen pages of the
journal, and we regret that the space at our disposal will only admit of an abstract
being given of what is really an interesting memoir of a member of our specialty
on the other side of the Atlantic, who was a man of exceptional talent and admini¬
strative ability, of unflagging industry, lofty aims, and sterling character; a man
who was held in affectionate regard by a large circle of friends, both professional
and lay, who felt his death as nothing less than a genuine personal bereavement.
The notice is not merely a memoir of the man, but it also embodies a sketch, brief
no doubt but illuminative, of the progress of enlightened ideas and action in
America as regards the care and treatment of the insane over a period of more
than half a century.

On his father’s side Dr. Chapin was of Puritan ancestry, being in the eighth
generation from Samuel Chapin, who was born in Paignton, Devonshire, in 1598.
This Samuel Chapin was one of the founders of Springfield, Massachusetts, and is
commemorated by St. Gauden's beautiful statue in that city. His father was
William Chapin, a man of artistic tastes and literary ability, and with a practical
knowledge of the art of steel engraving. He early became interested in the educa¬
tion of the blind, and made this his life-work. He was for some time Superintendent
of the Institution for the Blind at Columbus, Ohio, and subsequently Principal of
the Pennsylvania Institution for the Instruction of the Blind in Philadelphia. His
mother was Elizabeth H. Bassett, daughter of the Rev. John Bassett, D.D., a
graduate of Columbia College, and the recipient of honorary degrees from several
other colleges, minister of the Reformed Churches at Albany, at Bushwick, and at
Kingston, all in New York State, and was partly of French, partly of Dutch origin.

The educational opportunities at Columbus not being satisfactory young Chapin
was sent to Philadelphia, and entered the North-west Grammar School there. He
took the A.B. degree in Williams College, Philadelphia, in 1850, and the same
year, having decided to enter the medical profession, in accordance with the
custom of the time he entered the office of Dr. John A. Swett, one of the physicians
to the New York Hospital, as a student of medicine. Soon afterwards he obtained
a substitute interneship in the hospital, and in 1852, after examination, an appoint¬
ment on the house staff. During this period he had attended medical lectures at
the Jefferson Medical College in Philadelphia, from which he received the degree
of M.D. in 1853. In 1854 he was made House-Physician in the New York
Hospital, where he had a period of very active service, cholera and typhus fever
being epidemic at that time, and yellow fever more or less prevalent. In April,
1852, while an interne at the hospital, he attended the seventh annual meeting of
the Association of Medical Superintendents of American Institutions for the Insane,
now the American Medico-Psychological Association.

Having no predilection for private practice, when he had completed his service
in the hospital, Dr. Chapin had the intention of entering the medical service of the
United States Army. Just about this time Dr. John P. Gray, Medical Superin¬
tendent of the New York State Lunatic Asylum, now the State Asylum at Utica,
offered him an appointment as Assistant Physician at that institution. This being
in accordance with his inclinations, he accepted, and in September, 1854, entered

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upon the duties of the position. He had no previous training in psychiatry, but
his training in general medicine enabled him to meet and surmount any difficulties
resulting therefrom. The American Journal of Insanity was edited and published
in this asylum, being printed by the patients under competent supervision, and in
its editorial conduct in connection with the medical superintendent Dr. Chapin
found congenial occupation.

The condition of the insane in the county almshouses was about this time
occupying the attention of superintendents of the poor, and Dr. Chapin by request
took up the work of procuring data and drawing up a report on the subject, which
appeared as Senate Document No. 17, January, 1856, N.Y. State Legislature.
Thus began his work for the better care of the chronic insane of New York, and
the removal of all insane persons from the county almshouses, which culminated
in the establishment of the Willard Asylum, now the Willard State Hospital, with
which his name will be for ever inseparably connected. The result of his investi¬
gations was that a Bill was introduced in the Senate in 1857 creating two additional
asylums for the insane, and an asylum for the reception of insane convicts and
criminals. The first provision failed owing to selfish contentions as to the loca¬
tion of the asylums, but a measure was passed creating an asylum for insane convicts
at the State prison at Auburn.

In 1857 he resigned his position at Utica, and had an idea of starting practice in
either Philadelphia or New York. When returning to Philadelphia he called on
Dr. George Cook at Canandaigua, who proposed that he should join him in the
conduct of Brigham Hall, a small private hospital for mental disorders which Dr.
Cook had established at Canandaigua in 1856. The addition of a new wing was
agreed upon, to be completed in i860, and meantime Dr. Chapin was engaged in
organising a new institution for the blind in St. Louis at his father’s suggestion.
This was, of course, only a temporary position, and in i860 he resumed his pro¬
fessional work amongst the insane along with Dr. Cook at Canandaigua. His
work and associates there were most congenial, and his mind turned there as to a
pleasant haven of rest when he retired from hospital work in 1911.

After the failure in 1854 to effect any improvement in the condition of the insane
in almshouses, nothing was done in this direction until in 1864 the State Medical
Society inaugurated a movement on their behalf, into which Dr. Chapin heartily
entered. A committee consisting of Dr. Charles A. Lee, Dr. S. D. Willard, and
Dr. George Cook, in conjunction with members of the Legislature, formulated a
Bill, which became law in April, 1864, directing the county judges to appoint a
physician in each county to visit the almshouse and report upon its condition and
that of the insane contained therein. The reports were made to Dr. Willard,
Secretary of the State Society, and in April, 1865, a Bill was passed creating the
new asylum, which was named the Willard Asylum in memory of Dr. Willard, who
died just before its final passage. Its title was “An Act to Authorise the Esta¬
blishment of a State Asylum for the Chronic Insane Poor.” Sections of the law
stating its purpose to remove the chronic insane from the almshouses to the new
asylum, and making it mandatory to transfer and in future commit acute cases
to the asylum at Utica, were mainly Dr. Chapin’s own composition. He with two
others were appointed Commissioners by Governor Fenton to locate and build
the new asylum. This was designed on the villa system, the buildings being
arranged in detached groups located convenient to the gardens and farm-barns,
where the patients would be near the work in which they might be engaged. This
was a radical departure from existing methods, and met with the usual adverse
criticism. The plans also provided for an administration building with a main
hospital group attached. For these Dr. Chapin was wholly responsible, and under
his direction the buildings were located and completed, and for the first time in
this country an institution was established with a thoroughly elastic plan, with a
segregation rather than an aggregation of buildings, and with the distinct purpose
in view of facilitating the occupation of patients upon the farm, and in other ways
to aid in their own support. This was really the beginning of State care in New
York. The principle of State care was engrafted in the Willard Act. It was
intended to take and thereafter keep from county almshouses the insane poor.

The first Board of Trustees appointed underthe Act elected Dr. Chapin medical
superintendent of the new asylum—a position he had not sought or desired; nor
did he accept it until after three months' consideration, when he did so on the

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condition that the service was to continue during the period of organisation only,
and not longer than three years. This, however, he did not adhere to, and remained
in charge until 1884, when he was called to succeed Dr. Kirkbride at the Depart¬
ment for the Insane of the Pennsylvania Hospital, Philadelphia. The invitation
was twice declined; the roots had struck deep in Willard—there was a disinclina¬
tion to abandon a work to which for many and obvious reasons he was deeply
attached—but finally he became convinced that it was his duty to accept, and in
September, 1884, he entered upon a service in Philadelphia which continued for
twenty-seven years. He had at that time reached the age of fifty-five, was still
active, and by no means lacking in enthusiasm and initiative.

Shortly after going to Philadelphia a fire occurred in the insane department of
Blockley, the city almshouse and hospital. Several insane patients lost their lives,
and much property damage was incurred. Blockley Asylum had long been con¬
demned as a place for detention for the insane, and after the fire Dr. Chapin and
Dr. Brush were asked to confer with the Board of Guardians of the Poor as to the
best course to follow. At that conference Dr. Chapin outlined a plan which, if
followed, would have given Philadelphia the honour of establishing the first
psychiatric clinic in the United States. He pointed out to the Board the real
situation, showing them that Blockley was badly overcrowded, that there were no
adequate means of exercise in the open air, no provision for occupation, no proper
nursing, and not sufficient medical care and supervision. He called attention to
the very large annual admission-rate, small recovery-rate, and a large death-rate.
He then dwelt on the need of training in psychiatry for young men, which then in
this country in medical schools was wholly lacking, and the excellent opportunities
at Blockley for the medical schools of the city. He said:

“ Establish here a small hospital of from too to 200 beds, to which all cases
coming under city care shall be sent at once. Concentrate here the medical work,
to be done by a large, resident staff under a competent chief. Establish laboratories
and all the requisites of a good hospital, and use the material for clinical instruc¬
tion. A certain proportion of the cases admitted will need but a few weeks' care
here, many others longer care, and many permanent care. Establish therefore in
the country a colony farm, with its -hospital, medical, and nursing staff, and its
groups for permanent cases, who should be employed on the farm and in shops,
and contribute to their own support.”

We have given here but a hasty outline of a lengthy conference, but it can be
seen what an excellent scheme was laid before the Board, only, alas, to be rejected
as too expensive! The burned wards were rebuilt, and the old routine went on,
to the everlasting disgrace of the city of “ Brotherly Love.”

Dr. Chapin received the honorary degree of LL.D. from Jefferson College, Penn¬
sylvania, and from his alma mater, Williams College. He was a Fellow of the
College of Physicians of Philadelphia, and an honorary member of the Medico-
Psychological Association of Great Britain and Ireland and the Soci£t <5 de M6de-
cine Mentale de Belgique.

On December 1st, 1904, he was given a complimentary dinner at the Bellevue-
Stratford Hotel in Philadelphia, which was very largely attended, and which
marked the completion of fifty years’ work in hospitals for the insane. On this
occasion he was presented with a life-size portrait of himself. He had at this
time exceeded the Psalmist’s limit of three score years and ten, and had more than
once brought before the managers of the hospital the question of laying down his
office ; but it was the desire of the Board that he should continue at his post, and
so for seven years longer he remained at the hospital in West Philadelphia, resign¬
ing and moving to a home which he had prepared in Canandaigua in the summer
of 1911. His last attendance at a meeting of the Association was in 1913 at
Niagara Falls, when he showed but little of the physical weakness of age and no
perceptible diminution of his mental vigour. [In this feature of the maintenance of
freshness and power of intellect a not unworthy comparison may be drawn between
him and our own countryman, the late Dr Henry Maudsley, who died within a week
after Dr. Chapin's decease.— Eds. J.M.S.]

In 1858 he had married Miss Harriet E. Preston,and in her death in the summer
of 1916 he met the greatest grief of his life, after more than fifty-eight years of the
most intimate and loving association. After her departure he seemed more or less
dazed. He could not adjust himself to the changed conditions—he had lost not

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only his occupation in looking after her every wish, but he had lost his bearings in
a measure.

His home life was made as cheerful as possible by the continued presence in
turn of one of his three daughters. He went about the streets of the beautiful old
town when the weather permitted. A day or two before his death he went down
town with his daughter, and shortly after returning home complained of feeling ill.
When a physician was sent for he said it was unnecessary, as he knew what was
the matter—it was the breaking down at the end, and so it proved to be. He
retained his old jocular manner almost to the close. His medical adviser called
in a consultant, and together they gave their patient a thorough physical examina¬
tion. As they went from the sick room to confer he remarked, “They’ll go down
stairs and give my disorder a name, but that will not change the result.” The end
came rapidly, with fortunately little suffering, and on the afternoon of Thursday,
January 17th, 1918, in his eighty-ninth year, “ in the comfort of a reasonable
religious and holy hope," he fell asleep.

Dr. Chapin’s great force arose from his self-control and his careful preparation
for the work before him, which led him to study every problem presented with a
feeling, as he expressed it, that the knowledge obtained would become available
“ somewhere, at some time.” He was a man of most straightforward character,
with no suspicion of indirectness in his methods. Of deep religious convictions,
he carried his religion into his daily life, and made it a religion of service to God
and his fellow men. In this he exemplified Whittier's dictum, “ He who blesses
most is blest.”

As a great administrator, as a far-seeing philanthropist who accomplished more
for his fellow men than can now be estimated, as a conscientious and well-trained
physician, he has set his mark upon the history of his country and his profession.

“ Servant of God, well done; well hast thou fought
The better fight.”

Alfred Hume Griffith, M.D.Edin., D.P.H.Camb.

Superintendent and Medical Officer of Lingfield Colony for Epileptics, Surrey.

Although Dr. Alfred Hume Griffith was but a comparatively recent member of
our Association, his many activities and his manifest zeal for the welfare of others
demand that his premature death—which occurred on September 24th, and by
which the medical profession has lost a member of the type it can most ill spare—
should receive something more than its record in our obituary list. The second
son of the late Reverend Edward Moule Griffith (B. A.Cantab.), he was born in
Worcestershire in 1875, and received his preliminary education at Persse School,
Cambridge, and at Totnes and Bedford Grammar Schools. The spirit of altruism
and of the missionary—in the best sense of that word—strongly characterised even
the earlier years of his manhood, and it was in order to fit himself in what seemed
to him the best possible manner to be of service to others, and not at all from its
lucrative possibilities, that he decided to enter the medical profession. With this -
intent he matriculated at Edinburgh in 1893, and graduated in Medicine in 1899.
In the following year he married Mary, daughter of George Welchman, of Cul-
lompton, and immediately thereafter they went out to Persia in order that he
might take temporary charge of the medical mission work at Ispahan. In 1901 he
was appointed to undertake pioneer work in Kerman, and it was there—during a
year of strenuous work, reluctantly relinquished on account of his wife's ill-health
—that by his personal influence and by the magnetic force of his character, fortified
with his medical training, he was so successful in breaking down much opposition
and hostile fanaticism—dangers which, in similar circumstances, have all too often
cost the lives of those determined to face them. During part of 1902 and of the
following year he assumed charge of the medical mission work at Gaza, and finally
left Persia in 1903. After a short furlough, largely spent in study at Edinburgh
and during which time he took his M.D. degree, Griffith offered himself for work
in Palestine; he was appointed to the C.M.S. hospital at Nablus, and while pro-

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ceeding thither he obtained at Constantinople the Turkish certificate, enabling him
to practise medicine throughout the Turkish empire. In 1904, after a year’s resi¬
dence at Nablus, he moved to Mosul in Mesopotamia, where for four years he
lived a life of noble self-sacrifice and devotion to the needs of those about him.
He founded a hospital, where, in the absence of the aid of any European doctor or
nurse, and assisted only by native men whom he himself had trained, he performed
an extensive amount of surgical work, including many major .'operations and
numerous operations for cataract and lithotomies. His collection of calculi is in
the museum at Cambridge. But his unfailing obedience to the ceaseless calls
on his time and strength proved too great a strain on his health, and, to his’deep
disappointment, he had to submit in 1908 to being invalided home.

It was in October, 1910, after a period of further study, during which he obtained
the Cambridge D.P.H., that Griffith was appointed Superintendent andiMedical
Officer of Lingfield Colony for Epileptics one of the several homes established by
the National Union for Christian Social Service, and an institution the deservedly
high reputation of which he has done so much to enhance. If his impaired health
compelled him to confine his energies within a comparatively restricted sphere, he
none the less threw them heartily into his new work, and he was able to bring to it
a rare union of qualities best suited for the successful handling and treatment in
colony life of a malady and temperament admittedly presenting peculiar difficulties.
Himself of athletic instincts—he was an Edinburgh "blue” in football, and when
abroad never so happy as in the saddle—he saw to it that his patients as far as
possible lived an open-air life, abundantly supplied with occupation, recreation
and hobbies. Nevertheless, he was an omnivorous reader, and kept himself well
abreast with the results of medical research, especially those which he could use
to his patients’ advantage. His own powers of observation and research are dis¬
played in the contributions he made to medical and other literature, among which
mention may be made of " Hereditary Factors in Epilepsy" (Review of Neurology
and Psychiatry, 19x1), “Cerebellar Abscess” ( Scottish Medical and Surgical
Journal, 1904), “ Lingfield Epileptic Colony” (The Child, 1911), " Mental Tests
in Defective Children ” (The Child, 1916), "The Epileptic” (a chapter in Kely-
nack’s Human Derelicts), and some chapters on medical missions in his wife’s
book, Behind the Veil in Persia and Turkish Arabia.

On intimation being made that the Ministry of Pensions were in pressing need
of further accommodation for the institutional treatment and training of discharged
sailors and soldiers suffering from epilepsy, and that through the British Red Cross
Society initial funds would be available to meet capital expenditure, Griffith with
the assent and co-operation of his Committee and despite his precarious health
readily agreed to meet these needs so far as the possibilities at Lingfield permitted!
Experience has shown that the satisfactory treatment of these particular cases is a
specially difficult problem: so many of the men fail to realise their disability, and
are, not unnaturally, impatient of the necessarily prolonged treatment. But Griffith
knew his men ; he possessed the technical skill requisite to obtain insight into their
individual peculiarities and often into the origin of the latter, and his sympathy
with them and determination to restore them to a normal civilian life engendered,
besides affection, a loyalty to regime that explains much of his success. He had
many projects in view for the development of the Lingfield Colony's sphere of
usefulness, and the carrying of these into effect will be the best tribute to his
memory.

Besides his patients, staff, and many friends, he leaves to mourn his loss his
widow and a young daughter, the former of whom has been his indefatigable com¬
panion and collaborator, and to whom, throughout the ten painful weeks of his
fatal illness, he made no murmur of complaint. He was buried in Lingfield
Churchyard. C. H. B.

Capt. Ernest Fryer Ballard, R.A.M.C.

It is with very deep regret that we have to record the death of Capt. Ernest
Fryer Ballard, R.A.M.C., at the early age of thirty-three, from influenza and
pneumonia, which took place at Brighton on October 23rd last.

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Capt. Ballard received his education at the Merchant Tailors’ School and at
St. Thomas’s Hospital, where he won a scholarship. After graduating M.B., B.S.,
at London University, he for upwards of four years was Assistant Medical Officer
at the Somerset and Bath Asylum at Wells. He was never robust, and, his health
breaking down, he returned to his home at Brighton, where for some time lie was
House-Surgeon to the Throat and Ear Hospital. He joined the Army in June,
1915, and, being in a very low category, he was given home service, and was attached
to the 2nd Eastern General Hospital. The experience he had gained in mental
disease led to his being posted to the Portland Road Section of the 2nd Eastern,
which was devoted to the care and treatment of soldiers suffering from nervous
and incipient mental conditions. He was deeply attached to the mental aspect of
the work, and although he had ceased to be actively connected with this sphere of
medicine for some time previous to entering the Army, he yet continued to interest
himself in modern psychiatry, and particularly in psycho-analysis. He retained his
membership of the Association and attended the meetings when opportunity offered.
He contributed articles to the Journal—-in fact his last article appeared in the
October issue—and he published an Epitome of Mental Disorders, which is a
useful introduction for students. He had a most agreeable personality, was an
indefatigable worker, and did not spare himself in the interests of his patients.

The funeral took place at Brighton, the special service held in the Chapel of the
2nd Eastern General Hospital being attended by a large number of senior officers
and staff and also patients.

By the death of Capt. Ballard the Association has lost a very charming and
accomplished member, and we tender to his family an expression of our sympathy
and regret.

Capt Ballard was passionately fond of cricket and football, but his indifferent
health prevented him taking as active a part in these games as he wished. He
was a keen botanist and entomologist, but his chief interest lay in his home life,
devoting himself to the happiness of his parents. His brain was ever at work—
always reading to acquire knowledge. Although not making much outward show,
he was deeply religious, and took great pleasure in reconciling his scientific
knowledge with the truths taught in Scripture.

Thomas Herbert, M.R.C.S., L.R.C.P.Lond.

We regret to hear of the death on October 23rd, 1918, of Dr. Thomas Herbert,
late Senior Assistant Medical Officer in York City Asylum, Fulford. Dr. Hopkins,
Medical Superintendent of this Asylum, writes of Dr. Herbert as follows :

“ Dr. Herbert had been the Assistant Medical Officer at this Asylum since its
opening in March, 1906—a period of 12J years. He left here on holiday on
October 18th, and whilst on a visit to his brother-in-law in Cardiff was found dead
in bed on the morning of October 23rd. The cause of death was given as
valvular disease of the heart. He had not been well previous to being here, but I
did not know of the existence of any heart disease, so that his death was entirely
unexpected.

" I can say that he was greatly respected by the staff and patients, by whom his
loss was much felt, as well as by myself, to whom he was a great assistance and
an agreeable colleague.”

NOTICES BY REGISTRAR.

Nursing Examinations.

Preliminary .... Monday, May 5th, 1919.

Final.Monday, May 12th, 1919.

Papers for Bronze Medal must reach Registrar prior to June 20th.

The Examinations for Certificate in Psychological Medicine and Gaskell Prize
will be held early in July.

For particulars apply to Registrar, Dr. A. Miller, Hatton, Warwick.

Publication of results of November Examinations has to be deferred until our
April issue.

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NOTES AND NEWS.

63

NOTICE TO CONTRIBUTORS.

N.B. —The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to ux(a) of the
Articles of Association, " all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Papers read at Association Meetings should, therefore, not be published in other
Journals without such sanction having been previously granted.

The Editors regret that the Journal has to be reduced in size to such a large
extent. They have received instructions that, owing to the exigences of existing
circumstances, scarcity of paper, increased cost of production, etc., its dimensions
on this occasion must not exceed 64 pages, exclusive of List of Members. They
have therefore been obliged to postpone the publication of a good deal of the
material in hand, and already printed, to a future issue. Writers of papers which
have thus to be withheld for the present will kindly accept this notice as
explanation.

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*

\

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JOURNAL OF MENTAL SCIENCE, APRIL, 1919.

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Georgk William Mould, M.R.C.S.

Obiit January 14th, 1919.

Pre.sicL'nt, 18S0.

A (Hard S' Son £"* West Newman, I Ad,

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 269 [ n ; n w 0 "T] APRIL, 1919. Vol. LXV.

Part I.—Original Articles.

War Psychology: English and German. By the late
Dr. Henry Maudsley.

[The following article was sent to the Editors so far back as
the autumn of 1916. Exception was taken by the Censor to
certain passages, and as it was felt that it was preferable that it
should be published in its entirety or not at all, its publication
was withheld in the hope that the objections would eventually
be withdrawn. This has now been done, and the Editors are
glad to be in a position to present the article as it came from
the pen of Dr. Maudsley, and without any mutilation.

It is not to be expected that everyone will agree with the
views of the writer, but there is little doubt that the paper will
be read with interest coming from such a source, written as it
was shortly before the termination of his career, and constituting
one of the latest utterances of a great thinker, whose writings
have always been infused with a truly scientific spirit, and
characterised by a dispassionate philosophy expounded with
almost judicial fairness, and rare literary genius maintained to
practically the close of a life prolonged far beyond the average.
The whole article embodies a quasi-prophetic warning, delivered
at a time when the nations were in the convulsive throes of a
world-wide conflict, from the bitter aftermath of which we are
scarcely as yet emancipated : a warning which, if somewhat
pessimistic in tone, may be, perhaps, not altogether unheeded,
as the outlook is still full of uncertainty, and as there is at
least a possibility that our roseate anticipations of a Golden
LXV. 5

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Age, a millennium of peace on earth, and universal mutual
goodwill among all nations, may fail to reach its long wished
for fulfilment.]

To understand truly the psychology of the nations which
have plunged headlong into the present unprecedented war, it
is incumbent not only to study their elaborate historical records
but to take a deeper biological account of the native vigour of
each national stock. Mind being fundamentally life in mind,
and life being essentially motion, its manifestations presuppose
and disclose the vigour of its native vital force. For that
reason the psychology which concerns itself only with con¬
scious display must needs be wanting in depth and hold of
reality. Is the Teutonic race perchance superior in vital
vigour, as it believes, and the Latin races comparatively weak
and decadent; its present outburst of military force therefore
just the natural consequence of its stronger vitality?

The universal characteristic of life notably is its amazing
productiveness and unceasing impulse to prolific increase from
the moment when it comes into being in its simplest vital
plasm. A continual destruction immensely disproportionate
to survival is the consequence : in the order and purpose of
Nature death as normal a factor as life, although conscious life
is loth to think it as natural and necessary. In this perpetual
vital propulsion stronger life survives and grows at the cost of
weaker life, building up higher vital complexes in ascending
scale by feeding on lower vital complexes. Thence the so-called
struggle for existence and survival of the fittest; which is a
fundamental fact of the procession of Nature from age to age.
Such ethical considerations as right, justice, pity, mercy, have
no part or place on that low plane of vital energy which will
withal, be it understood, not fail to continue to operate actively
even after they come into being and application on a higher
plane of human development. This is an important fact
which the enthusiastic humanitarian, shrouding reality in a
haze of incontinent sentiment, is apt to lose sight of in his
optimistic expectation of a complete moral regeneration of
humanity after the war is over.

Whence in the system of Nature is life’s immanent impulse
to increase derived? Without doubt immediately from the

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perpetual heat of the sun’s rays on the vital plasm to which it
owed its origin, and by which it is sustained in being : vital
force, no self-sufficing and self-determining fictitious entity as
commonly supposed, but a natural continuity and complex of
unified material forces, its impulsion fundamentally propulsion.
Remotely, of course, from the ultimate supreme reality of the
universe which, being incomprehensible and ineffable, cannot
be expressed in terms of human thought. Certain it is that
the one universal dynamic energy unknown and unknowable,
however named, comes from above and is distributed down-
wards*in countless channels through every grade of being—
through stars and suns, grass and flowers, insects and birds,
beasts and men. That is the plain conclusion of physical
science beyond which it cannot and forbears to go.

Such stay of thought is unwelcome to human feeling.
Hence the postulate of the Divine source ascribed to it by
imagination urged by feeling to transcend in its flight the
narrow limitations of thought^ 1 ) Construing the illimitable
universe in terms of his limited experience and understanding,
man is impelled to postulate and personalize a Supreme Being
as the ultimate reality and source whence all things proceed,
and thereupon to fashion it more or less in the image of his
ideal self. T^iat is to say, when he has risen to the conception
of unity, and got quit of the effete notions of the various inferior
gods which he was compelled to imagine in his slow and
irregular ascent of thought to that height. Proceeding from
that conception of a one true God, and imbued with the social
feeling of the higher vital complex which he has reached in his
ascending organization, he naturally finds the Divine in all the
phenomena and processes of the visible world, and, above all,
specially and supremely incarnate at last in the person of Jesus
of Nazareth, who was therefore God and man. Thenceforth
he can look hopefully forward to a fatherhood of God and final
brotherhood of mankind through worship of that divine
Mediator, notwithstanding the disheartening events which, like
the present war, occur to perplex and confound him—until, that
is, he has divined their regenerative purpose.

Here, it is true, thought is brought into contact with two
apparently antagonistic forces. On the one hand is the funda¬
mental self-regarding force of prolific life ever pressing onward
to expand beneath all conscious manifestations, and on the

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other hand is the social or moral ideal of an altruistic suppres¬
sion of individual vital force to serve the construction of a
higher vital complex, and therewith the future development of
humanity. The question of paramount importance obviously
is, Which shall prevail in the end, the crude vital force or a
progressive incarnation of the Divine in human nature? Now
it is certain that the vital force cannot abate its essential
impulsion and stay its natural self-regarding energy so long as
the sun’s rays continue to beat upon its vital plasm with
unabated energy. But it is nowise incredible, on the contrary
quite conceivable, that its force shall, in the human sphere, be
minutely divided, regulated, refined, and absorbed into a pro¬
gressive social and moral development of the race, and that be
accomplished in reality which is yet a pious aspiration in the
abstract. Therein lie the hope and promise of an indefinite
human progress in time to come.

Is the abstract ideal then destined to be realized at last?
Or is it possibly only an illusion, nothing more than the effect
and expression in consciousness of the underlying perpetual
vital push of the incorporate sun’s rays? Can it justly be
assumed to be prophetic of things to come ? Mankind have
always needed and progressed by means of the illusions and
fictions which they created to inspire and spur *hem in their
successive developmental ascents, and have abandoned them
one after another when they were no longer serviceable. In
all times and places the unfailing vital energy has thus enshrined
itself in fitting fictions of thought, as it will no doubt continue
to do while it lasts in full vigour. That life will live and grow
for ever on earth is without doubt an illusion. End it must
when the sun is “ turned into darkness.” But that is an event
so remote that present life need not concern itself with it. How,
indeed, can relative life, which is propelled motion, possibly
realise absolute motionlessness ? Meanwhile, within the im¬
measurable time of its continuance, it is instinct with the implicit
conviction of a progressive ascent to higher vital complexity.
The history of its past rise from lower to higher vital complexes
justifies the hope and patient expectation of a continuance of
the process of organic ascent, and therewith the faith in its
progress along a moral line of evolution. Even from the
scientific point of view, therefore, the opinion that the crude
struggle for material existence will be superseded by a struggle

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for higher moral existence is not unwarranted. Higher vital
complexes shall presumably be gradually organized, in whose
structure the crude vital force is divided, regulated, refined, and
condensed. Not otherwise, in fact, than as in the formation of
living protoplasm the simpler physico-chemical forces have been
controlled, regulated, and combined in its complex struc¬
ture, and are constantly thus subtilized and combined in the
secret operations and processes of the bodily metabolism.
The process of moral ascent will be simply a continuance of
the process of organic evolution which has gone on from the
beginning of life, and the survival of the fittest be a survival
not of the strongest in a merely physical struggle to live,
naturally indifferent then to all moral considerations, but of the
fittest in a natural evolution making for social advancement
and righteousness on earth. International immorality, con¬
cerned only with the victory of might and guile, may be
expected then to prove as unfitting and disastrous as intra¬
national immorality would be in a particular nation which
should adopt that pernicious practice. That the motions of
the two apparently antagonistic forces shall thus be harmonized
and combined in a higher vital unity, and the self-regarding
vital force merge its absorbed energy in refined forces of
altruistic evolution ; such is the pleasing hope and pious
aspiration.

Assuredly the present murderous war has been a rude shock
to such idealistic expectation. After nearly two thousand years
of Christian profession, the most civilized specimens of the race
have found no better use of their gains than to plunge into the
biggest, bloodiest, and most destructive war in human history,
and to prosecute it with all the most devastating means of
destruction which their conquests and control of the forces of
Nature have enabled them to devise and employ. All the long
and laboriously accumulated acquisitions of human intellect
through the ages have been applied with the utmost ingenuity
and fiercest resolution to purposes of self-destruction. Such is
the result which Nature, operating through its human nature,
has brought about as necessary effect in the proper course of
its system of evolution. Had any gifted seer a month before
the unforeseen eruption of brute vital passions in floods of
devastation been bold enough to predict the inevitable catas¬
trophe he would certainly have been denounced as a madman,

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or scouted as a despicable and anti-human disbeliever in the
value of Christianity and the progress of humanity, if any notice
had been taken of him at all. Yet it ought to have been fore¬
seen by beings so proud of their present height of intellectual
development, and might perhaps have been predicted by a
sufficiently cool, penetrating, and prescient student of history.
Frederick the Great, as deliberate and resolute an embodiment
of treacherous, unscrupulous, and successful brutality as the
world is perhaps ever likely to see and enthrone in its admira¬
tion (his successful fraud and force having enshrined him as
‘ The Great ’), is the ideal monarch of North Germany, and its
present ruler Wilhelm II, its ‘All Highest,’ and ‘Supreme
War Lord.’ What then has naturally and necessarily hap¬
pened ? That the brute force of vigorous life has asserted and
mercilessly executed itself in open and deliberate defiance of
the gentle growth of a slowly progressive humanity, and, were
it to prove successful, might gloriously enshrine a Wilhelm
the Great or Greater—at any rate in Germany. That is the
real fact to be faced by an optimistic idealism, a fact the
significance of which cannot be got rid of, as the manner
is, by putting on an extra strain of sentimental idealism to
hide it.

Moreover, in frankly facing the disagreeable fact, it is proper
to bear in mind that the fighting nations are alike sincere in
their belief that they are fighting for the right and the promo¬
tion of a true human development. It is absurd for one
nation to assume that the enemy is purely hypocritical, as it
might indeed perceive and own were it to try to see itself as
the other sees and its own history reveals it, which is truly
revealed in the nation, as in the individual, not by its words,
but by its deeds. But how can Germany, it is asked, really
believe that it acted rightly in its unprovoked attack on
nations which wished only to be left at peace, and in treacher¬
ously preparing for years—steadily, secretly, and systematically
—the means of such ajsudden and unexpected attack when the
opportune moment arrived ? But Germany does not for an
instant admit that the attack was unprovoked and unjustifiable.
Looking farther back than the immediate precedent circum¬
stances, it found sufficient provocation there, and concluded an
immediate attack to be the sensible and righteous defence.( 2 )
A strong, virile and expanding nation perceived itself sur-

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BY THE LATE HENRY MAUDSLEY, M.D.

7 I

rounded by secretly hostile nations in tacit league to bar its
needed outlets of expansion and deliberately resolved to obtain
them. Having made a modest attempt in Morocco to find a
place in the sun—nominally, but really a most formidable post
and war station—when the French were taking possession of
that country, it was met with the threat of a determined
opposition in which the French relied upon the support of
England, and presumably of Russia. Yet France was then
aggressively extending its colonial dominion, although by
deliberate and systematic restriction of its families at home it
was not producing sufficient children to keep up its own
population. What else could a vigorously vital nation with a
superabundant population do but patiently watch and wait
until it had perfected the means of breaking down the environ¬
ing opposition ? Vital force in the life plasm would not be
vital if it suppressed itself, or allowed itself to be suppressed by
its environment. Futile discussion as to whether Germany
started the war is no better than puerile pedantry concerning
itself with words on the part of shallow-minded diplomatists
who, blind to the real forces at work, did not foresee its certain
and immediate outbreak—although such foresight was the
reason of their being—and persuaded themselves that they
could prevent it by words.

The Allies on their side are, no doubt, sincerely convinced,
as they hearten themselves by protesting, that they are fighting
for right and justice and the cause of true civilization. Yet
the Germans, who believe themselves to be good Christians, are
passionately convinced that their cause is just, join whole¬
heartedly in prayer to God for its triumph, and rightly deride
the ridiculous notion that the whole nation is a docile people,
enslaved by a few domineering Prussians from whose yoke it
would wish and welcome deliverance. That is the foolish
opinion of persons who did not foresee the impending and
inevitable storm, but contemptuously scouted the urgent
warnings of those who strove in vain to awaken them to the
portentous signs. If such deliverance is to come, sound reason
teaches that it must come gradually from a change of mind
within the nation. A nation cannot change its constitutional
habit of thought and feeling at the bidding of other differently
constituted nations. As well ask the lily to blossom like the
rose.

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The Germans are not merely the thoroughly practical people
which they have proved themselves to be in industrial, scientific,
and military organization, but are essentially a nation of
idealists. They have not lost the idealistic spirit which showed
itself so eminently in their philosophers—in Fichte, Schelling,
Hegel, and many less distinguished thinkers—but have turned
and applied it systematically to material and scientific uses.
They still conceive theories, and having conceived a theory,
philosophic or scientific, make it a creed for the time, thereupon
prosecuting it by patient and systematically organized trial
either to success and acceptance or to failure and abandon¬
ment. In every branch of knowledge, in theology, philosophy,
history, and science that is their habit of mind. And the theory
which they have now formed is that they embody the highest
culture in the world and are justified in spreading it for the
advancement of humanity. Arrogant as the assumption seems
now in its naked crudity, the theory would not have seemed so
outrageous before the war when it was being quietly assumed,
peacefully prosecuted, and indeed generally accepted in England
and America by writers who industriously provided for their
pupils hashes of German philosophy in their Universities, and
greedily sucked in the latest German scientific theories by
whomsoever and wheresoever propounded in Germany. Like
the Jews of old, the Germans claim to be a chosen people and,
like them, ordained to fulfil the Divine Will. Monstrous as
the claim now appears on its bare face, it ought not justly to
shock and revolt Christians who accept the theory that the
Jews were a chosen people, and glorify Christianity as the Divine
evolution of Judaism.

The wonder and the pity of it is that, while hugging the
creed, the Germans, like the Jews of old, should have sincerely
convinced themselves that they were divinely ordained to
accomplish their mission by unscrupulous treachery, systematic
devastation, and ruthless butcheries of men, women, and chil¬
dren, in fact by systematically practising with German thorough¬
ness a rule of infamous “ frightfulness,” and that they should
now with German thoroughness justify their deliberately
practised terrorism as the right means to enforce a speedier
submission, and ensure German dominion on earth. Yet this
theory showed no new spirit in them, was no exceptional
ebullition of brutality ; it was the natural expression of the

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Prussian brutal nature. Their Emperor, in his memorable
address to his troops about to depart to China to suppress the
Boxer rising, sternly adjured them to rival the frightfulness of
the Huns. And his troops faithfully obeyed his injunctions,
ruthlessly shooting harmless women and children who flocked
into a street, out of curiosity to see them pass, and thereafter
justifying and triumphing in their uncensured butchery—
silently condoned indeed by its then allies and present enemies.
To their military subordinated minds their Supreme War Lord,
their All Highest, was the chosen instrument in the ordained
progress of the human race, as he apparently sincerely believes
himself to be. Ingrained in the German nature are docile
service to the State and its military organisation as the habit
of life, and unquestioning obedience to the Plead of it ; all sense
of individual responsibility swallowed up in adoration of the
‘All Highest ’ himself, in sure alliance with the Most High as he
has persistently claimed to be, and has apparently infused into
them.( 3 ) Withal they conform to the inspired Jewish teachings
of the Old Testament, which were practically efficient and
fulfilled the Divine Will before the New Testament came into
being with a new order of precepts, which are yet only ideal
and confessedly impracticable between States in the actual
world. The profession of them by those who do not and
cannot practise them they naturally count hypocrisy and
despise as inefficiency.

But is not that, it will be asked, to throw Christianity clean
overboard? No ! is the confident answer even of their divines,
it is only to restrict it to its proper sphere at the present level
of civilization in the Divine procession of events. The morality
between State and State cannot possibly for a long time to
come be the morality of the Sermon on the Mount. Indeed,
it never was nor ever could have been the morality of any
State ; for no State could have been built and kept up on the
foundation of such principles, nor any State continue to exist
which practised them. In things which belong to the domain
of the construction and maintenance of the State it has always
been necessary to discriminate between spiritual and worldly
matters. The State has grown up by the will and force to
make weaker peoples subservient to it, and will continue
naturally to do so. And inasmuch as in the progress of
human development the manifest impulse of the vital force is

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to the formation of more and more complex social bodies, and
to its embodiment in the State as the supreme social complex
it necessarily follows that the strongest vital force will embody
itself in the strongest State. When the superior State,
pre-eminent in vital strength and intellectual culture, has per¬
fected itself and fulfilled its mission, then shall come the time
when it can rightly be impregnated with, and apply ethical
principles in its dealings with subjugated peoples. Meanwhile,
it needs and must use more force than justice, more pitilessness
than pity, more rigour than mercy. International morality is
the possibility and ideal of the future, when humanity has risen
to that height of development. That is the German theory
which is now being systematically tried in practice with German
thoroughness.

It is withal the logical application in practice of German
philosophy, the effect of which, good or bad, remains to be
seen. A fair summary of Hegel’s philosophic teaching would
seem to be much as follows : The great State is built up by
war, by conquests, by annexation, by subjugation of weaker
peoples. It stands for an idea, a grand beneficent civilizing
idea, pregnant and prophetic, and is in duty bound to conquer
and annex small States. But, as every State will naturally
take it for granted that its own idea is the best, the best can
only be distinguished by victory. It is victory which proves
that the victor is not only stronger materially, but, standing for
a nobler and more vital idea, is the mark of a moral superiority.
War is a necessary condition of the evolution of humanity,
and generations to come will witness a succession of the
triumphs of vital force—for the triumph in fact of the prophetic
idea which contains the future over an idea out of date, senile
and decadent. Germany, therefore, thus instructed, cares
nothing for accusations of infamous barbarity in its conduct of
war ; they do not touch its conscience ; they are not applicable
to civilization at its present transitional level. War is war,
intrinsically conscienceless, and must be waged relentlessly.
Every act which is done to discourage, defeat, and destroy its
enemies is a brave and justifiable deed. Victory must be
won ; nothing else matters. And when it is won, it will be a
proof of moral as well as material superiority, being then the
fulfilment of the Divine Will.

It is a theory which does not commend itself to the British

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mind. Yet it is what the stronger British race has constantly
approved and practised in its subjugation of weaker and so-
called inferior races—in India, in Egypt, in New Zealand, in
every part of the earth where it has enforced and established
its vast dominion. The benefits which it has conferred on the
subjugated peoples by raising them a step in its type of
civilization (which Ruskin describes as “ in many respects one
of the most horrible types of society that has ever existed in the
world’s history”) it counts a justification of the servitude which it
has imposed upon them. And it is now unsparing in its
expenditure of missionary zeal and money to inculcate by the
propagation of the Gospel the Christian doctrines and principles
which it systematically disregarded and defied in taking
possession of their countries for commercial and military
purposes. Why then is it so grievously shocked at the
proposed application to itself of similar methods by the
Germans, who deem themselves similarly justified by their
racial and mental superiority, and intend, like it, to bring
Christian principles into use when they have established the
supremacy of their sounder and more vigorous vitality and
higher intellectual culture ? British expansion, when all is
said, was really the crude effect and expression of rude vital
force, the sequent moral justifications having been the embellish¬
ing after-thoughts.

It is a characteristic and perhaps an advantage of the
British practical mind that it is not idealistic nor severely
logical, nor anywise disturbed by inconsistencies of thought.
Life has its logic deeper than thought to which thought in the
sequence adjusts itself. It believes that it can somehow combine
spiritual and worldly matters in the international relations of
life, and thinks to do so ; its so-called cant and hypocrisy a
practical testimony to the immanent ideal, the expression of a
pious wish for what it wishes should be. Yet, as such
combination is not really possible in practice, and would be as
disastrous to a State as it would be for an individual in a
particular nation when someone steals his cloak to give him
coat also, the attempted compromise is necessarily disadvan¬
tageous ; it incurs the immediate danger of ineffective practice,
as well as provokes the natural accusation of cant and
hypocrisy. In a deadly war between two nations the one
which uses every means it can to conquer will have an

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advantage over the enemy which compromises between right
and wrong means ; the result necessarily a simple matter of
pure vital force struggling to maintain and expand itself. A
brutal and horrible struggle, it is true, but inevitable: just a
repetition of what has been hitherto in the procession of
human events. If war be wicked, though it has hitherto been
the efficient and divinely ordained factor in the evolution of
the human drama through the ages, the impious conclusion
would follow that the world has been wickedly governed ;
which is as absurd a banishment of the spiritual from the
government of the Universe as it would be to introduce the
spiritual freely into the method of actually conducting a war
in an international life-and-death fight. Even Luther, who
believed his native brutality to be Christianized—though it
never was—stoutly affirmed the necessity of separating the
spiritual from the real in war and other worldly matters. And
Christian pastors in Germany now openly defend the doctrine
which Christians outside Germany are forced implicitly to
acknowledge and actually to practise, though loth explicitly
to confess, the elimination of the ethical conscience from
conduct even in unethical war.

The habit of the English mind is to treat conscience as
something sacred in the abstract without considering at all what
it actually is in the concrete. To it conscience is a divinely
implanted something in every individual mind which ought
always to be respected as sacred. That is really to delude
itself with words without thinking in the least what they
mean. For what is conscience, sincerely considered as a
reality, not abstractly as a pious theory ? It is really a general
name, a fine spiritual abstraction, a fictitious entity, connoting
so many and varying particular consciences of all sorts and
qualities. The particular conscience always rests at bottom
on the particular opinion, which may be narrow, ill-informed,
positively irrational, hopelessly prejudiced—the opinion of a
crackbrained neurotic, a crank, a faddist, a self-sufficient lop¬
sided mind, the more intensely conceited the narrower it is,
and in that matter, as in other matters, the prouder in its
conceit of superior wisdom to despise and oppose the inferior
intelligence of the community and to resist its regulations.
Yet the opinion is not made sound and infallible by being
invested with a sacred halo and called conscience. The

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consciences of the “ passive resisters ” in England obliged them
to resist the Education Act and count their resistance righteous¬
ness ; the consciences of the suffragettes and their allies to
violate the law by arson, destruction of pictures, churches and
property, and by the other criminal deeds which feminine
imagination conceived, and acute feminine ingenuity put into
practice ; and the consciences of not a few “ conscientious
objectors ” now to refuse military service in defence of their
country fighting for its existence, while comfortably claiming
and obtaining the benefits of military protection by the
sacrifices and sufferings of their fellow citizens’ lives. The
result is that everybody except the convicted criminal and the
certified lunatic is entitled to his sacred conscience, of what
quality soever that be, and however mean a creature he be.
His formed or more often tamely received opinion he then
frantically hugs, without ever giving the least thought to how
he got it and what it is worth. His abstract conscience is
brought into instant use to oppose the collective conscience, and
consecrate his prejudiced opinion.

Obviously such opinions carried into practice by a minority
of the population are not consistent with the true weal
of the State and would, were they generally adopted, be
its ruin. Service to the State and obedience to its
laws by its citizens are the plain duty of the individuals
constituting it and consenting to live in and by it, the
necessary condition indeed of its strength and stability : the
so-called conscientious refusal of such civil duty from whatever
personal motives a proportionate weakening of its strength and
hurt to its stability. The British mind, inveterately addicted
to compromise, and content to deal with phrases and con¬
ventions rather than realities, shrinks from thoroughly sincere
and logical thought, and when trouble comes from the break¬
down of the conventional practice and decisive action is neederd,
thinks to surmount the danger by the appointment of a
committee to consider it and report. For that reason, when
real vital forces are in opposition, it is at a disadvantage in its
conflict with the German mind whose systematic military
organization, ingrained obedience to the State, and concentrated
application of its forces under single and revered leadership,
enables it to use them directly, forcibly, and effectively. By a
loose organization of all sorts of committees and commissioners

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and compromises promptly required action is consequently
delayed and ineffectively applied ; which is perhaps a practice
hardly less foolish than it would be to think to win a battle
by an army commanded by several loosely co-ordinated and
often wrangling committees.

It isnot surprising if the German military authorities—looking
on the demoralised state of citizenship in England before the
war, on the various resisters to law, and the licence freely
granted to them to parade the streets and assault ministers,
police, and others, on the interminable talk and vote-catching
legislation of party politicians^ 4 ) on the virtual emasculation of
one estate of the realm by a subservient House of Commons
whose members voted money to themselves for their private
use out of the public revenues of which they were elected to
be trustees, on the unchecked so-called peaceful but actually
forcible picketing of factories by Trade Unions put above the
law by law, on the lack in fact of honest leadership and effective
government—thought they saw a nation sunk in selfish indi¬
viduality and the sure signs of a moral decadence, and were
tempted to seize the favourable opportunity of vigorous action.
Obsessed with their notion of the value of their brute vital
force, they overlooked the possibility of the uprise of such a
latent force in England, and, disdainful of all ethical considera¬
tions in war, they underrated and despised the possible value
of moral force in the procession of the human drama. Their
psychology was the crude psychology of the essentially brutal
Prussian nature. They had gladly embraced the doctrine of
the evolution of man from the animal, and the survival of the
strong in the life-struggle, but they blindly or wilfully ignored
the fact that man, whatever his historical descent, is not now a
mere animal, but essentially something higher, in fact a social
and moral animal, who has developed and expects to continue
to develop along that line of evolution otherwise than through
German dominion.

That ethical aspiration has been an important and abiding
factor in human development through the ages is an incon-
testible truth. Human ascent from its lowest stage of being
to its present height witnesses positively to its operation,
irregular and uncertain it may be, but on the whole undeniable
and decided. However near akin to the gorilla in his historical
evolution and physical structure he be, man is not a gorilla,

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nor, although of the same species as the Hun, is the Hun’s
spirit now congenial, at any rate outside Prussia. He is not,
in fact, an evolution only but an epigenesis. Even the Germans,
despite their adoration and brutal use of force, feel in some
degree the reality of the ethical spirit in human nature, and
partially recognize it in practice. Notwithstanding their gospel
of terrorism deliberately devised and systematically practised,
they do not openly advocate and justify the habitual killing of
the wounded and the merciless shooting of prisoners ; they
allow some intrusion of the ethical factor, however illogically ;
and they deny angrily as lies or excuse their calculated
brutalities and bestial defilements of occupied houses in con¬
quered territory, perpetrated systematically in defiance of Hague
Conventions which they had agreed to observe. Brutal and
brutish as they may be in practice, they resent as an insult
being called beasts. The recognition that they belong to the
human species and wish to be thought human is an implicit
acknowledgment by them of something higher in human nature
than brute animality. But so sure are they of their vital
superiority and pre-eminent intellectual culture that they
reconcile their inconsistency by the moral conviction that their
embodiment of the highest human development is the express
purpose of the Divine Will, and the justification of the
supremacy which they would achieve in the world. Their
Emperor loudly and exultantly proclaims the doctrine, and
they in their adoration of their All Highest, and rigidly
disciplined obedience to his military control as Supreme War
Lord, docilely accept it and its consequences. It does not
appear that a single voice from Christian pulpit or professorial
chair or literary cabinet was ever raised to protest against his
ruthless adjurations to his troops to imitate the Huns in the
conduct of war, and the carefully framed instructions of their
military manuals mercilessly to terrorize the civil population of
the devastated country. On the contrary, when the war was
declared and Belgium treacherously overrun with savage
brutality, systematic butcheries, and unspeakable atrocities,
professors, priests and pastors, theologians, and distinguished
persons in literature and science hastened with one consent to
assure their All Highest in a servile and laudatory address of
their approval and loyalty. That any ruler of a civilized nation
in the twentieth century should have seriously given the advice

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and openly sanctioned the method of barbarous warfare which
he exultantly proclaimed few persons beforehand would have
believed possible, but perhaps not a single person could have
conceived it possible that it would be enthusiastically received
and endorsed by such distinguished representatives of German
culture. Patriotic passion instantly swept away all quiet
reflection. When a nation is hurt it feels as a whole, and
responds in sympathetic and synergic unity of vital action.

The thing duly considered is not, of course, so strange as it
looks on its face ; it was a natural and necessary event. The
three wars which Bismarck secretly devised, carefully prepared,
and successfully carried through against Schleswig-Holstein,
Austria, and France—in defence of German interests, as he
alleged, which to him were avowedly German rights—had raised
the German pride of military power and inflated the conceit of
national superiority to an extravagant height, which their
immensely increased and rapidly advancing material, economic,
and commercial progress was not calculated to lessen ; a
progress so great that it was gaining, and might perhaps have
continued to gain, peaceably all or more than all which they
can hope to obtain by the present war. Not a single person
in Germany could now perhaps be found (as the writings of
their Christian pastors prove) to disapprove those wars, and
their unscrupulous methods of provocation. They are approved
as necessities of intern ational life to which /«/ranational rules
of morality must be subjugated. What reason then to wonder
at the patriotic outburst of exultation and adulation when their
Supreme War Lord in his capacity of ruler of the State by
divine right declared and entered on the greatest war in the
world’s history, in order to obtain and secure the domination
of Germany in Europe and on earth ?

What wonder again that their Emperor should have acted
as he did ? Think with adequate insight on his character as
displayed in his speeches and conduct from the time when he
succeeded to the throne, and with amazing self-sufficiency
instantly took on himself the whole burden and responsibility
of the government of the State as the Lord’s anointed, dismiss¬
ing the Great Chancellor whose genius had made it what it
was. Apparently he was sincerely convinced that his grand¬
father, by sole virtue of being a Hohenzollern, had done the
work which he had been guided and ruled to do under

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Bismarck’s powerful tutelage, and he, by virtue of his being a
divinely instituted Hohenzollern, was perfectly competent to
continue and perfect. His secret if unavowed ambition was
possibly to imitate Frederick the Great, and to be as great or
even a greater figure in German history by operating on a
grander scale, and with the vastly augmented resources of
wealth and modern military science. The greatest war in
human history would be the splendid theatre of his exploit, and
his glorification for ever in human admiration. ■

Is that perchance a misreading of his character? Let the
motive have been what it may, explicit or implicit, the judg¬
ment is certainly not a misreading of his character. Think on
his many eloquent and boastful orations, his sermons, his
telegrams, his fierce injunctions to his recruits, his restless
journeys and constant poses in the limelight, his self-confident
instructions to painters, sculptors, actors, even tailors, and his
indiscreet speeches which provoked the submissive Reichstag
at last to a humble remonstrance and forced him to a sort of
apology through his Chancellor, whom, however, he soon after
dismissed. Europe looked with a mixed admiration and
afnusement on so picturesque a figure in its drab procession
and did not take him very seriously. Yet all these exhibitions
were the exponents of character which could not fail to show
itself in future conduct, and just insight might have foreseen.
On March 23rd, 1890, Edmond de Goncourt wrote in the
Journal des Goncourt (vol. viii, p. 142) : “ Ce jeune souverain
allemand, ce ndvrose mystique, ce passioning des dramas
religioso-guerriers de Wagner, cet endosseur en reve de la
blanche armure de Parsival, avec ses nuits sans sommeil, son
activite maladive, la fievre de son cerveau, m’apparait comme
un souverain bien inquictant dans l’avenir.” The history of
his earlier life was the revelation of his character, and what
could his later life be but its natural continuation and expres¬
sion ? A mystical megalomaniac was possessed with the belief
that he, th'e All Highest in Germany by divine right, was in
alliance with, and the ordained instrument of the Most High
in Heaven. So he shrunk not from plunging his country into
war, and his subjects, content to be autocratically governed
and docilely habituated to a strict military organisation, which
treated the least imagined offence to military arrogance by a
civilian as a crime justifying instant killing of the culprit by
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the hurt vanity of the officer, joined patriotically in the
struggle.

The sequence of events was natural and inevitable. But it
certainly was a painful surprise to Englishmen who supposed
that the Emperor possessed some element of the quality which
Englishmen imply in “ a gentleman ” should have sanctioned,
extolled and rewarded the barbarities systematically practised.
Military reasons, however, entirely obliterated such superficial
feeling, if it ever existed, and furthermore justified every guile,
lie, and atrocity which might serve to promote military success.
An organized system of falsifications, forgeries, perversions and
suppressions of truth, effected with all the thoroughness and
completeness of the German national character, was deemed
right for military reasons and a necessary and justifiable method
of conducting military operations. The sole aim being to win
in the fight, no consideration of truth or right must stand in
the way of success ; the matter was purely a triumph of might,
and the use to be made of it in the end justified the means used
to obtain it. Herein the German certainly does not conform
to the English standard. Englishmen have an inveterate
national prejudice in favour of fair play and strict observance
of the rules of the game. It is doubtful whether there is a
single well-authenticated instance of an English officer insulting
or brutally treating a German prisoner, officer or private,
whereas it is undeniable that there have been several such
instances of assault and brutal treatment of so-called “ English
swine ” by Prussian officers. Goethe, whose calm and lucid
insight into Prussian character will hardly be contested even by
Germans, said : “ The Prussian is cruel by birth ; civilization
will make him ferocious.” And that is just what has happened,
even where it might have been least expected in the appar¬
ently cultivated Kaiser ; a cultivation which events have shown
to have been quite superficial veneer not native in character.
Although his mother was English, the element of gentler
breeding was instantly swept away by the uprush of native
Hohenzollern brutality when the crisis came.

The truly English element must at best have been slight,
for his maternal grandfather was a German, and withal a
Coburg. Moreover, going further back in heredity and
considering the strong stream of Hanoverian German ancestry
in the English Royal family, it must have been a very thin

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stream of pure English heredity which percolated downwards
to affect his nature. No wonder then that it was quickly
swept away by the torrent of native brutality. No wonder
again that he has never shown the least sympathy with the
qualities of his father’s gentler character or, so far as appears,
ever said a good word of him in all his manifold orations. He
has gloried in praise of the coarser quality of his revered
grandfather to whom he ascribed the successes which a very
ordinary mind owed entirely to Bismarck’s firm control and
intelligent guidance. It is not in the least strange then that,
brutal by Prussian birth, civilization has made the Prussian
ferocious, as Goethe’s prescience predicted.

So much for a cursory glance into individual psychology.
But it would be unjust to Germans to suppose that they all
•share the brutal Prussian nature, although, having now given
themselves up wholly to Prussian rule and militarianism, they
condone and even rejoice in the barbarities practised. That
the German people as a body believe that they are fighting for
the salvation of their country and are heartily imbued with
patriotic feeling cannot be reasonably doubted. They believe
what their rulers tell them and suffer now the consequences of
docilely putting the destinies of their country into the hands
of a virtual autocracy. They do not learn the real merits of
the matter because they depend for what they learn on their
rulers, who strictly control all the sources of information, tell
them only what they wish them to believe, and scrupulously
hide from them what they do not wish them to know.
Democracy is nowise lovely and has its disagreeable defects
and dangers, but autocracy is perhaps a greater danger to the
nation and assuredly to the world.( 6 ) In view of present
events it would seem therefore to be righteously resisted in
the interests of civilization and humanity, to be a fight of moral
right against immoral might.

The Allies on their side, and the English in particular, might
do well not to delude themselves with the notion that they are
really fighting from purely righteous motives, even though their
cause be the cause of true human progress. They are fighting
fundamentally from motives of self-interest which will continue
to operate in the future when the war is over and to produce
its inevitable consequences. France is fighting with admirable
bravery and unsurpassed devotion in defence of its national

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existence against a ruthless attack which its past national
policy and traditional glorification of Napoleon and his great
victories for the glory of France have certainly done something
to provoke. Russia has been moved by its Slav sympathy
with Serbia, and its desire to uphold its Balkan interests, which
were gravely menaced by Austrian aggression. Great Britain
was instinctively urged by the necessity of preventing the
destruction of Belgian independence and the subjugation of
France, which would have been a great and abiding peril to her
shores and to Britannia’s proud rule of the waves. Each
nation in fact is struggling to maintain its life and future weal
against an ambitious, vigorous, and expanding nation resolved
at all cost to obtain more room in the world, and the supremacy
in Europe which it is sure its superiority in might and culture
rightly deserves : fundamental vital forces operating from
different motives the real factors at work, and the inevitable
result the triumph of the strongest, since Providence is
confessedly on the side of the big battalions.

The forces of the Allies are united for the time in strenuous
effort and somewhat extravagantly effusive professions of
sympathy and anticipations of eternal friendship which are not
in the least likely to be eternal ; for the attraction which now
holds them together in union against a powerful enemy may
quickly dissolve when their respective interests no longer
coincide. Nations do not any more than individuals change
their character in a miraculous manner, and knowledge of their
past history is the only safe basis for prediction concerning
their future. Reviewing the histories of France, Russia, and
Great Britain, which are nowise stories of peaceful unaggression,
and judging national character as exhibited therein, it might
not be well for Europe and humanity that Germany should be
so completely vanquished as to supply no effective check on
their actions. The English are notably liable to waves of
unthinking sentiment, and their present sentimental effusions
and enthusiastic anticipations of lasting friendships with France
and Russia, as expressed in newspapers and speeches which,
may please the populace but the judicious cannot but look on
with grave doubt or amused contempt, exhibit a signally short
memory and foolish forgetfulness of former and comparatively
recent conflicts of interests verging nearly on war. What
good reason is there to suppose that France, if it comes

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triumphant and exultant out of the present war, will have the
same peaceful and chastened spirit which, knowing its weakness
in face of Germany’s strength, it undoubtedly showed before
the war ? Is it expected then to repudiate its adoration of
Napoleon and its glorification of his splendid victories which
Germany has good cause to remember, if not avenge ? Before
it was vanquished and heavily penalized in the Franco-German
War it did not exhibit under Napoleon III any such quiet and
moderate spirit ; on the contrary, it showed a quite different
spirit of unrest and aggression which caused many persons to
sympathize with Germany and approve her success before they
learnt the story of her atrocities. The truth is that the whole
history of France is a decisive refutation of the expectation of
a miraculous transformation of national character. And if
Russia under its present amiable sovereign may perhaps be
trusted to avoid an aggressive war, though not probably its
persistent habit of silent aggression—if he is not seduced or
overruled by his military and interested counsellors, as in the
Japanese war—a new Czar of a different disposition disposing
autocratically of its forces and resources (especially if in
possession of Constantinople) might endanger British interests
and be thought to necessitate their defence by war. Conflict
between England and Russia in the not distant future (not to
speak of France) seems to cool reason a more natural and
probable event than the lasting friendship which sentimental
enthusiasts fatuously expect to last for ever. More fatuous
withal the humanitarian optimism which expects the result of
the present sanguinary war to be a complete moral regeneration
of humanity, when people shall not learn war any more, when
there shall be a peaceful federation of nations, when they shall
institute an International Court of Justice (without troubling to
devise an International Executive), when righteousness shall
reign everywhere on earth. Would that stagnant state of
international felicity which fancy fondly pictures—should it
ever come—be a boon or a bane to the human race ? The
doubt need not gravely disquiet mankind : the illusion or
fiction of a Paradise Regained in lieu of a Paradise Lost will
be a useful incentive to endurance and effort in the pilgrimage
of labour and sorrow which reason teaches that human life is,
a lesson which the lust of life joying to live prevents man for
ever really minding.

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WAR PSYCHOLOGY : ENGLISH AND GERMAN. [April,

Note.

The writer of a letter in the Spectator of August i 2th, who
is serving in the war, is much saddened by the levity shown by
our troops in their attacks on the enemy’s trenches. “ Is there
not something lacking,” he asks? “Is our levity altogether
sound and wholesome ? The spirit that jests with death, that
calls through the din of the attack—* Sixpence the front row ’
.—is it the spirit of true strength ? Doesn’t it lack something
somewhere ? ” He would doubtless similarly regret the
dribbling of a football in front of the attack and the reported
praise of the King by the troops as “ a real sport.”

He and those who feel with him “ have seen the hand of God
in the business,” and wish for the inspiration in which alone
“ can we find the strength of the faith that will enable us to
tread in the victorious steps of those great forbears who through
faith subdued kingdoms.” It is a cheering thought and might
no doubt be a useful inspiration, but the writer in his pious zeal
neglects two considerations: he does not reflect that the Kaiser
feels exactly in the same way and confidently claims the help
of the “ hand of God,” which after rival claims can be certainly
known only by the event. Secondly, the jesting spirit which
he deprecates is evidence of strong and exultant vitality which
will be necessary to win in the end, for the pious inspiration of
faith would not avail if there were not the rude vital force for
it to vivify. The reckless “ jest with death,” which must sooner
or later come, shows a nobler spirit than the craven fear of
it as “ the last enemy.”

(') Le coeur ades raisons que la raison ne connait pas. —Pascal. — ( ! ) Le veritable
auteur d’une guerre n’est pas celtii qui la declare, mais celui qui la rend n^cessaire.
—Montesquieu. —( 3 ) The Vienna Arbeitcr Zeitung calls attention to a sermon
delivered at Hamburg by an evangelical pastor named Ebert. It contains passages
like the following : “ When it is a question of the Judgment of God, God’s word
knows nothing of mercy . . . God has put the sword of Justice into our

hand . . . God has placed in our hands all means to defeat the enemy . . .

God has given us the most brilliant leader of our days.” Captain Valentiner, son
of the Dean of Sonnenburgh Cathedral and the reported officer in command of the
German submarine which sank the “ Lusitania,” has been decorated with a number
of orders since the deed, including the first-class order of the Iron Cfoss and the
Hohenzollern House Order with swords, a special distinction in the personal gift of
the Emperor.—( 4 ) Some of them belonging to what Burke describes as “the profane
herd of those vulgar and mechanical politicians who, so far from being qualified to
be directors of the great movement of Empire, are not fit to turn a wheel in it.”
— ( 5 ) The following quotation is from an article by Lord Cromer in The Spectator
(August 19th, 1916) : “ Mr. Fortescue and other historians have drawn attention to
the fact that the European chaos produced by the French Revolution was in some
measure due to the abundance of half-witted or incapable Sovereigns who, during

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the eighteenth century, governed their respective countries. The Emperor Paul
of Russia was a madman. King Christian VII of Denmark was subject to inter¬
mittent attacks of dementia, as also was George III of England. Queen Marie of
Portugal and Gustavus IV of Sweden were both lunatics. Charles IV of Spain
and his brother, Ferdinand of Naples, were half-witted. Louis XVI of France,
Victor Amadeus of Sardinia, Francis of Austria, and Frederick William of Prussia,
though not of unsound mind, were all wholly unfit to occupy with advantage to
their countries the exalted positions which they held.”

The Factors of Criminal Actions. By Sir H. Bryan Donkin, M.D.,
F.R.C.P.

An article under the title of “The VEtiology of Crime” by Dr.
Goring, in the April number of the Journal for 1918, consists to a great
extent of criticisms of one by me, entitled “Notes on Mental Defect in
Criminals,” which appeared in the January number for 1917, and con¬
tained special comments on Dr. Goring’s well-known work “The
English Convict: a Statistical Study.” As it then seemed to me neces¬
sary to consider Dr. Goring’s views when writing on this subject, it
seems equally necessary now to make some comment on his criticisms.
The main reason for the following remarks is the interest and impor¬
tance of the subject-matter on which he and I differ ; but since some
of his strictures depend greatly on misrepresentations of what I have
written, or on imputations of arguments and opinions that I have not
uttered, I am forced to occupy more space in this paper than I could
have wished in quoting from Dr. Goring’s charges and re-stating my
own position.

Dr. Goring starts with the charge that I criticise “adversely an impor¬
tant modern idea—the idea that criminological science, that all social
science, must be built on facts, and facts alone." This statement, as it
stands, uninterpreted, is baseless, if not meaningless, and, at any rate,
unjustifiable. If it means, as its wording unquestionably implies, that
I have denied that scientific study must be based on facts only, the
statement is false. If, however, Dr. Goring means that I criticise
adversely his attempt to found a “criminological science” on the
basis of the biometrical statistics he has worked upon, why does he not
openly say what he means ? It is clear throughout my paper that I do
not regard the biometrical method as co extensive with the scientific
method of inquiry, and still less as the sole or chief instrument of the
scientific study of things either biological or social. Whether he or I
be right in our estimate of the applicability of this instrument does~not
matter one jot in connection with the charge Dr. Goring makes against
me—a charge which, as it stands at the outset of his article, worded as
it is, and totally unsupported, is acutely calculated to prejudice the

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reader’s mind and clear the ground for further attacks. It reminded
me, indeed, while reading it, of a discharge of gas preparatory to fire.

Dr. Goring next imputes to me a “ prejudice against biometry which
is not shared with many other informed thinkers,” thus evincing an
attitude scarcely worthy of a purely unemotional and scientific disputant.
He may, of course, regard me, or anyone who questions his views, as
an uninformed thinker, but he does not strengthen his case by bringing
this charge of prejudice, which he makes retrospective, and fails to
support by evidence. He proceeds, however, to say that he has at last
found, in the article with which he is dealing, some long-sought explana¬
tion of my attitude; and then makes two inaccurate and incomplete
quotations from that article. By joining these quotations and thus
producing them in the guise of a continuous argument he succeeds in
achieving a misrepresentation of such gravity as compels me-to repeat
here my words as they appear in my original article, and also Dr.
Goring’s perversion of them.

On p. 31 of this Journal for June, 1917, I wrote as a conclusion
drawn from preceding considerations: “[The totality of] the complex
environment which moulds the characters of men—[‘physical,’ ‘mental,’
‘ moral,’ ‘ intellectual ’—and either encourages or stunts the develop¬
ment of their natural or inborn capacities] cannot be analysed or
reduced to such items as can be established or eliminated, or reasonably
dealt with, by statistical handling. [It is not possible to disentangle the
various factors that contribute to the production of a criminal except
in cases that may be marked by patent incapacities to acquire such
characters as are possessed by the average man and are fundamentally
necessary to social life. Nor is it possible to assess in any case with
precision the proportionate influence of the undeniably necessary factors
of ‘heredity’ and ‘environment’ in the development of a criminal
man.]”

At the beginning of the paragraph next following that which I have
just quoted I wrote: “ [It is far from my intention to use any
argument from consequences against the chief position maintained in Dr.
Goring’s work. Such an argument is only too common in controversy
on this subject. It may, however, be fairly noted that one apparent
consequence of this position seems to be largely irreconcilable with
some admissions made at the end of this work.] If it be true, as Dr.
Goring has proved, that law-breakers in the mass are notably less
intelligent than law-abiders [and further, if it were true that their
inferior intelligence is due solely to inborn incapacity], it must follow
that there would be little if any reason for making efforts to reform
them.”

Now here, again, it signifies nothing whether Dr. Goring’s or my
views be right. What I desire to show is the deliberate misuse that

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Dr. Goring makes of these two distinct paragraphs. On the first and
following pages of his article he says : “ Sir Bryan states that the complex
environment which moulds the characters of men cannot be analysed or
reasonably dealt with by statistical handling ,” because “ if it be true , as
Dr. Goring has proved ” through the medium of biometry that the facts
are as biometry shows them to be, “ it must follow that there would be
little if any reason for making efforts to reform law breakers." Dr.
Goring adds : “ In other words, since biometry, by disturbing precon¬
ceived notions, may threaten the stability of our institutions, the
employment of biometric methods must be deprecated.”

A comparison between what I wrote and what Dr. Goring attributes
to me is easily made. The words in brackets in the quotation from my
article above were omitted by Dr. Goring, while all that he quoted, and
imperfectly quoted, from me are printed in italics in my present
quotation from him. It will thus be seen that for dialectical purposes
Dr. Goring quotes from part of one paragraph, and, linking the quota¬
tion directly to part of the next by his own introduction of the word
“ because,” gravely and falsely charges me with condemning his method
because I do not like its results.

Now it is abundantly clear throughout my article that lam criticising
Dr. Goring’s conclusion, based on his biometrical method of inquiry,
that “ relatively to its origin in the constitution of the malefactor, and
especially in his mentally defective constitution, crime is only to a
trifling extent (if to any) the product ... of any manifestation of
what may be comprehensively termed the force of circumstances.” And
it is equally clear that I did not admit or even imply in the quotation
I have just made from my former article that Dr. Goring had proved
this conclusion. What I did imply, or rather state, was that, granting
that Dr. Goring had shown that convicted criminals were of inferior
intelligence as compared with the average man, his main conclusion
seemed to be irreconcilable with some admissions made elsewhere in
his own article.

A detailed reply to the argumentative matter contained in Dr.
Goring’s article would involve the repetition of a considerable part of
my former paper, which he has either ignored or misrepresented.
There are, however, some further points which call for notice.

Following on the ridiculous charge that my argument (as set forth
by him) was “ an appeal to the emotions in favour of an environmental
origin of crime,” Dr. Goring proceeds, “ by parity of reasoning,” to
set up more “ Aunt Sallies ” for the pleasure of bowling them over.
He quite ignores the iterated insistence in my article that crime is
referable neither to “constitutional” nor “environmental” causes
only, but to both combined; and he ventures to say on p. 134 of
his article that I have “ made a statement to the effect that it may

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be laid down in advance as an d priori proposition, and even despite
statistical evidence to the contrary, that environmental conditions must
of necessity have a determining influence upon crime. He then gives
his own interpretation and limitation of the meaning of “ environ¬
ment,” drawing therefrom certain conclusions, and ends the paragraph
by misquoting a passage from my article, which he characterises, as
an astounding outburst.

The “ outburst ” in question runs as follows in the original: “ Even
if, for the sake of argument, the [complete] validity of [the] methods
employed and [of some of the subordinate] conclusions arrived at [in
the “ Study of the English Convict ”] be assumed [including even that
of the denial of any ‘ significant correlation ’ between crime and the
particular environmental conditions investigated by Dr. Goring], it
cannot possibly be held that any significant proportion of the innumer¬
able influences that act upon all men from infancy to age, for good or
for ill, and contribute so largely to the make-up of each of us, have
been eliminated or could be eliminated by such an inquiry as we have
been considering.”

It is to be noted here that Dr. Goring’s version of this paragraph
omits all that is included within brackets, and thus becomes a perver¬
sion. Why this paragraph, with or without the words omitted by Dr.
Goring, should be styled an “outburst” it is not easy to understand,
unless the mere fact that in its proper and quite clear sense it contains a
brief statement of my contention against Dr. Goring’s chief conclusion
anent the aetiology of crime is sufficient reason to mark it as another
“ appeal to the emotions.” But this is of little moment. What does
matter is Dr. Goring’s further perversion, on p. 135 of his article, of
what I said when writing of the “ innumerable influences acting on all
men, and contributing so largely to the make-up of each of us.” I
meant, clearly, the innumerable and various influences acting on every
individual person throughout their lives ; and the paragraph is part of
my argument that such influences cannot be eliminated by any statistical
study of men in the mass.

To touch upon another point arising from Dr. Goring’s criticisms.
It may be gathered from some of his remarks that misunderstanding
may possibly be caused by the interpretation I have placed on the
meaning of the words “ constitutional ” and “ environmental ” as used
by Dr. Goring. I take it that he uses these terms, in connection with
the special characters or items which he studies, as indicating two
different origins which can be separated for the sake of investigation ;
that he denotes as “ constitutional ” such characters as are very
commonly described by various writers as “ innate,” “ hereditary,”
“transmissible,” “germinal,” “natural,” as opposed to “acquired,”
“nurtural,” “environmental”; and, lastly, that he means by “environ-

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mental ” somewhat the same as other writers mean, but with more or
less definite limitations of his own.

An important question arises here, bearing closely on this discussion.
If Dr. Goring boycotts the terms “ innate,” “ hereditary,” etc., and
substitutes the term “constitutional,” what connotation does he give to
“constitutional”? By a member of the Biometrical School, “whose
characteristics,” he says, “ are clear thinking and precision of language,”
it is absolutely necessary that a precise meaning should be assigned to
this term, but Dr. Goring gives none whatever. I was already quite
aware, and am now once more assured by Dr. Goring, that the
Biometrical School repudiates the use of what it calls “ figurative ”
terms, and employs the term “association” instead of words implying
any notion of causation other than that of “uniform antecedence”; nor
was I unmindful, when I wrote my article, that Dr. Goring had said
that ancestral resemblance need not necessarily be due to hereditary
influence. But, nevertheless, biometrical investigations undertaken
into biological and social questions have, I believe, usually resulted in
finding that certain degrees of ancestral resemblance are due to a
“constitutional ” factor; and Dr. Goring says that absence of resem¬
blance, unless absolutely screened by environmental influences, does
imply absence of “inheritance.”

Biometrical teaching thus appears clearly to admit a practical
dichotomy of “natural” and “nurtural” influences in the case of
investigations into questions of “inheritance”; and, as Dr. Goring’s
researches into the origins of criminal action exemplify, this teaching
includes more than the exhibition of certain statistical facts of family
resemblance. It either states or implies that environmental influences
can be sufficiently ascertained and studied to justify a further conclusion
as to what extent these facts of family history are due to the inheritance
of a constitutional anti-social disposition apart frotn environmental
influences.

It is true that Dr. Goring refers to “family contagion” as a possible
or alleged environmental influence which can be studied sufficiently to
ustify its inclusion or exclusion as a factor in crime. By this is
apparently meant the personal association of the criminal with criminal
members of his family, or perhaps other closely associated groups.
But even such a limited inquiry into environment would be difficult in
most cases, and still more difficult would be a research into the mere
“school” education of persons who become criminals.

In this place it must be said, in denial of Dr. Goring’s statement, that
I have never implied that characters can be differentiated as either
inborn or acquired without investigation. On the contrary, I have
iterated my conviction that characters, and especially human characters,
and most especially human mental characters, are both inborn and

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acquired, or, if these terms are preferred, both “ constitutional" and
“ environmental ” in origin. Again, I have never said, as stated by
Dr. Goring on his p. 142, that his “conclusion that crime is influenced
by heredity is erroneous because the fact that inborn capacities are
necessary for the production of human character is accepted knowledge,
no longer a hypothesis in need of verification.” I deny that I have
ever said or even implied that crime is not influenced by heredity; and
so far from stating that this conclusion was erroneous, I have treated it
as calling for no elaborate evidence now, but as universally accepted.
This charge by Dr. Goring is another example of his misuse of the
word “because”—another very serious misrepresentation, seeing that it
imputes to me a conclusion I did not draw, and a statement of which
I have repeated the contrary.

Towards the close of his article Dr. Goring says that he cannot
discover in my criticism “any sense of the fact that the aim of his
inquiry was not to support speculation, but to discover what actually
the relations of crime are in conditions prevailing to-day”; and he ends
by stating, as his summary conclusion, that “between a variety of
environmental conditions examined such as illiteracy, parental neglect,
lack of employment, the stress of poverty, etc., including the states of a
healthy, delicate, or morbid constitution per se, and even the situation
induced by the approach of death—between these conditions and the
committing of crime we find no evidence of any significant relation¬
ship.”

In the first place, as regards the aim of Dr. Goring’s inquiry, I have
neither implied or thought that he wished to support speculation, or
that his aim as a whole was other than he has stated it. My conception
of his aim was based on his own statement on p. 18 of his original
Report, when he says it is two-fold : (1) To clear from the ground the
remains of the old criminology based on conjecture, prejudice, and
questionable observation ; (2) to found a new knowledge of the criminal
upon facts scientifically acquired, and upon inferences scientifically
verified, such facts and inferences yielding, by virtue of their own
established accuracy, unimpeachable conclusions.

My criticisms have been directed solely to what he has written
concerning his second object.

In the second place, I have from the first taken his main conclusion
to be, not as he now states it in his criticism of my article in this
Journal, but as he indicated it in p. 371 of his original work—“The
English Convict.” For the sake of clearness I quote once more those
words of Dr. Goring’s—“ Our second conclusion is this : that relatively
to its origin in the constitution of the malefactor, and especially in his
mental defective constitution, crime is only to a trifling extent (if to any)
the product of social inequality, of adverse environment, or of other

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manifestations of what may be comprehensively termed the force of
circumstances.”

For the opinion I hold that the conclusion has not been established
by Dr. Goring I have given my chief reasons in my article in this
Journal for January, 1917, to which 1 would refer such readers as are
interested in this subject. Of course, the adverse criticism that I have
made of Dr. Goring’s conclusions implies that I do not admit that he
has founded a “new knowledge of the criminal” on the results at which
he has arrived, unless his exhaustive disproof of the teaching of the
“ Lombrosian,” or “anatomical,” or “positive” school of “crimino¬
logists ” may be regarded in that light.

Dr. Goring asks me, or suggests that I ought to say, what my con¬
ception of “ inheritance ” is, and in another place he implies by a
quotation that I have given a “ definition of criminology,” which is,
according to his gloss on it, on my own showing inherently futile. I will
put my position as plainly as I can on these points. As regards the term
“ criminology,” I have always avoided it as much as possible owing to the
great confusion both in writing and thought that its use has occasioned.
At the outset of my article I said that I proposed to comment on some
of the recent literature of “what is known as criminology,” and
remarked that this term may (I should have said might possibly) be
properly applied to investigations undertaken with a view to giving such
an account of criminal conduct and criminal men as may assist in the
formation of practical measures towards the prevention of the one and
the appropriate treatment of the other. I have never attempted to
formulate or define any special science of “criminology,” nor do I
deem such an attempt practicable. Dr. Goring and 1 both start in our
study of criminals with assumptions of importance, and to some'extent
similar in appearance, different as the uses of them made by each of us
may be. On p. 23 of my article I said, in repetition of what I had
written elsewhere several years before, that "‘the study of criminals had
long convinced me that all of us were potential law-breakers,” and Dr.
Goring states in the introduction to the Report on the English Convict
(p. 26), that in this inquiry he is “forced to the hypothesis of the
possible existence of a character in all men, which in the absence of a
better term we call the criminal diathesis.”

But Dr. Goring’s assumption is really very different from mine; for
he says —“ all that we can assume, and what we must assume, is the possi¬
bility that constitutional as well as environmental factors play a part in
the production of criminality.” It is quite clear that the method of Dr.
Goring’s inquiry must make this assumption, for his object is to investi¬
gate, by a statistical method, how far crime is referable to each of these
two factors respectively j but this method involves the further assump¬
tion that these two factors can be sufficiently appraised and isolated for

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the attainment of the object in view. And Dr. Goring concludes, as
we have seen, that environmental factors have little or nothing to do
with crime-production.

My assumption, on the other hand, is a pure assumption, not made
for the purpose of proving its truth, or its untruth ; but though I do
not attempt to prove it true by the method employed by Dr. Goring,
it is clear that when I criticise Dr. Goring’s conclusion I cannot justly
be charged with ignoring the “ constitutional factor ” in crime. My
assumption is necessary to my argument, and my conclusion is that
Dr. Goring has not succeeded in proving that what he implies by the
constitutional factor is the sole or supremely significant element in the
make-up of the criminal.

Coming now to the question of my conception of the meaning of the
word “inheritance,” the reader will find, in my article in this Journal
of January, 1917, at least a fair notion of the meaning in which I use
it. All “ characters ” are inheritable in the sense that the capabilities
of developing them, not the characters as we see them, are carried
in the germ. What is commonly called an “ acquired character ” (this
term being now used in a much wider sense than that originally attri¬
buted to it by Lamarck) is thus assuredly inheritable as any other
“ character.” Characters are developed in response to some sort of
“nurture,” such as functional activity, injury, internal secretions, heat,
light, moisture, nutriment, teaching, experience, etc. Thus all
“ characters ” are products of both “ nature ” and “ nurture,” and are
referable, as regards origin, both to inheritance and to acquirement—to
“constitution” and to “environment.” “The frequency,” says Dr.
Archdall Reid, “ with which characters are reproduced, (not inherited)
depends on the frequency with which certain influences are encountered
—certain nurture. Nurture concerns, not inheritance, but the environ¬
ment. With the exception of variations in the offspring the potentiality
of developing any character is inherited with certainty. Like begets
like when parent and child develop under like conditions. But the
reproduction of any character is uncertain in proportion as the environ¬
ment is variable.”

In Dr. Goring’s inquiry the biometrical method seems to be concerned
with studying frequency of reproduction—not “ nature,” but “nurture”—
and is thus not applicable to the study of developed human characters.
What the human being, over all other animals, has especially inherited
is an enormous capacity for developing acquirements, and he inevitably
encounters in his course innumerable opportunities for, or obstacles to,
the development of these capacities. This consideration applies pre¬
eminently to the development of the mental characters of man which
are subjects of observation, not to the necessary inheritance of his
capacities for developing them.

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This leads me to emphasise again an important ftyw in the course
of the argument which guides Dr. Goring to his chief conclusion.
His reasoning necessitates the introduction, into his general con¬
ception of the criminal, of the item or factor of “ wilful anti¬
social proclivities” in addition to the other factors of physical and
mental inferiority—all of which three factors he regards as indepen¬
dent of each other. Now the statement that a factor in the make up
of the criminal is the possession by the offender of “ wilful anti¬
social proclivity” is merely equivalent to saying that the man who acts
anti-socially or criminally is at least in some degree of an anti-social or
criminal nature, and this is tautological or meaningless as argument, unless
I am mistaken in assuming that Dr. Goring classes “anti social proclivi¬
ties ” in his group of “ constitutional ” factors. It is true that Dr. Goring,
in introducing this item of wilful anti social proclivity into his conception
of the criminal diathesis, remarks that it is a bond of association with
conviction for crime less close than those of physical or mental
inferiority ; but it is no less true that, without such introduction, the
smaller, but by no means inconsiderable, number of physically and
mentally superior convicts could find no place in the generalised class
of men with high potentiality for crime that has been described by Dr.
Goring himself. No “science of criminology” can omit from its scope
the recognised number of men with good physique or high intelligence,
or with both these qualities, who are convicted of crime, or the still
larger number of this class of law-breakers who escape conviction
altogether.

I have endeavoured in my original article, and in some additional
remarks above, to show why I hold that Dr. Goring has quite failed to
prove that “ crime is only to a trifling extent, if to any, the product of
what may be comprehensively termed the force of circumstances ” ; and
I fail to see how Dr. Goring’s conclusions have provided any new basis
for the study of the genesis of crime and criminals. It is certainly
true that the marks of mental or physical inferiority are much more
observable in some kinds of criminals than in others—kinds, that is, of
convicts classified by the crimes they commit. It is also true that a high
degree of such inferiorities is not observable in criminals taken in the
bulk, although I do not question—nor in my opinion would anyone
conversant with criminals question—Dr. Goring’s conclusion that con¬
victed criminals are as a whole physically or mentally inferior to the non-
convicted population. Further, inferior intelligence does not characterise
the so-called class of “ habitual criminals,” who of recent years have
been sentenced as such to a long term of “preventive detention,”
any more prominently than it characterises the other groups of
criminals; nor do these habitual criminals respond less satisfactorily than
others to the opportunities for rehabilitation that are provided for them

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when released on licence. I make these brief statements, after reflec¬
tion based on a not inconsiderable experience of many years, and
corroborated during the last five to six years by a large number of
interviews held with all kinds of convicts sentenced to preventive
detention (with a view to deciding whether or no to recommend them
for licence), and by the reported results of the cases licensed.

I am of opinion, far more strongly than when I began my observations,
that even the most correct generalizations which have been or probably
will be made concerning convicted criminals in the mass are not likely to
be of much positive value in the study or treatment of individuals, so
great are the differences of the observable characters of both criminal
and non-criminal men.

Artes et Medicina. By Alan F. Grimbly, M.A., M.D., L.M.(Rot.

Dub.).

The question of a combined arts and medical curriculum has long
been a source of dissension among the authorities of our universities,
and it is my intention in these pages to lay emphasis on the enormous
value of a modified arts course to students of medicine. The average
student looks on the enforced study of arts askance, and regards the
accompanying lectures and examinations as the deliberate attempt of a
malevolent professorial hierarchy to wreck his scientific career; but in
later life, when he finds himself thrust upon his own resources with
education and common-sense to guide him, he unconsciously begins to
reap the benefit of his B.A. degree.

Although medical students do not lake the full course in arts, yet the
scope of work to be done is considerable. In the University of Dublin
the standard for entry to the medical school is that of the ordinary
Matriculation examination, together with the term examination at the
end of the first or Junior Freshman year, so that a fairly comprehensive
general knowledge is required before a youth can commence his pre¬
liminary scientific studies. In the ensuing four years he attends lectures
in mechanics, logic, ethics, and astronomy, devoting the Trinity term of
each year to one subject, while throughout this period he is examined in
English composition and instructed specially therein if found deficient.
The important arts examinations are the “ Littlego ” at the end of the
second, and the Final at the completion of the fourth year, but numerous
term examinations are held at regular intervals at which a definite per¬
centage of marks must be obtained to gain credit for the year—a highly
desirable accomplishment when it is remembered that no man is allowed
to have a medical degree conferred until he is qualified in arts.

There are certain subjects in the aits syllabus which are of particular

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importance to the professional man. It is indispensable for marked
success in the world that he should have a sound knowledge of his own
tongue, a broad acquaintance with Latin and, if in less degree, with
Greek, and, above all, instruction in the sciences of logic and ethics.

Medical men are renowned for their ignorance of the structure and
grace of the English language. Their writings are marred by mal-
punctuation and the consistent use of that enormity, the “split-infini¬
tive,” and much good work is spoiled by incompetence to find expres¬
sion for thought in their own tongue. The study of English essay trains
men to write in a polished and cultured style, to think regularly and to
reason.

Moreover, it seems absurd that many medical men should have little
or no acquaintance with Latin or Greek, when one reflects that these
languages form the basis of medical terminology. Every day of their
lives they make constant use of terms whose present-day significance
they realise, but of whose origin they are quite unaware. A sound
understanding of Latin is essential for the young student to master
with ease the complexity of anatomical nomenclature—a task in itself.

But I wish to lay especial stress on the importance of a thorough
grounding in logic and ethics. Surely it is essential for a successful
doctor to be acquainted with the “ science of the form of thought ” ?
Logic does not instruct afresh ; it teaches how to think. It does not
inquire into the truth or falsity of the premises but, in the conclusion,
brings whatever is implied therein into the domain of consciousness.
In practice correct premises depend on sound knowledge and trained
powers of observation, and it is an invariable rule that an eminent
physician or surgeon is a wise logician. Medical evidence in courts of
law is frequently illogical, and diversities of opinion arise on this account
that are in no way creditable to the profession. It is absurd if men are
expected to become successful diagnosticians while they are unacquainted
with the very framework of the process of reasoning, or if they are
supposed to deal in wisdom with the varied problems of social life that
come to their notice if ignorant of the sciences that treat of right
conduct and of the workings of the human mind. Here lies the
foundation of that broadness of view and clarity of thought requisite in
every practitioner.

Certain objections have been raised in connection with the necessity
or advisability of a concurrent arts course which may be mentioned :

(1) Additional expense entailed in the payment of fees in the arts
school.

(2) Interference with work in the medical school. This is unavoid¬
able to some extent, and it is no doubt trying to the young student
to be obliged to attend lectures and pass examinations in arts when
he wishes to devote all his energies to his profession ; but this objection

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is far outweighed by the ultimate gain later in life. Those students
who, on account of such additional work, leave their University to
pursue their medical studies elsewhere are generally failures, and never
succeed in passing the barrier of their second or third professional
examination.

(3) It is held by some people that the study of arts at all is waste
of time; but such people, by heredity or acquisition, are cursed with
an habitual attitude of mind that places them outside the pale of
reason, and renders them immune from all argument save the
argumentum basilinum.

The claims of concurrent education in arts to recognition as a
definite phase of modern scientific teaching are manifest if we consider
the advantages thereof in tabulated form :

(t) Young students are trained to form sound judgments and to
think in logical sequence of ideas. Guidance in argument is afforded,
and by inculcation of regular habits of thought and steady growth of
the powers of reasoning the foundation structure is evolved whereby
in future years difficult problems in diagnosis are grappled with in
triumph.

(2) Training of memory is inseparable from cultivation of rational
thought, and the power of rapid and intelligent interpretation of the
objective. Only by weeding out the tares from the medley of impres¬
sions ceaselessly reaching the conscious mind, by the elimination of
unessentials, can a satisfactory end be attained. Pure Reason exists
only in the fantasy of early Kantian imagination ; for all reason springs
from a myriad association of past experiences culled from pre-existing
impressions—from the memories of the bygone—and is directly
influenced in the individual by the receptive and retentive faculties
of the cerebral cortex. Upon accuracy of memory depend our ideas
and judgments manufactured in the marvellous synthetic laboratories
of the spheres of association.

(3) The origin and true significance of terms and phrases used
throughout existence are understood ; otherwise the language of the
medical man must be but superficially intelligible to him and funda¬
mentally incomprehensible.

(4) The sphere of education is enlarged, and the gain in general
knowledge thereby is of vast importance to the practitioner in his
dealings with people in all walks of life with whom he is constantly
brought in contact.

(5) Knowledge of logic and ethics is essential for the preliminary
study of psychology—a science much neglected in the medical curri¬
culum. A doctor should not only be broad-minded and logical in
argument, but for success should have a thorough understanding of the
psychology of complex man and of possibly more complex woman.

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(6) There are few occupations in which the sapient physician, who
has availed himself to the best of his ability of the resources of his
University, cannot take an intelligent interest. We live in a prophylactic
age, and if the medical man is able to, and does, take such interest in
the lives of his neighbours, particularly in the case of bodies of men
found in foreign stations and ships at sea or far from civilisation, he
exercises unconsciously a mental prophylaxis arising from his personality
and depth of knowlege of men and events.

(7) By nature of the widened scope of University life, the student
encounters every day men of his own age engaged in other lines of
study, and becomes acquainted with thoughts and ideas of all sets and
parties. Every medical student ought to belong to one of the estab¬
lished arts societies on this account. From listening to, and taking
part in, debate and meeting regularly his fellows in other phases of
life, his horizon is broadened, and he becomes better adapted to play
his part in the eternal struggle for existence.

There are certain changes desirable in the present curriculum of
our Universities, both in the arts and medical schools, which appear
to me to be very greatly needed, and which ought to be put into execu¬
tion with little delay. The suggestions I wish to make are the following :

(1) The substitution of lectures in psychology for those in astronomy
in the fourth year in arts .—Scant attention has been paid to the study
of psychology and insanity in the past, but some slight effort has been
made in recent years to recognise their significance. The subject of
mental disease has been practically left to the individual inclination,
with the result that hardly 1 per cent, of students know anything about
this important branch of medicine, the few that attempt to do so
finding their way barred by insuperable obstacles arising from ignorance
of elementary psychology. Men qualify in their profession with but
the haziest notions with regard to the nature of concepts and percepts,
volition, the formation of ideas, and so forth, and some are not even
able to differentiate between a delusion, an hallucination, and an
illusion. Men employ drugs to cause sleep without any knowledge of
the theories relating to the state they attempt to induce, and a common
indication of the neglect with which this science has been treated is
found in the frequent use of “mind” and “brain” as synonymous
terms by physicians of age and standing. The study of psychology
follows in natural progression from that of ethics and logic, and it
would be of enormous advantage to the profession to inaugurate
lectures and examinations in this important science, and, furthermore,
to lay more stress than has been the case hitherto on instruction in
mental disease.

(2) The establishment in schools of medicine of a chair of medical
etiquette .—On reflection it appears more than strange to think that this

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subject should never have been regarded as a necessary part of the
medical curriculum. It is unworthy of the magnificent resources of
our Universities that students should be allowed to qualify with abso¬
lutely no instruction in the recognised code of professional men.
Breaches thereof are sometimes committed which would have been
avoided if the offender had been forewarned. It is a duty to teach
every fifth year student medical etiquette for his own protection, in
view of the great responsibilities that fall on his shoulders when he has
his professional degree conferred.

(3) Fixing the minimum age of entry to the medical school at eighteen
years .—I realise fully that objections are many on this point, and in
particular that it is impracticable in time of war, when young doctors
are urgently needed for our Navy, Army, and Air Force. But with
the approach of peace in the near future it would be a wise stipulation
to make. When a youth enters the school of medicine he leaves his
boyhood behind, and settles down to several years’ hard work if he be
ambitious, and if not ambitious he fails to count in the world, where
the fight for life is continuous by night and day. A boy of sixteen is
too young to undertake such serious studies, and has not the physical
powers of endurance, whatever be his mental capabilities; moreover,
far too young is he to learn the first cruel incompatibility of life—
the incompatibility of work and play.

I have endeavoured in the above pages to enumerate the benefits of
a conjoint teaching in arts and medicine, but I would issue an especial
warning to the unwary few who may be led astray by evil counsel into
the abyss of metaphysics. There are young men who gambol through
life in endless quest of the summum bonum —the Chief Good—wasting
precious years of youth in search of eudaimonia, an eternal striving
after the intangible somewhere in the nebulous zone between the
exotic realms of Epicurus and the trackless wastes of the Utilitarians.
Let students of medicine beware of metaphysics !

I plead for lectures in medical etiquette and regular instruction in
psychology and mental disease. To quote Haeckel: “The psycholo¬
gist especially acquires, by the study of 'mental disease and the visiting
of asylum wards, a profound insight into the mental life which no
speculative philosophy could give him.” The foundation of a success¬
ful career is built upon education and early practice, and if a student
avail himself with diligence while young of all the resources at his
command, he will emerge into the world learned in his profession and
wise in philosophy, endowed by his University with one of the greatest
of gifts—an understanding of the Science of Life.

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1919-3 PSYCHOSES IN THE EXPEDITIONARY FORCES.

IOI

Psychoses in the Expeditionary Forces. By O. P. Napier Pearn,
M.R.C.S., L.R.C.P., Temp. Capt. R.A.M.C.

At the present time, to investigate fully the psychoses of those in
military service would necessitate an inquiry into the mental health of
the male moiety of the entire British nation. Admitting the truism
that the war has not produced any new form of mental disease, it is
nevertheless interesting to bring forward and accentuate the differences
and similarities found in psychiatric military and civil institutional
practice.

When it is considered that a soldier on active service abroad requires
observation on account of his mental condition he is sent away from his
unit, usually with the diagnosis of N.Y.D.—not yet diagnosed (mental).
After a varying, but, as a rule, comparatively short stay at various
medical units in the country in which he is serving, he arrives at one
of the specially selected hospitals in Great Britain.

At the time of writing, one of these, the Lord Derby War Hospital,
has admitted over 6,000 such cases, who have all seen some form of
service with an expeditionary force. Of these I have personally
investigated 2,000. With such a large amount of material a medical
staff varying in number with the exigencies of the service, and an
amount of time varying in inverse proportion to that number, one is
liable to retain only vague generalities. In order to avoid this I have
thought it well to collect and tabulate some 200 cases, and use them as
pegs on which to hang my facts, endeavouring at the same time to
refrain from wandering in an arid desert of figures. I have selected
cases which have made a sufficiently good recovery to warrant their
being returned to duty, as being those concerning whom it is easiest
to obtain some form of after-history either from their friends or from
their regimental records, and also because the non-recoverable cases
(dementia praecox, general paralysis, paranoia, etc.) resemble more
closely those met with in ordinary civil practice.

Before considering these in detail it is advisable to make some
remarks on the question of the war psychoses as a whole, as regards
aetiology, diagnosis, and treatment.

“Stress of campaign," which is so often, and so justly, given as a
primary causative factor, is by no means synonymous with stress of
battle. To the popular mind, which generally figures the soldier as
“ driven mad ” by terrifying scenes of carnage and rapine, it would come
as a surprise to hear that 20 per cent, of the 200 cases have never been
under fire, but the psychiatrist will have no difficulty in realising other
pathogenic constituents inseparable from active service in a foreign
land. The forcible divorce from the familiar entourage, the separation
from home and family, the anxiety as to how the latter are faring, only

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temporarily alleviated by correspondence, and the fear of the unknown,
all serve as pabulum to the seed of mental ill-health which may already
have found suitable soil in which to germinate. The effect of an
entirely strange environment is emphasised by the comparative frequency
of psychoses in men of alien nationality who have enlisted in colonial
contingents.

Heredity only figures among the causative factors in io per cent.,
although special inquiries were sent to the relatives of each patient.
This is obviously too low a figure, but I have long since come to the
conclusion that the investigation of family histories can only be satis¬
factorily carried out with the co-operation of someone working outside
the walls of the institution dealing with the cases concerned.

A history of excessive indulgence in alcohol was obtained in io per
cent, of the cases also, and it is probable that the percentage here
approximates more nearly to the truth, as the physical signs of the
patients and the absence of any report to the contrary in the vast
majority of them supported their affirmations of temperance. A few
were seasoned topers who would have obtained means of getting drunk
in the Desert of Sahara, and I have some remembrance of one who
actually did. A few others had forsaken the beer of their forefathers,
and followed after Bacchus in the strange and seductive guises he
assumes in foreign lands.

A more frequent manner for an alcoholic psychosis to arise is in the
case of the man who has been home on leave. After a period of enforced
abstinence at the Front a man takes advantage of his furlough to
indulge, and is found wandering about the port of embarkation on one
or other side of the Channel in a confused state. This may occur even
if he has taken only an amount which formerly would have had no
gross effect on him, owing to his resistance having been lowered by
his period of abstinence and stress. Syphilis does not figure as a
causative factor in the selected cases, who are mostly too young for
cerebro-spinal syphilitic affections. It may be noted in passing that
general paralysis seems to have its onset hastened and its course
accelerated by active service. This is in accord with the finding of
Shaikewicz during the Russo-Japanese War. Syphilophobia is not
infrequent, and will probably be met with more often while the education
of the public in venereal disease is in the transition stage between
ignorance and knowledge. Other infective diseases figure rather
prominently. Of 60 cases from eastern theatres of war, 30 per cent.
gave a history of malaria and 16 per cent, one of dysentery. It is
remarkable, considering its prevalence, that in only two cases was trench
fever considered connected with the onset of the psychosis, but the
comparatively short duration of the acute stages of this infection is
probably the explanation. As regards the front line, apart from the

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obvious causes of stress, a factor frequently met with is the fear of being
thought afraid.

The question of diagnosis is a very difficult one, and it is for this
reason that the headings in the table are so indefinite. Incipient,
aborted, and mixed psychoses all occur frequently, and borderland
states are often met with. The so-called functional nervous diseases
daily contribute intricate and fascinating psychological problems. It is,
in my opinion, natural that the nosology should be more puzzling in
military cases than in asylum practice, when the differences in the
circumstances under which they are brought to observation are
considered. In civil life friends and relatives co-operate with the patient
in concealing eccentricities indicative of incipient mental troubles, with
the result that the patient not infrequently remains without medical
advice until he becomes a danger to himself or others. The doctor is
finally confronted with a subject violently excited or acutely depressed,
with delusions rationalised, and hallucinations of the reality of which he
is firmly convinced. On the other hand, the non-commissioned officer,
who in the Army stands in loco parentis , looks with no friendly eye on
any deviation from the normal in conduct or conversation, so that the
embryo psychotic finds himself receiving attention from his company
or medical officer at an early stage, and the result is that he is in the
hands of the specialist before many days have elapsed. The patient
himself often seems to realise that a state of confusion is incompatible
with the handling of lethal weapons, and reports sick at times when he
would not have consulted a medical man in civil life. Difficult as it
is at the best of times to pigeon-hole the infinite variations from the
indefinite normal of mind, it becomes still more difficult when such
variations are, as it were, half fledged.

The effect of this early attention manifests itself in results which
amply compensate for any diagnostic difficulties, for these cases respond
to treatment in a very gratifying way. The following summary of the
cases discharged to duty does not reveal very brilliant results, but it
must be remembered that these represent quite a small proportion of
the total recoveries, as the majority are returned to civil life. It will be
universally admitted that it would be unwise to put a recovery from a
tubercle sanatorium to work in any place where he stands a chance of
reinfection, and it is equally unjustifiable to subject the ex-psychotic
a second time to the stresses and strains under which he broke down.
The 200 exceptions instanced herewith are mostly men who have
manifested a strong desire to put on khaki again, and signified their
intention of re-enlisting if discharged to civil life. It will be noticed
that about 26 per cent, are regular or re-enlisted soldiers. These return
to a familiar environment, and are often men more at home in the Army
than anywhere else who are less likely to be subject to the very real

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mental pain of nostalgia. Home service for twelve months is the rule
for these cases, but it is difficult to keep a man back when his friends
are going to the front, and this doubtless accounts for the large pro¬
portion noted as having found their way overseas again. In spite of
the discrimination employed the percentage of definite recurrence is
15, a number of others (12 per cent.) have been subsequently discharged
from the Army, and the quota known to be doing well at the time of
inquiry is but 47 per cent. In view of these facts, it is doubtful
whether, from the national point of view, the occurrence of a psychosis
should not be an absolute bar to any form of military service. It seems
questionable whether the good work done by those who remain stable
is enough to compensate for the trouble and expense involved in dealing
with those who have a second attack, while if returned to civil life the
latter would probably be- useful assets to the State.

With reference to treatment, it will be found that the soldier is,
broadly speaking, a good subject for institutional care. Subject as he is
to a disciplined life, he does not find routine irksome, and is appreciative
of privileges. A system of parole for convalescent patients does much
to re-establish self-confidence. Comparatively few sedatives are found
necessary, many of the patients being at a stage when a drachm of
psychotherapy is worth an ounce of paraldehyde. I have found a
popular exposition of Claparede’s theory of sleep useful in some cases
of insomnia. The visits of a kindly and tactful committee of ladies
are much valued, and contribute, I think, towards doing away with any
feeling of being sequestrated from the outside world. Such adjuncts
as massage, electrotherapy and hydrotherapy are found useful from time
to time.

In exhaustion cases mental and bodily treatment should go hand in
hand ; as the patient’s weight increases his mental readaptation should
be aided by psychotherapeutic conversations. Without this cases of
“ institution cure ’’ will result. The patient appears so rational and
well-behaved that it is not thought necessary to detain him any longer,
but he has never obtained any real insight into his condition, and
breaks down again on the slightest provocation after his return to the
outside world. In the psychoneuroses I incline to explanatory methods
rather than to suggestion per se. The latter yields excellent results as
regards isolated symptoms but does not touch the root of the matter.
Intensive suggestion is very valuable in patients too opinionated or
feeble-minded to appreciate explanations.

Occupation is essential to recovery; but it must not be of such a
kind as cannot be done automatically, and is congenial to the patient.
Patients are told to aim at the ideal of being always interested and
never tired. Such things as fancy needlework, artistic work, mat- and
basket-making are very valuable as being easily graduated employ men

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at which the patient can recover self-confidence as he sees his output
increasing. As soon as his fatiguability has sufficiently decreased he
may be put to some outdoor occupation.

Summary of the 200 Cases.

Care has been taken to exclude cases whose history was incomplete,
and those in whom the difficulties of diagnosis were so accentuated as
to make it doubtful as to where they should be placed in the very
elementary classification adopted.

Excluding professional soldiers, the composite picture obtained by
taking averages of these is that of a man, ret. 27, who has had eighteen
months’ total service in the Army, ten of which have been spent on
active service abroad. He has then had an attack of mental trouble
which has lasted about four months. In connection with the duration
of the psychosis, it is interesting to note that of 149 cases discharged
from the London County Asylums in 1913, in only 63 did recovery take
place in less than six months. I refer, of course, to cases of parallel
age to those forming the subject of this article. In all but 12 per cent
I have been able to obtain some data as to their career after leaving
hospital, and have embodied some of the findings. The time of inquiry
varied between eight months and two years after their leaving the
institution.

States of excitement .—Under this heading have been placed all cases
presenting the physical signs and mental symptoms of mania, but it is
quite likely that some have been included who really belong to an
exuberant phase of an exhaustion or other psychosis.

States of depression. —Striking similarities occur between the figures
relating to these cases and those referring to cases placed in the fore¬
going category. It will be noticed that the average age is slightly
higher. Men previously in the Army form a considerably higher
proportion here, and I suggest that the subconscious comparison between
service in the present times of crises and in peace time may have an
influence in the direction of depression. It is possible that in some
cases included here the depression is but secondary to a delusional
state, which in those noted as not doing well after discharge has
reasserted itself. The fact that in only one out of six cases with an
alcoholic history was the subsequent progress satisfactory rather supports
this view.

States of confusion .—The majority of the exhaustion psychoses are
placed here, together with a few cases of acute delirium. A source of
endogenous or exogenous toxaemia is traceable in most of them. It
has been stated that neurasthenics never become insane, but when it
is considered how much real fatigue is associated with a state of
neurasthenia, and the amount of mental energy expended on processes

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that are normally automatic, it seems only reasonable that they should
be more, rather than less, liable to the ill-effects of fatigue products. It
is certain that many definitely psychotic cases are met with who have
been what is now generally described as neurasthenic prior to the onset
of their psychosis, and remain so after their return to their apparent
normal.

It is amongst confusional states of exogenous toxic origin that the
cases most fitted for further service are found, as would be expected
from consideration of the incidental nature of their most important
aetiological factor.

Psychoneuroses .—Every variety of mental affection, from general
paralysis of the insane downwards, has at some time or another been
admitted with the label “ shell-shock.’’ The cases classified here under
that heading are those who have exhibited acute functional symptoms
such as paraplegia or aphonia immediately following on some source of
extreme emotional excitement, such as being buried, or knocked down
by the windage of an explosion. In many cases a source of w r orry
antedating this for a variable period of time is discoverable, and the
shock has only acted as the culminating factor—the final crystal to
the supersaturated solution, to use a hackneyed simile. The great
preponderance of cases from the Western Front shows what a definite
relation the frequency and intensity of shelling bears to the incidence
of these troubles. Some of those classified here under neurasthenia
commenced their psychopathic career with similar symptoms, but these
had passed off at the time of their admission, leaving them in a
condition the most salient features of which were tremulousness on the
physical side, and lack of concentration on the mental. In other cases
the onset took the form of a period of amnesia. It will be seen that
these cases have not done very well after discharge, but it must be
remembered that only those bad enough to be considered “ mental ”
have been admitted, and that limitations of time have prevented that
“ following-up” treatment which is so desirable.

Delusional states .—Exclusive of a few alcoholic cases these have
been mostly of a paranoidal nature, and such as one would have
ordinarily regarded as unlikely to improve. With explanatory treatment
many of these clear up even when they have had definite ideas of
reference with some attempts at systematisation. Cases of paranoia
proper have been comparatively rare. The average age, total service,
and foreign service are all higher in this class than in any other.

Mental defectives .—Those considered here are naturally of high
grade, men of poor general mental development who have been
considered capable of coping with manual labour on home service.
Two cases of “mental instability” have been included—subjects who
developed attacks of irritability and intolerance of discipline due to

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108 PSYCHOSES IN THE EXPEDITIONARY FORCES. [April,

failure of adaptability. Both of these have had fairly long service,
as also had one man whose defect was chiefly on the moral side.
Excluding these, it is remarkable how little active service causes a
mental defect to become obtrusive even in those who have done fairly
well in the Army at home.

Other psychoses .—Five eases of dementia praecox are included under
this heading. Although the average time under treatment has been a
month longer than that of any other class, none of these have done
really well. In spite of an apparently complete recovery, their subsequent
history shows that what was obtained was only a remission. There
have been many cases which at first seemed to be dementia praecox,
the catatonic, hebephrenic, and paranoid forms being simulated, but
which have cleared up very quickly without leaving any mannerisms or
psychopathic aftermath. These I regard as cases of “ regression”—
an attempt at adaptation on lower psychic levels when the superior
functions are in abeyance. Capt. Maurice Nicoll, in the Lancet of
June 8th, 1918, summarises them well in the following words : “ Persons
who showed a greater or less degree of infantility, with abnormally
reinforced fantasy or dream life.” In the present paper they have been
placed with the confusional states. Two cases classed as impulsive
insanity were unstable subjects who had committed impulsive actions
through increased irritability under strain rather than under the influence
of true obsessions or imperative ideas. In the one case of stupor the
condition was preceded by a short period of excitement.

Conclusions.

While laying claim to no new discovery, I think that the facts
presented in this article furnish additional arguments in favour of three
propositions which have already received some support.

(1) That the early treatment (compulsory or voluntary) of psychotics
is very important.

(2) That the presence of a psychiatrist on medical recruiting boards
is very desirable.

(3) That careful consideration before returning a man who has
suffered from an established psychosis to military service is very
necessary.

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Clinical Notes and Cases.

A Short Note on the Use of Calcium in Excited States. By T. C.

Graves, B.Sc., M.B., B.S.Lond., F.R.C.S.Eng., L.R.C.P.Lond.,

Temp. Capt. R.A.M.C.

According to Prof. William Bayliss, calcium is necessary for the
normal effect of adrenalin on sympathetic nerve-endings. Acting on
the assumption that in acute excited states there can be no lack
of adrenalin in the body but an absence of its “ fixation ion,” I have
exhibited calcium lactate in ten-grain doses to many cases of more or
less acute excitement with satisfactory results. The cases include,
of the manias: epileptic, simple, delirious, and recurrent; agitated
melancholia and recent acute hallucinations. The effect of the drug is
to calm the mental state and improve the physical condition. A rapid,
weak pulse becomes slower and stronger, any diarrhoea present ceases
or is improved, a dry, harsh skin becomes moist and supple, the appetite
also is improved. The younger the case the better the result, similarly
the more recent the case, especially if of influenzal origin. Some of the
cases, however, have responded although over forty years of age, and
several old-standing cases have shown a temporary improvement.

Part II.—Reviews.

Diseases of the Nervous System: A Text-Book of Neurology and
Psychiatry. By Drs. Smith E. Jelliffe and W. A. White.
Second edition. Philadelphia and New York : Lea & Fibiger.
1917.

The form of this book is best described in the authors’ own words—
“ a work on the diseases of the nervous system rather than two books,
one on neurology and one on psychiatry, which would perpetuate a
distinction which the authors believe to be artificial.” A work written
from this standpoint should be welcome after the numerous clinical
volumes compiled on the supposition that the lower realms of nervous
action have little more than a bowing acquaintanceship with the cerebral
cortex.

The volume has been divided on physiological lines into three parts
which treat respectively with the vegetative (endocrino-sympathetic),
the sensori-motor, and the psychic systems, between which there is
uninterrupted reaction; and all the clinical entities under these headings
are dealt with in a remarkably clear fashion. The book opens with
a useful and concise chapter on methods of examination, in which

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important points are illustrated by photographs of the clinical features
and diagrams of the spinal or cerebral area involved. We note that
some of Dejerine’s figures have been made use of to the advantage of
the reader.

Part I, “ The Physio-Chemical Systems,” which deals with vegetative
or visceral neurology, contains much information of value to the
clinician, and emphasises the relationship now known to exist between
this system and psychic function. The writers are impressed with the
important correlations which exist between the lower or vegetative
mechanism and cerebral disturbance, especially in the emotional field.
“ The role of this system (vegetative) in its reaction to mental stimuli
. . . has helped to give an interpretative status for empirically held

beliefs ” : and the anatomical foundation for this statement is that “ the
ganglionic system which in man serves the vegetative functions of the
body is represented in the primary metameres, the spinal cord, again
in the brain-stem, central grey matter and mid-brain, lenticular nucleus
and optic thalamus (hypothalamus), and finally in the cortex, where
the different organs under vegetative control have localisation as surely
as those of the body musculature.” Throughout this chapter there is
ample clinical evidence in support of the view that faulty stimuli at
psychological levels can and do produce equally faulty reactions in the
vegetative sphere, and vice versa.

Part II is concerned with sensori-motor neurology, and although
this section is rather compressed, the authors have succeeded in giving
a clear account of the symptomatology. The subject matter is well
illustrated by photographs and anatomical diagrams, some of which are,
as noted under Part I, taken from Dejerine’s work.

In Part III, “The Psychical or Symbolic Systems,” we note that
psycho-analysis occupies a prominent position, especially in its applica¬
tion to the aetiology of mental disease. Emphasis is laid upon failure
of mental adjustment to the difficulties in life with its consequent
egocentricity, introspection, defective reaction, phantasy formations,
conflicts, repressions, and dissociations. In this mechanism infantile
pleasure-seeking plays an important part, and on this point there are
some interesting illustrations under the “compulsion neurosis.”

Manic-depressive insanity is, according to the authors, “ an effort at
compromise and defense resulting from an endopsychic conflict.” “ In
the depressive stage the affect has broken through and invaded con¬
sciousness, while in the manic phase the patient, by feverish and restless
activity, by constant alertness, fights off every approach that might
touch him on a painful point, that might reach a vulnerable spot.”
The patient flies into reality to avoid the conflict, hence he is “extero-
verted.”

In direct contrast to this a patient suffering from so-called dementia
prsecox is “ introverted.” Here there is a splitting of the personality
which results in regression to the infantile and archaic in the individual,
thus permitting older phylogenetic thought symbols to appear in
conduct. Somatic disturbances in the realm of the vegetative nervous
system assist in this process, although the authors admit that prominence
must be given to the psychic factor. Still, though the mental symptoms
may be psychogenetic their reaction on the sympathetic system cannot

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be ignored. In this connection attention is directed towards considering
the patient as a unit in whom no distinction can be drawn between
mind and body.

The whole work contains many suggestive thoughts. To many these
may appear to have an insufficient basis; to others they will be welcome
on account of their very suggestiveness. The book, however, apart
from controversial matters, has the special merit that it links up
neurology with pyschiatry, both of which have been separated too long
to their mutual detriment. The whole nervous system must be treated
as one single entity, and the writers have, and with considerable success
too, given the reader an insight into many of the problems dealing
with the interaction of its several parts. David Orr.

Mysticism and Logic. By Bertrand Russell, M.A., F.R.S. Long¬
mans, Green & Co., 1918. Pp. 234, 8vo.

This volume consists of a series of essays by Mr. Russell which have
previously been published in other collections and various journals. In
so far as some of these essays are out of print and others may be
inaccessible to the general reader, the present collection will be welcome
to those who are acquainted with the philosophic works of the author,
as well as to those to whom this volume may open up new ground.
Perhaps one of the chief charms of this collection, from the point of
view of the ordinary reader, is the fact that several of the essays are not
highly technical in presentation, and thus it becomes possible, without
any special knowledge of philosophical methods of expression, to obtain
a useful insight into the view-point of the leading exponent of the New
Realism—a system of philosophic thought with which the name of Mr.
Russell is particularly associated.

In the first essay, which furnishes the title to the book, the writer
outlines what he conceives to be the necessary attitude for the erection
of a truly scientific philosophy. He shows how most philosophic systems
have been really no more than the rationalisation of preformed intuitive
beliefs, and that the conceptions of the universe which are presented
by such systems are subjectively determined—a reflection of our inner
emotions and wishes which view the world as we should like it to be,
rather than as it actually is when viewed with scientific detachment.
Philosophy should above all be ethically neutral, and freed from such
terms as “ good,” “ evil,” “progress” and the like in seeking to explain
the phenomena with which it deals, if it is to attain scientific success.
To quote the author: “The physicist or chemist is not now required
to prove the ethical importance of his ions or atoms ; the biologist is
not expected to prove the utility of the plants or animals which he
dissects. In pre-scientific ages this was not the case. Astronomy, for
example, was studied because men believed in astrology ; it was thought
that the movements of the planets had the most direct and important
bearing upon the lives of human beings. Presumably, when this belief
decayed and disinterested study of astronomy began, many who found
astrology absorbingly interesting decided that astronomy had too little
human interest to be worthy of study. Physics, as it appears in Plato’s

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Timaeus, for example, is full of ethical notions : it is an essential part of
its purpose to show that the earth is worthy of admiration. The modern
physicist, on the contrary, though he has no wish to deny that the earth
is admirable, is not concerned, as physicist, with its ethical attributes;
he is merely concerned to find out facts, not to consider whether they
are good or bad. ... In philosophy, hitherto, ethical neutrality has
been seldom sought and hardly ever achieved. Men have remembered
their wishes and have judged their philosophies in relation to their
wishes. Driven from their particular sciences, the belief that the notions
of good and evil must afford a key to the understanding of the world
has sought a refuge in philosophy. But even from this last refuge, if
philosophy is not to remain a set of pleasing dreams, this belief must
be driven forth. It is a commonplace that happiness is not best achieved
by those who seek it directly, and it would seem that the same is true
of good. In thought, at any rate, those who forget good and evil and
seek only to know the facts are more likely to achieve good than those
who view the world through the distorting medium of their own desires.”

It is not the affair of the psychiatrist, as such, to follow in all their
refinements the opposing claims of realism and idealism as schools of
philosophy; and it is certainly not the province of the reviewer to
discuss these vexed questions, but it does seem that such views as
the above establish a direct point of contact with those whose more
particular interests are the problems of normal and abnormal psycho¬
logy. Is it not the aim of the psychiatrist to lead back his patients to
reality, to break down the defensive erections which serve to protect
them from a strenuous adjustment to life, and thus to carry into
practice, as far as it is possible or advisable, the theoretical aim of the
philosopher? Modern researches tend to demonstrate increasingly to
what an extent the world is viewed in accordance with hidden desires,
how strenuously individuals will defend irrational beliefs founded upon
unconscious cravings, and how even dependence on some external power
behind the immediate painful experience of reality can be traced to inner
tendencies of which the individual is unaware.

That human beliefs depend on instinctive and emotional factors
always will be the case as applied to every-day thinking, but, as Mr.
Russeft says, scientific philosophy, in its particular aims and sphere,
should come nearer objectivity than any other human pursuit. It will
not pretend to satisfy the inner cravings and needs of humanity, or
offer ‘‘the glitter of outward mirage to flatter fallacious hopes,” but it
will lead to the acceptance of “ the world without the tyrannous imposi¬
tion of our human and temporary demands,” and thus furnish its own
intellectual reward. In such a conception of philosophy there is, of
course, no attempt to ignore the practical importance of ethical
teaching; on the contrary, underlying these essays it is possible to
detect the expression of the perhaps truly religious attitude towards
life and experience, but in this volume the true sphere of philosophy is
narrowed down and defined—“ it aims only at understanding the world,
and not directly at any other improvement of human life.”

The best religious thought of the present day is by no means static
or reactionary: it is freeing itself from traditional influences, it tends to
be increasingly ethical in teaching, and finds practical expression in a

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variety of necessary and beneficial social activities. Perhaps in so far
as its assumptions are recognised as intuitive in basis, so will its influence
be more cogent, but unfortunately there is a tendency at the present
time for a considerable section of the community to associate themselves
with pernicious modes of thought, disguised under a cloak of pretentious
philosophic or pseudo-scientific phraseology, which can only be charac¬
terised as harmful regressive tendencies—to use the terminology of
modern psychology. The reference is obviously to spiritualism, which,
though disguised by an apparent attitude of detached scientific im¬
partiality, is yet so clearly determined by the mechanism of “wish-
fulfilment,” and also Christian Science, an instance of that tendency to
evasion of reality which ignores and denies the existence of what is pain¬
ful—crudely expressed, the traditional policy of the ostrich in danger.

To mention these modern tendencies, which are no doubt to some
extent an inevitable reaction after years of stress and loss, would not
seem here to be out of place, since it is such a vigorous facing of
reality, such clearness of vision, and such an attitude towards experience
as find expression in this volume, combined with a humble recognition
of the limits of knowledge, which may tend to counteract the frank and
aggressive assumptions, the product of distorted desires and mistiness
of thought which are contained in the various pseudo-sciences and
philosophies now springing into such prominence.

Some chapter headings will indicate the scope of the subjects con¬
sidered. In “ The Place of Science in a Liberal Education ” the author
defines education as “ the formation by means of instruction of certain
mental habits, and a certain outlook on life and the world.” In “ A
Free Man’s Worship” is suggested the attitude towards life of those
who have no dogmatic religious belief; perhaps a rather depressing
though lofty outlook is here presented, perhaps, also, inevitably so; and
essays on “ The Study of Mathematics ” and “ On Scientific Method in
Philosophy ” contain much to stimulate and interest.

Throughout these essays Mr. Russell insists on the importance of
seeking for truth in itself rather than for any material rewards research
in any direction may bring; so that though scientific philosophy may
have no directly ethical aims, yet the principles underlying it have
definitely ethical value for those who carry them into practice. All
those who are interested in any branch of science will find much in
this volume to inspire, and they will certainly gain a clearer vision of
what the scientific attitude towards experience should be. This is
expressed in the following quotation, in which Mr. Russell is discussing
the lack of the scientific spirit in philosophy: “Philosophers and the
public imagine that the scientific spirit must pervade pages that bristle
with allusions to ions, germ-plasms, and the eyes of shell-fish. But as
the devil can quote Scripture, so the philosopher can quote science.
The scientific spirit is not an affair of quotation, of externally acquired
information, any more than manners are an affair of the etiquette-book.
The scientific attitude of mind involves a sweeping away of all other
desires in the interest of the desire to know—it involves suppression
of hopes and fears, loves and hates, and the whole subjective emotional
life, until we become subdued with the material, able to see it frankly
without preconceptions, without bias, without any wish except to see it
LXV. 8

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[April,

as it is, and without any belief that what it is must be determined by
some relation, positive or negative, to what we should like it to be, or
to what we can easily imagine it to be.”

Emphasis has beer> laid on those elements in this volume which
suggest what should be the general attitude towards scientific investi¬
gation in whatever particular sphere. Much scientific work is by no
means free from bias and preformed opinions, and it is perhaps
inevitable that it should be so, mental life being what the psychologist
knows it to be. Nevertheless, the mental attitude towards phenomena
indicated in the above quotation may well be the ideal at which the
scientist aims, however difficult it may be in practice.

To do this volume full justice, however, it should be mentioned that
several essays are more technical in character, and will thus be of special
value and interest to the student of philosophy. The following titles
will serve to indicate sufficiently the full scope of this collection, viz.,
“The Ultimate Constituents of Matter,” “The Relation of Sense-data
to Physics,” “ The Notion of Cause,” and “ Knowledge by Acquaintance
and Knowledge by Description.” H. Devine.

Essays in Scientific Synthesis. By Eugenio Rignano. Translated by

J. W. Greenstreet, M.A. London: Allen & Unwin, 1918.

Pp. 254. Price 7 s. 6 d. net.

Sig. Rignano. of Milan, is the able and energetic editor of the
international review, Scientia, published in Italy, and he has shown
himself indefatigable during the war in bringing together distinguished
scientific and philosophical contributors to his review. He is also,
however, a remarkable thinker and writer whose penetrating and
suggestive essays seldom fail to throw light on old questions or to
advance new questions. He excels in showing how one branch of
scientific activity may fertilise or illuminate another branch. This
attitude of mind is revealed, as indeed the title indicates, in the present
volume, which consists of a series of separate studies on the rdle of the
theorist in biology and sociology, the synthetic value of the evolution
theory, biological memory, the mnemic nature of affective tendencies,
the nature of consciousness, the religious phenomenon, historic
materialism and socialism. Diverse as the subjects may seem, the
spirit and object, as the author points out in the preface to the
English edition, are the same: “That of demonstrating the utility in
the biological, psychological, and sociological fields of the theorist, who,
without having specialised in any particular subdivision of science,
may nevertheless bring into those spheres that synthetic and unifying
vision which is brought by the theorist-mathematician with so much
success into the physico-chemical field of science.” In the introductory
essay the author sets forth clearly the beneficial part which the theorist,
able to embrace impartially the opposing views due to the inevitable
limitation of the specialist, may play in the advance of science. He
refers, for instance, to the problem aroused by vitalism, to the contests
between physiologists and psychologists, both in part right, concerning
affective phenomena, to the attempts of psychologists and sociologists
to appropriate exclusively the phenomena of religion which rightly

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belong to both, and he adopts the mnemic theory—now gaining
increased support in its reconciliation of the advocates and opponents
of the transmission of acquired characters—which he uses fruitfully in
some of the subsequent chapters.

The mnemic theory, with its insistence on the organic impress of
habit, is visible, indeed, in the following essay on the synthetic value
of the evolution theory. Summarising the contest between the
preformist and the epigenetist, each of whom can bring forward a long
series of facts which tell dead against the other, Rignano finds support
for his own centro-epigenetic theory (set forth in an earlier volume),
according to which the development of each part would depend not
on that of all the other parts of the soma, but rather on the continuous
action which the germinal substance of the central zone exercises on
the rest of the organism during development. The wonderful
phenomena of the recapitulation of phylogenesis by ontogenesis, he
insists, is simply an aspect of an essentially mnemic phenomenon,
a sign that the living substance remembers all the stages through
which the species has passed in consequence of the continuous
acquisition of new characters successively added to the old. Here,
in “ this affirmation of profound and unsuspected analogies between
the vital phenomenon in general and the mnemic phenomenon,
enabling us to conceive of the latter as the fundamental substratum
and inner essence of the former,” we have “an imposing synthesis of
biology and psychology.” “ All vital phenomena are also mnemic.”

In the essay which follows, the author summarises clearly his centro-
epigenetic theory, confronting it with many established facts, and argues
that the law of the recapitulation of phylogenesis by ontogenesis is the
immediate consequence of the transmissibility of acquired characters
in the mnemic sense, as understood by Hering, Semon, Butler, and
Francis Darwin, the mnemic faculty being the corner-stone of the
centro epigenetic hypothesis.

An instructive and searching study follows of the mnemic origin and
nature of the affective tendencies. In a certain sense Rignano would
accept a somatic or visceral basis for the fundamental affective
tendencies, constituted by “an infinite number of elementary specific
accumulations, differing from point to point of the body, and whose
combined potential energy would form, as it were, a force of gravitation.”
Hence special affectivities originating by way of “ habit.” Everywhere
we find verification of Lehmann’s law of “ the indispensability of the
habitual,” which he established for every stimulus to which one grows
accustomed, and in the absence of which we become conscious of a
“ need.” Maternal affection, as resting upon lactation, is here instanced.
We must attribute a similar mnemic origin, the author believes, to all
the affective tendencies, since the innate and the acquired do not differ
in their nature. “ Habit is second nature,” and that adage must be
completed by the inverse axiom—“ Nature is nothing but first habit.”
In this connection Rignano (like Stout) insists on the important distinc¬
tion between affective tendencies and emotion, and criticises the
confusion into which Sherrington has fallen at this point. Every
emotion presupposes an affective tendency, but an affective tendency
by no means necessarily involves an emotion. If we see a vehicle

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approaching in the distance an affective tendency leads us to step
calmly out of the way; if it suddenly comes on us round a corner we
experience an emotion and dart out of the way. It is not the emotion
which impels us, it is the affective tendency; the emotion is but the
reaction of a too rapid or intense realisation of the affective tendency.
The will, Rignano declares (in harmony with Maudsley), is nothing but
a true and characteristic affective tendency. “ The mnemic property,
the property of ‘specific accumulation,’ is everywhere present in
organic nature, and makes the world of life a world apart, of which the
most essential characteristics cannot consequently be explained by the
laws of physics and chemistry alone.”

What is consciousness ? This is the subject of another study, and
the author concludes that a psychic state is notin itself either conscious
or unconscious, but becomes one or the other in relation to some other
psychic state. Consciousness is thus not an intrinsic and absolute
property, but extrinsic and relative.

In dealing with religious phenomena, Rignano attaches primary
importance to the propitiatory attitude as unknown in animals (though
surely one may see it clearly in the domesticated dog), but appearing
early in the struggle between man and man. “ The first man who threw
himself prostrate, but no longer before another man, was the first believer
and the fiist founder of all religions.” Other elements, it is admitted,
become associated, but propitiation assumed struggle, and also assumed
that something was to be gained by the weaker from the stronger party,
who might be turned into an ally or protector. In keeping this weaker
party in parasitic subjection the stronger party could make use of
religion to fortify his power, for religion tends, as Reinach remarks, to
become an aggregate of taboos. All law thus has a religious origin, and
the social order at first rests entirely on religion. In developing his
exposition the author insists much on the primitive importance of war :
“No social activity set the religious organ in motion more notably than
war,” which we must consider as “ the greatest, the most universal, and
the most fundamental of all social activities.” Let it be added at once
that the author believes that “ war is condemned to disappear,” like
cannibalism ; as also religion (except in so far as it is the sweet and
intimate consolation of the individual soul) is condemned to disappear,
since both war and religion gain their power from primitive social con¬
ditions which are now passing away. It may, however, be pointed out
that the view here accepted as to the immense significance of war in
primitive society is contested. It is not accepted by many distinguished
sociologists. There are many good reasons for believing that war only
developed very slowly; even to-day among savages in the most various
parts of the world war is not a serious matter, and Sig. Rignano would
be well advised to study the powerful arguments and array of facts
brought together by the Finnish sociologist Rudolf Holsti four years
ago in his book (published in English) on The Relation of War to the
Origin of the State.

While, however, it is sometimes possible to differ from the author,
there can be no difference of opinion as to the suggestive and stimulating
value of his vigorous and thoughtful book, which is nearly always well
abreast of current research and speculation. Havelock Ellis.

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PSYCHOLOGY.

ii 7

Part III.—Epitome of Current Literature.

i. Psychology.

Why is the “ Unconscious ” unconscious ? (The British Journal of

Psychology, October, 1918.) Nicoll, Maurice , Rivers, IV. H. R.,
and Jones, Ernest.

Three papers which were contributions to a symposium at a joint
session of the British Psychological Society, the Aristotelian Society
and the Mind Association. Dr. Nicoll presents the teaching of Jung
upon the nature of the “unconscious.” To Jung the primitive life
force, or libido, is not sexuality, but an energy one of whose manifesta¬
tions is sexuality. He supposes the “ unconscious ” to have two
constituents, the one, the personal unconscious, derived from repressed
and forgotten material that has an intimate and personal significance,
and the other, the collective unconscious, impersonal and made up of
primordial thought feelings, which form the primitive pattern of all
thought, and which is worked up, according to the mental powers,
into more or less elaborate thought-systems. It would seem that
potentially in the “ unconscious ” of all people are equal possibilities
of achievement in any sphere of thought, the conscious expression
being a matter of individual capacity for elaboration and detail. "Thus
material included in the “unconscious” may find expression in a
vague inarticulate feeling which eludes definite formulation, it may
find expression in the phantasies of dementia prsecox, or it may be
adapted to reality and reach definite systematic formulation in the
production of genius.

The “ unconscious ” is thus unconscious because it is nascent
thought—thought which is not yet adapted to reality. The view is
an evolutionary one. The progressive transmutations of psychic
energy are carried out at levels beneath consciousness, just as the
progressive transmutations of the embryo are carried out in the womb
of the mother, and it is only the comparatively adapted form that is
born into waking life.

In the second paper Dr. Rivers points out that Dr. Nicoll more
or less ignores the personal unconscious, and deals with the unconscious
with which man is endowed at birth, the latter being identical with
that which the psychologist knows as instinct. Dr. Rivers devotes
his attention to what are generally known as dissociations of conscious¬
ness, i.e., elements of mental life which become unconscious, and only
enter conscious mental life in sleep or hypnosis, or in waking life
under special conditions. He seeks an answer to the following
questions: (1) Why should an experience become unconscious? (2)
why, having become unconscious, should it persist in a dissociated
state, ready to appear in consciousness after years of dormacy, if
special conditions arise? In considering the first question he shows
that in some forms of animal life, e.g., the frog, instinctive phases of
experience must pass into a state of unconsciousness in the widely

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differing phases of life-history since the instinctive needs and conditions
of life are so different. Similar, if not such striking, differences occur
in the life-history of man, and infantile instinctive reactions which are
incompatible with the reactions of adult life must become unconscious.
Proceeding on these lines the writer suggests that dissociation is a
state especially prone to occur whenever it is required to put instinctive
modes of reaction into abeyance, to suppress instinctive modes of
behaviour which would interfere with the harmony of an existence
based on less immediate and more modifiable reactions.

Though instinctive reactions are especially susceptible to dissociation,
complete suppression does not occur in human beings as in the case
of insects and amphibians in varying stages of development. In man
in whom instinct has become subject to reason the process has been
employed in a selective manner, certain elements of the instinctive
complex having been suppressed while others have been combined
with later modifiable modes of reaction. This affords a clue to the
second problem as to why the unconscious should persist. What is
incompatible with the intelligence in instinct is subject to suppression
or dissociated, but part of the instinctive process is still utilised to
form products blended with reason. The experience which is dis¬
sociated persists, partly because of the inherent vitality of instinct,
partly because the suppressed experience usually forms an integral
part of a complex, other constituents of which have been utilised and
incorporated into the personality.

Dr. Ernest Jones approaches the subject from a view-point according
closely with that of Freud. Unconscious material is characterised by
the “ resistance ” which is displayed when an attempt is made to render
it conscious, and by the fact that its content is of such a nature as
to be in sharp conflict with the tendencies and attitude of the conscious
mind. While Dr. Rivers would say that unconscious is dissociated
because it is “detrimental to welfare,” incompatible with reason.
Dr. Jones regards the process as hedonic rather than utilitarian in
nature; it is unconscious because it is unpleasant to the conscious
personality. The “unconscious” is unconscious because of the
inhibiting pressure of the affective factors grouped under the name
“repression.” These affective factors develop with mental growth, and
inhibit and repress infantile impulses which are perfectly natural in
the early stages of life. In early life the primitive pleasure-pain
principle dominates the reactions of the organism ; with mental develop¬
ment the “reality-principle,” i.e., the subordination of immediate
pleasure or avoidance of pain to the exigencies of objective reality,
supplants the pleasure-pain principle. The primitive infantile impulses
thus acquire an unpleasant feeling-tone and constitute the unconscious;
they undergo repression as a result of their increasing incompatibility
with the conscious mental life. H. Devine.

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119

2. Clinical Neurology and Psychiatry.

(1) A Personality Study of the Epileptic Constitution. (Amer. Journ.

Med. Sci., 1914, c. xlvii.) Pierce, Clark L.

(2) The Psychological and Therapeutic Value of Mental Content During
and Follo 7 ving Epileptic Attacks. (Ne 7 v York Med. Journ., October
\$th, 1917.) Pierce, Clark L.

(3) Clinical Studies in Epilepsy. {Psychiatric Bulletin, January, 1916,
to January, 1917..) Pierce, Clark L.

(4) A Further Study of Mental Content in Epilepsy. {Psychiatric
Bulletin, October, 1917.) Pierce, Clark L.

(5) The True Epileptic. {New York Med. Journ., May 4 th, 1918.)
Pierce, Clark L.

The researches contained in the above series of papers indicate a
promising line of study, which should lead not only to a greater insight
into the nature of epilepsy, but also suggest directions into which mental
therapy may be usefully applied. For some time a marked reaction
against the purely drug treatment of epilepsy has become manifest.
The establishment of colonies for the segregation of epileptics, together
with a more rational form of therapy, diet, hydrotherapy, and detailed
plans of work and exercise, indicate a recognition of a more individual
and psychological method of treatment, and of the necessity of creating
an environment to which the epileptic can make a useful adjustment.
These researches suggest that a still more intensive individual treatment
is possible, and they indicate an effort to introduce a rational psychologic
therapy for epileptic conditions founded on essential defects in the
make-up of the epileptic constitution.

An understanding of this problem can only be gained by a study of
the primary and fundamental make-up of the epileptic which antedates
the grosser epileptic manifestations for years. The usual make-up of
the potential epileptic child is one of ego-centricity, emotional poverty,
morbid sensitiveness, and an inability to take on the adaptive social
training in the home and school. Such a type in contact with an
exacting environment expresses itself in rages and tantrums, which
expressions of mal-adaption should be side-tracked by directing the
interest to another channel. In these exhibitions of baulked desire the
child’s psychic activity must be regarded as a continuously outflowing
stream of interest, unfortunately thwarted, which should not be dammed
or blocked, but should be re-directed by individual approach and pains¬
taking attempts to create an atmosphere to which the defective child
can make a satisfactory adjustment.

The main epileptic defect is an inheritable one. There is an
attenuated desire to reach out into the external world, and the social
instinct is soon withdrawn, and becomes centered on the epileptic
producing the classic ego-centric make-up, with its peculiar character
distortion. This early repression of emotion not only results in failure
of social contact, but hinders intellectual development, leading to new
stresses and humiliations. The ego-centricity is not a lack of emotional
feeling, but it is feeling wrongly directed leading to increased sensitive¬
ness. The effects of a stressful environment on such a temperament

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EPITOME.

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inherently inadaptable to normal social life are seen in the regressive
tendencies of day-dreaming, lethargies, somnolence, and, later on, definite
epileptic reactions. The last occur as a final outbreak of a too severe
tension, and psychologically may be viewed as an intense reaction away
from an intolerable situation—a regression to a primitive mentality
comparable to that of infancy or intrauterine life. The fit is thus a
kind of emotional cathartic, the sting of the previous stress is removed,
and annoying incidents are but half remembered, the amnesia acting as
a kind of protective curtain.

Therapy in essential epilepsy should concern itself especially with the
eradication, as far as possible, of the defective instincts shown in ego-
centricity, supersensitiveness, and rigidity of adaption to the home and
community. This is best brought about by a reduction of environmental
stress, educating the child in adaption to the various types of stress and
the search for a spontaneous outlet for his keen individualistic desires,
and the creation of his own interests in a healthful environment. Since
these individuals with this defective make-up tend to show pronounced
epileptic manifestations whenever they fail to make proper life adaptions,
the fit is to be regarded both a regressive as well as a protective pheno¬
menon—a reaction away from stressful reality.

In order, therefore, to obtain indications for therapeutic training,
it is important to obtain some knowledge of the epileptic mental
content in twilight states or post-epileptic conditions, in so far as this
reveals the intimate part of his unconscious strivings, and furnishes
insight into his humiliations and conflicts. In obtaining mental content,
three main divisions of psychic events are to be considered : (i) The
remote or immediate stresses that promote and aggravate the occurrence
of individual epileptic reactions ; (2) the actual mental content obtained
in the specific attack ; (3) the early or ultimate free association upon the
material expressed in the content. Proceeding on these lines, the writer
furnishes details of his investigations upon a number of cases, and he
proves that the epileptic regresses from the displeasurable difficulties
of life, and that in the first stage of the fit the stress alone may be
discerned, but that when the patient reaches a deeper unconscious
state he gains the level of an easily recognisable sexual striving. The
basic idea in such studies is to determine the defective make-up and
its specific conflicts, to bring into the patient’s mind a better insight
into his malady, and then cause him to see the consequence of his
crude handling of life. A knowledge of the epileptic content furnishes
a specific point of analytic attack by simple explanatory talks, and
indicates more definitely the type of special education which should be
adopted for each individual patient.

The task of rehabilitating such epileptics is extremely difficult
because of the depths of unconscious regression taken, and the ex¬
treme infantilism of the instinctive trends brought out. Such investiga¬
tions, however, enable them to make the best use of their lives, and
while, of course, there can be no change in the facts of life, talking
over difficulties gives much relief—it gives a new view-point, and shows
the patient that there are other ways of reacting to unpleasant stresses.

H. Devine.

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19 19-J CLINICAL NEUROLOGY AND PSYCHIATRY.

I 2 I

Psychoses associated with Influenza. (The Journal of the American
Medical Association, January zfh, 1919.) Menninger, Karl A.

The cases upon which this study is based were observed at the
Boston Psychopathic Hospital during the recent epidemic. One
hundred cases of mental disturbance associated with influenza were
admitted during a period of three months, eighty of whom were
intensively studied. The cases are divided into four groups: (1)
Infection-toxin delirium, prefebrile, febrile, and post-febrile; (2) de¬
mentia praecox; (3) other psychoses, manic-depressive insanity, psycho¬
neurosis, paranoia, alcoholic psychoses, and neurosyphilitic psychoses;
(4) unclassified. It was found that in all but the febrile deliria there
was usually an interval of from two to eight da^s from the termination
of the influenza and the first manifestations of the psychosis.

The writer suggests that these observations furnish some evidence
for the organic basis of dementia pnecox. The facts on which this
view is based are: (1) The frequency of its occurrence (31 percent.)
in this series; (2) the tendency of the cases between the ages of
20 and 30 to develop this form of disorder; (3) the frequency of
schizophrenic symptoms in otherwise typical cases of delirium ; (4)
the occurrence of several cases in which a diagnosis could not be made
between delirium and dementia praecox. The psychiatric prognosis
in influenza, excluding cases with a previous psychotic basis, such as
alcohol and neurosyphilis, may be expressed in general as delirium
(with recovery), death, or dementia praecox. H. Devine.

The Treatment of Delirium Tremens by Spinal Puncture, Stimulation,
and the Use of Alkali Agents, (fourn. of Nerv. and Ment. Dis.,
February, 1918.) Hoppe, H. //.

The method of treatment here outlined is based upon the pathology
of the disease. Delirium tremens is an acute exhaustion psychosis
developed upon a basis of chronic alcoholism. There are thus the
characteristic pathological changes in the brain, heart and blood¬
vessels, the result of chronic alcoholism, and also an acute condition of
the meninges caused by a poison which has found its way into the
cerebral circulation. Degenerative changes and passive congestion of
the intestinal tract lead to the formation of an intermediate toxin, which
is probably the cause of the delirium. As long as this toxin can be
eliminated by the kidneys, with the help of the circulatory apparatus,
conditions are fairly normal. As soon as there is a failure of elimina¬
tion, however, cerebral oedema, an increase of cerebro spinal fluid,
arterial ganglionic cell asphyxia, acidosis, and then delirium tremens
occur. The underlying causal factors, the toxin, weakened circulation,
deficient elimination, increased pressure of the cerebro-spinal fluid are
therefore rationally treated by elimination, stimulation of the circula¬
tory apparatus, and the removal of the increased pressure on the brain
and cerebral circulation.

Briefly, the routine method adopted is as follows: (1) Catharsis—
calomel and Epsom salts ; (2) digitalis and nux vomica ; (3) alkalies;
(4) hot packs ; (5) spinal puncture—from 30-60 c.c. being withdraw

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As a result of considerable experience of treatment upon these lines
the writer concludes that the disease is thereby rendered shorter and
milder, the patients are easier to nurse, complications are avoided, and
the death-rate is definitely reduced. H. Devine.

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at 11, Chandos Street,
Cavendish Square, London, W., on Thursday, February 20th, Lieut.-Col. John
Keay, M.D., F.R.C.P., R.A.M.C. (President), in the chair.

The following signed their names in the book as having been present at the
meeting or as having attended meetings of committees : Sir G. H. Savage, Sir
Robert Armstrong-Jones, Drs. M. A. Archdale, G. F. Barham, Fletcher Beach,
Charles H. Bond, David Bower, A. N. Boycott, James Chambers, R. H. Cole, M. A.
Collins, Maurice Craig, Alfred W. Daniel, H. Devine, J. Francis Dixon, R. Eager,
Claude F. Fothergill, R. W. Dale Hewson, G. H. Johnston, H. Kerr, A. C. King-
Turner, R. L. Langdon-Down, S. Rutherford Macphail, John Marnan, W. F.
Menzies, Alfred Miller, Hubert J. Norman, David Ogilvy, E. S. Pasmore, Bedford
Pierce, Daniel F. Rambaut, Charles Stanford Read, David Rice, Marriott L.
Rowan, J. Noel Sergeant, Edward B. Sherlock, G. E. Shuttleworth, Thomas
W. Smith, J. G. Soutar, T. E. K. Stansfield, R. C. Stewart, W. H. B. Stoddart,
F. R. P. Taylor, John Turner, C. M. Tuke, James R. Whitwell, H. Wolseley-Lewis,
Reginald Worth, and R. H. Steen (General Secretary).

Present at Council Meeting-. Lieut-Col. John Keay (President) in the chair,
Sir R. Armstrong-Jones, and Drs. David Bower, James Chambers, R. H. Cole,
A. W. Daniel, R. Eager, Alfred Miller, Bedford Pierce, J. Noel Sergeant, G. E.
Shuttleworth, H. Wolseley-Lewis, and R. H. Steen.

Drs. S. Rutherford Macphail, J. G. Soutar, T. E. K. Stansfield and R. Worth
were present by special invitation.

Apologies for unavoidable absence were received from: Drs. T. S. Adair,
H. D. M. Alexander, G. N. Bartlett, R. B. Campbell, Maurice Craig, Arthur N.
Davis, Thomas Drapes, J. R. Gilmour, G. D. McRae, J. Mills, L. R. Oswald, Donald
Ross, E. F. Sail, James H. Skeen, J. B. Spence, H. F. Stephens, Francis Suther¬
land, and D. G. Thomson.

The minutes of the last Quarterly Meeting, having already been printed in the
Journal, were taken as read and signed.

Obituary.

The President said that since the last meeting of the Association the death
had occurred of one of the past Presidents, Dr. George William Mould, the Medical
Superintendent of the Manchester Mental Hospital at Cheadle. Dr. Mould was
a very old member of this Association. He graduated in 1858, and then was
appointed to the post of Resident Medical Officer at Prestwich Asylum. While there
he received the transfer to the Medical Superintendentship of the Royal Mental
Hospital, Cheadle. Dr. Mould was Lecturer and Examiner in Mental Diseases at
the Victoria University, Manchester, and in 1880 became President of this Asso¬
ciation. He, the President, was sure it would be the wish of the meeting that the
Secretary be instructed to forward a suitable letter of condolence to Dr. Mould's
surviving relatives.

This was agreed to by members rising in their places.

The President said he wished next to refer to a personal matter. He was
very sorry that illness prevented his attendance at the meeting held in London last
November. At the same time he wished to express to members his thanks for the

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I 919 .]

letter of sympathy he received on their behalf from the General Secretary. Further,
he desired to express his indebtedness to Colonel Thomson for taking his, Col.
Keay’s, place on that occasion.

Greetings from the Medico-Psychological Society of Paris.

The President asked the Secretary to read a letter which had been received
from the Medico-Psychological Society, Paris.

SOClfiTfi MfiDICO-PSYCHOLOGIQUE.

Secretariat General.

Monsieur le President, —La Society Medico-Psychologique de Paris a tenu
sa stance mensuelle le lundi 25 Novembre dernier. Sur la proposition de son
President, M. le Dr. Henri Colin, elle a vote l’ordre du jour suivant:

“ La Society Medico-Psychologique, dans la joie de la victoire commune, adresse
a sa soeur, l’Association Medico-Psychologique de la Grande-Bretagne et de
l’lrlande, ses meilleurs souvenirs et ses vifs sentiments d'affectueuse sympathie;
elle emet le voeu que des liens d’une plus intime solidarity se nouent entres les deux
compagnies savantes pour le plus grand bien de la Science et de l’Humanite.”

Je suis heureux d’etre charge par mes collegues de vous envoyer cet ordre du
jour, faible temoignage de notre sincere attachement et de notre vive admiration
pour le Grande-Bretagne, cette noble Nation, qui a luttd vaillamment et noblement
i c6td de nous pour dfefendre la civilisation contre la barbarie.

Veuillez agrder, Monsieur le President, 1 ’hommage de mes sentiments respect-
ueuses et ddvouds.

“Le Secretaire Gdndral,

Paris; Ant. Ritti,

le 8 DScembre, 1918. 68, Boulevard Exelmans (XVI).

Monsieur le President de l’Association Medico-Psychologique de la Grande-
Bretagne et de l'lrlande.

The President said he was sure all members would reciprocate most cordially
the desire of their sister society in Paris for closer relationships, and, therefore,
that it would be the pleasure of those present to authorise a letter being sent
expressive of their sentiments, also their never-dying admiration for their gallant
comrades of France. The question arose as to the manner in which the closer
relationships alluded to could be manifested. It might be suggested that this
Association should invite representatives from the sister Society to attend the next
annual meeting of the Association. He would be glad to hear views on the matter.

Dr. Bedford Pierce moved that the President’s suggestion be adopted, namely,
an invitation be sent to the Paris Society to send representatives to the Associa¬
tion’s next annual meeting.

This was agreed to.

Resignation of Dr. Steen as Secretary.

The President said he presumed members were all aware that the General
Secretary, Dr. Steen, had been advised to curtail his activities, hence he found it
necessary to resign the office of Secretary of the Association. Dr. Steen had been
a most admirable Secretary, possessed of energy, tact and wisdom, he had been a
safe guide, and was always a most jealous guardian of the interests of the Society.
It was fortunate that he was able to announce that Major Worth had expressed his
willingness to take upon himself the burden which had been borne by Dr. Steen,
and it should be left to the President to express the confident hope and expectation
that he would be a worthy successor to Dr. Steen.

Dr. Steen thanked the President for the very kind remarks he had made con-
concerning him. At times the secretarial duties might seem rather heavy, but the
other officers of the Association were so very helpful and kind, especially the
Treasurer and the late Treasurer, that really the work had not been so very difficult
after all, and it certainly was a great pleasure to work for the Association.

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Asylum Administration as affected by Present Events.

The President : Members have all received an addendum to the business of
this meeting, in the form of a letter from the General Secretary, stating that he
had been written to by several members to say that, in their opinion, the Associa¬
tion should discuss the question of asylum administration as affected by present
events. It is suggested that that item of the business of the meeting should come
on now, therefore I will call upon Dr. Wolsejey Lewis to introduce the subject.

Dr. Wolseley Lewis: You ask me, sir, to introduce a discussion on asylum
administration as affected by present events, and I do so, not because I have a
scheme for an asylum millenium in my pocket, but because I think it is a matter
of paramount importance to this Association. The recent events alluded to are,
firstly, the issue of the programme of the National Asylum Workers’ Uuion; and,
secondly, some conferences which have been held at the Guildhall and at the
London County Hall recently, at which this programme, among other things, was
discussed. I have had the advantage of studying the National Asylum Workers'
programme, and also of having been present at both the conferences. Whether
we view the National Asylum Workers’ Union with sympathy or not, whether
we approve of the nursing staff of an asylum being members of a trade union,
whether we think it dignified, appropriate, or wise for them to join the Union
appears to me to be chiefly a matter of academic interest. The fact is that they
have formed a Union. The law allows, and public opinion approves of, the
principle of collective bargaining. It is our business, I submit, to deal with the facts.

What are the facts ? Firstly, a registered trade union has been formed by a
considerable percentage of asylum staffs, and they have been trying to enforce
their demands by strikes and threats of strikes. The ever-increasing demands of
this Union have driven public authorities to unite in order that they might formu¬
late some common policy to deal with the situation. The Executive Committee
of the Guildhall Conference and of the Conference which was held at the London
County Council Hall have written to the Ministry of Labour asking that ministry
to set up an Industrial Board, composed of ten representatives of the public
authorities and ten representatives of the National Asylum Workers’ Union. And
the delegates of the National Asylum Workers’ Union who were present at the
London County Council conference undertook to recommend to their executive
committee that they would make a similar representation to the Ministry of Labour.

So much, then, Mr. President, for the facts. Now, there are two points to which
1 wish to draw your very particular attention. The first is, that the National
Asylum Workers’ Union claims to be representative of a highly-skilled body of
workers. Is that claim well founded ? They admit—nay, they induce to become
members of the Union—any employee entering an asylum, however newly joined,
however untrained, and whatever measure of responsibility he may have. On the
other hand, they discourage, and I understand they exclude, an officer of any sort.
It seems to me that that necessarily means that the preponderance of their members
must be the comparatively irresponsible, those who know very little of the con¬
ditions of asylum life, and that their debates must necessarily lack the steadying
and wiser counsels of those who, by longer service and by their ability, have raised
themselves from the ranks. So that I ask again, Does the National Asylum
Workers' Union really represent the skilled nursing employd of an asylum?

The second point to which I wish to draw your attention is this : There are
many questions of asylum administration on which medical superintendents are
asked to advise their committees. But under this Industrial Council the medical
superintendents will have no representative on either side, and it seems to me,
under such circumstances, that members of this Association will find themselves
in a very anomalous position! Take, for instance, the first item on the Asylum
Workers’ Union programme. They ask for a 48-hour week. That is, by inference,
an 8-hour day, or night, as the case may be. Obviously our first duty is to safe¬
guard the interests and to promote the welfare of our patients by every means in
our power. Recognising this, I have long been in sympathy with a reduction of
the hours of the nursing staffs of asylums because I think it means improved
efficiency. But please note that, when I say that, I essentially mean hours per
day and not necessarily hours per week. It is the reduction of the working hours
per day that I believe the more intelligent of the asylum staff wish to have, and

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it is the reduction of the working hours per day which I think is likely to increase
their efficiency. In other words, I do not think 12 or 14 hours a day make
for efficiency. The war has taught us many things, and during our recent
enforced shortage of staff I had an opportunity of observing that there were
periods in the daily routine of a large asylum when a substantial reduction of
staff might occur without detriment to the patients. And this observation led
me to propose to my Committee a scheme which they have adopted and ordered
to be put into execution as soon as possible. If you will allow me I will very
shortly sketch that scheme. It is based on the old calculation of one attendant
to ten patients, and presupposes that patients rise at 6 and are in bed by 8.

Dr. H. Wolseley Lewis’s Scheme for Hours of Duty of Nursing Staff.

March , 1919.

Allow 100 Attendants or Nurses for Day Duty for 1,000 beds (i.e., 1 to 10).
Deduct 15 average number daily off duty.

„ 6 „ ,, on annual leave.

„ 3 „ „ sick.

Leaving 76 on duty.

Half Staff to commence duty at 6 a.m. and leave at 6 p.m.

Half Staff to commence duty at 8 a.m. and leave at 8 p.m.

Change of hours to be made weekly.

Staff Breakfasts 8-8.30 and 8.30-9.

Staff Dinners 12.30-1.15 and 1.15-2.

Staff Teas 5-5.30 and 5.30-6.

Allow 20 Attendants or Nurses for Night Duty for 1,000 beds {i.e., 1 to 50).
Deduct 3 average number nightly off duty.

Leaving 17 on duty.

(Other deductions allowed for in day duty numbers.)

Night Staff to commence duty at 7.45 p.m. and leave at 6 a.m.

Breakfast at 6.30 a.m.

Dinner at 7 p.m.

One meal during night in Ward Kitchens by arrangement among Staff.

Making a working day or night of io) hours, or 61 J hours per week.

Kent County Asylum, Maidstone.

Daily Routine.

Patients get up and Day Staff takes over Wards.

Night Staff Breakfast.

Patients’ Breakfast.

1st Staff Breakfast.

2nd Staff Breakfast.

Chapel.

Medical Officers’ Visits.

Airing Courts.

General Bathroom.

Female Patients’ Dinner.

Male Patients’ Dinner.

1st Staff Dinner.

2nd Staff Dinner.

Airing Courts.

Walking Parties.

Shopping Parties.

Funerals.

General Bathroom.

Lectures.

Fire Drill (Thursdays).

Catholic Service (Fridays).

Choir Practice (Fridays).

Band Practices.

6 a.m.
6.30

7 - 30

8- 8.30
8.30-9
9 l 5~ 12

12 noon
12.15

12.30-1.15

1.15- 2

2-5

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5 Patients’ Tea.

5-5.30 1st Staff Tea.

5.30-6 2nd Staff Tea.

Medical Officers’ Visits.

Entertainments.

Dances, etc.

7-7-30 Night Staff Dinner.

7 ~ 7 - 3 ° Patients go to bed.

7.45-8 Night Staff takes over Wards.

In working out the details of this scheme, I was very much impressed by
the fact that I could find no way of materially reducing the hours below what
I have said without sacrificing the patient. Of course, there is the three-shift
system. My objections to the three-shift system are these: First, it means a
constant change of personnel, and therefore a lack of continuity in the treatment
of the patient. We all know what it means if the “ charge ” and the second in
the ward are off duty. Those of you who have read your Times this morning
will have seen that in the general London hospitals there is the same move to
shorten hours, and I notice that in some hospitals they are proposing an 8-hour
day. I submit, Sir, that the condition in asylums is rather different from that
in a general hospital. I can quite understand that if you have a nurse who is,
we will say, cognisant of the proper treatment of a fractured leg, the nurse-in¬
charge might be changed three times in 24 hours without any detriment to
the patient. But in the case of mental disease, those of us who are acquainted
with the working of an asylum know it is very important that the person in charge
should have an opportunity of observing those slight alterations and gradations
in a mental state from hour to hour. The second objection is that it means a
difficulty in assigning responsibility in cases of neglect or improper treatment.
Thirdly, there is a great difficulty in assigning responsibility for stock in the
wards. Fourthly, it means a very large expenditure for the provision of the extra
staff which would be required—I mean in housing. Fifthly, it means such a
burden in the shape of wages that the ratepayer may well ask whether it is
justifiable, especially when we come to remember that though the duties of the
staff in an asylum are often very trying, and especially so in certain wards, they
are not usually arduous, and such duties as attending dances or chapels or
entertainments are certainly not so.

I have gone into this hours question at some length to show how complex
it is, and how intimately it is bound up with the welfare of the patients. It
was very noticeable that at the London County Council Conference the welfare
of the patients and the nature of the relations between the staff and the patients
was entirely ignored, and the hours question was discussed from a purely industrial
standpoint—that is to say, simply a comparison between the hours in other trades
unions and this, and not in any sense from that of the hours necessary for this
particular work. It is probable that at the Industrial Board it is thus that
this question will be decided, by bodies of men who have not the necessary
knowledge, and who will not consider how their decisions will affect the proper
care and treatment of the patients, such proper care and treatment being the only
reason why the question ever arises. That, Sir, I think, is a very Gilbertian
situation, and I think that is why this question is one of paramount importance
to the Association. I am of opinion it is imperative that we should take immediate
and definite action to place our views before any Industrial Board which may be
set up, and that we should be prepared to put forward a considered policy on these
very important questions.

If I am in order, Sir, I would like to move the following resolution : “ That
this Association, which has done much in the past to improve the treatment of
the insane, in the event of the establishment of an Industrial Board, consisting
of ten representatives of Asylum Authorities and ten representatives of the
National Asylum Workers’ Union, to decide conditions of service of the working
staff of asylums, strongly urges at the same time the provision of a board of
experienced asylum medical officers to indicate how such decisions would affect
the welfare of the patients.” And I would like to suggest, if I may, that such a
resolution, if seconded and passed by this Association, shall be sent to the
Ministry of Labour, to the Executive Committee of the Guildhall Conference,

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to the London County Council, to the Board of Control, and to the Chairmen
of the Visiting Committees of Borough and County Asylums and registered
hospitals and the National Asylum Workers’ Union.

Dr. Soutar : I second the resolution which Dr. Wolseley Lewis has moved.
I do not propose to discuss the suggestions or the demands made by the Asylum
Workers' Union. Our claim is that we, as representatives of the medical pro¬
fession dealing especially with the insane, shall be represented on, and that our
views shall be put before, any body which is considering matters concerning asylum
administration. It is suggested that that body shall consist of representatives of
managing committees of asylums and of representatives of the Asylum Workers’
Union. These look at asylum administration from two points of view. But there
is another—the most important of all—that is as to how decisions arrived at will
affect the well-being of the patients. On this matter medical officers only can
speak and advise with the authority which comes of knowledge. If they be excluded
from the body which is to consider asylum administration no informed and effective
advice will be available for securing that proposed changes in administration shall
operate to the advantage of the patients, for whose well-being alone our asylums
exist. There are committees and there are attendants who would be very glad
to have the assistance and the support of asylum medical officers in their delibera¬
tions. There are attendants—and many of them—who have in them the true
spirit of nursing, who recognise that they are not, like factory hands, merely
industrial workers. That spirit—the nursing spirit of sacrifice and readiness to
serve the sick—is active in many of our asylum nurses and attendants, and these
deserve and require the support which can be fully given only by medical officers
who are so closely in contact with them and with the persons to whom they
minister. There are, too, many asylum committees who turn to their superintendents
for advice and direction on these matters, asking how this and that proposal will
affect the patients. Such committees would, I think, regret the absence of
medical officers from a body to whom it fell to consider and decide upon matters
of asylum administration. I urge that we should endeavour to secure due
representation of the medical element on any body which is formed to deal with
asylum administration, and that to this end, and that detailed consideration be
given to the various matters raised both by managing committees and by the
Asylum Workers’ Union an advisory committee consisting of members of the
Medico Psychological Association be appointed. I have pleasure in seconding the
resolution.

The President : We shall be glad to hear the views of members or of visitors
upon this important matter ; I notice there are visitors present.

Dr. Pasmore : I support the resolution which has been proposed by Dr.
Wolseley Lewis and seconded by Dr. Soutar. The proposition is a very
important one in getting representation on this Industrial Council of medical
superintendents. Because what would happen is, that if we were getting men
who were not in sympathy with the insane, the attitude they would take up
towards the patients would be rather that of warder to convict, instead of that of
nurse to patient. It is most important that this last attitude should be preserved.
We know from books that in the past, when asylums were under lay control and
administration, the attitude was nearer that of warder to convict than that of nurse
to patient. Lay people, who do not understand the right treatment of the insane,
speak of lunatics in a derogatory manner. The Asylum Workers’ Union and the
programme which they have promulgated has received the attention of several
committees of the country. It received some attention at Croydon, but not very
much. With reference to the hours, they have asked for 48 hours per week. I
agree with Dr. Wolseley Lewis it is not feasible to work 48 hours a week, but
we have been working a 66-hour week for the last two years, and I think a 6o-hour
week is very workable. What we do is this: The patients, instead of rising at
6, rise at 7, and the nurses and attendants go off duty at 7.45. And the nurses
and attendants have two hours off during the day—an hour for dinner, half
an hour for lunch, half an hour for dressing. A 6o-hour week could be easily
worked by giving the nurses and attendants a half-day on Saturday, the whole
day Sunday, half a day Wednesday, and an evening in the week. I agree with
Dr. Wolseley Lewis that you get much fatigue emanating from the present day,
but where you break up the week, and have a break in the mid-week, that fatigue

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would be lessened. For three years 1 had the opportunity of working in the
Psychological Laboratory of University College, where we did much work on the
subject of fatigue. We found that if, when a person reached a state of fatigue, he
left off at once, he could recuperate in quite a short time ; but if he continued for
an hour after being fatigued, recuperation required a much longer time. If a man
had done a reasonable amount of work by 5, but he went on until 7 o’clock, he
would take, probably, four hours to recuperate. For that reason there is some¬
thing to be said for a shorter day, if it can be arranged.

Dr. Miller: I suggested before the meeting that there should be a time limit
for each speaker except the introducer. I shall, myself, be very brief. I think it
is right that it should be a sine qud non in the formation of these Whitley Com¬
mittees that both sides should be organised. 1 do not think medical superintendents
are going to be received on one side, and they cannot be received on the other.
Manifestly, they are employes, and I do not think it is possible for them to get
representation on these committees. For this reason they are out of court. I do
not suppose we should be sitting on the same side of the table as the asylum
workers in the Union, and we cannot be there as employers, because we are not
employers. Therefore, it seems to me, we cannot get representation on them.

The President : The idea is that there would be advisory committees, composed
of medical superintendents, who could be consulted.

Dr. Dixon : 1 suggest a slight amendment to the resolution—that we should say
“That this Association, composed of medical men who are specialists in the treat¬
ment of mental diseases.” I think it is likely some of the asylum authorities do
not know what the Medico-Psychological Association is at all, and I think it would
strengthen the resolution if that little proviso were put in, showing that the
Association is composed of medical men who are specialists in the treatment of
mental diseases.

Dr. Soutar : In regard to the question of the value of this Advisory Committee,
I think there is definite value in it, because it is clear that it is in the minds, at all
events, of some Government departments to have Advisory Committees appointed.
I heard Dr. Addison the other night speaking with regard to the appointment of
Medical Advisory Committees, and he was evidently going to make great use of
them. I think we might urge, in consideration of a matter of this kind, that an
Advisory Committee might be appointed and at all events consulted, and there
would at least be such a body in existence for the authorities to seek advice from
Some can, of course, become representative members of the proposed Board, and
we can, at all events, announce that we are in existence, and that we are prepared
to give advice and to express our opinion on the matter as it appears to us as
medical superintendents of asylums. Even if we do not go further than that, we
do take a step forward and establish our claim to be asked and consulted in regard
to a matter upon which we have experience.

The President : If no one else wishes to speak, I will put the resolution re¬
worded as follows :

“ That, in the event of the establishment of an Industrial Council (consisting
of ten representatives of Asylum Authorities and ten representatives of the
National Asylum Workers’ Union) to consider the conditions of service of the
nursing staffs of asylums, this Association, which is composed of medical men
actively engaged in the care and treatment of persons of unsound mind, strongly
urges the provision of an advisory board of experienced medical officers of asylums
to indicate how any alterations proposed would affect the welfare of the patients.”

The resolution was carried unanimously.

Dr. Bedford Pierce : May I now introduce a kindred matter for the con¬
sideration of this meeting ? It refers to the training of nurses and others engaged
in the care and treatment of the insane. As we are all aware, this Association has
worked hard at this subject for many years, yet we find in the proposals of the
Asylum Workers’ Union no reference to the training and no recognition of the
trained nurse as opposed to the untrained or the imperfectly trained one. And I
think that if we let this occasion go by without putting forward very plainly the
importance of training in the interests of the insane—it is also important in the
interests of the nurses themselves—it will be a mistake. They are not merely a lot
of uneducated people, but people who have taken up a calling which requires
training, a career which requires effort on their part to qualify for it. If we leave

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1919 ]

this out, I think we shall be undoing a great deal of the work we have done in the
past. If this training is ignored, very few in the future will take the trouble to
train. Therefore I propose that we bring this subject before the various bodies
who are dealing with this subject of conditions of service, and so I submit this
resolution :

"The Medico-Psychological Association of Great Britain and Ireland wishes to
lay stress upon the principle that the best interests of the insane demand the
careful and systematic training of all persons engaged in the care and treatment
of patients in mental hospitals.

“ The Association strongly recommends that nurses who are well trained and
duly qualified should receive considerably higher remuneration than those not so
qualified.”

Dr. Menzies : May I second that? The way we have to bring it before the
Asylums Workers’ Union is that they be requested to recognise the contracts of
apprenticeship.

Dr. Turner: I gathered from the meeting at the London County Council that
the Asylum Workers’ Union not only do not recognise the Medico-Psychological
Association, but they are under the impression that to be boxed up with the insane
means becoming a qualified nurse, and that they are going to do away with all
training. That is a very strong point.

Dr. Dixon : I attended this Conference, and I heard the delegates speak, and
from what 1 gathered they seemed to think that as soon as a candidate became a
nurse in an asylum she immediately became skilled—that a probationer on
the first day became skilled—and apparently they wanted a minimum wage
to be given to a junior employee as to a skilled worker. Of course, they
very rightly made the point that it is a very sound thing to get a better
class of worker to deal with the insane. They said if we want good treat¬
ment we must get a better class in to attend to patients, therefore we must give
them shorter hours and do various other things. But they did not say, “ There¬
fore we must train them.” It is a matter of wages and short hours. They expect
to get a good class of nurse. I do not agree with that. I think the less wages
you pay, the better nurse you get. (Laughter.)

The resolution was carried.

Dr. Bedford Pierce : I suggest that this be sent to the same people.

Dr. Macphail : Do we accept the principle of forty-eight hours per week? Do
we agree? And when we appoint this Committee from this Association, what are
they going to say ? What views will they bring before them ? I ask whether we,
as a society, accept the principle of working forty-eight hours per week ?

Dr. Steen : To answer Dr. Macphail, the Council have to-day decided to call
a special meeting of the Association to consider all these questions at an early
date.

Dr. Taylor : Am I in order in raising the question of the agenda of the meeting
at the Mansion House with regard to the business Executive Officer ? Dr.
Wolseley Lewis alluded to it in his opening speech. It is a very important
question. It appears it must be a medical administration, and I thought that
possibly the Association would make some comment on the appointment of this
proposed business Executive Officer. It seems to me to be an impossible position
for the superintendent if such an officer is appointed.

The President : That point might be brought up for the special meeting
which has just been announced by the Secretary.

[A paper was read by Lieut.-Col. E. P. Cathcart on “ Psychic Secretion—the
Influence of the Environment.” We regret that limitations of space will not
permit of its appearing in this number of the Journal. It will, however, be
published in our July number, along with the discussion which followed.— Eds.,
Journal of Mental Science.'] ,

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

At a Special Meeting of the Association, which was held at 11, Chandos
Street, Cavendish Square, London, W., on March 13th, 1919, the following
resolutions affecting asylum administration were passed unanimously:

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(1) Proposed by Dr. Soutar and seconded by Dr. David Bower—" Resolved
that to deny any asylum authority the discretionary power to appoint a medical
officer as its representative on the National Council of Institutions for the Treat¬
ment of the Mentally Afflicted is inimical to the best interests of the patients, in
whose treatment and care there often arise questions in which administration and
medical considerations are so inextricably involved that the special knowledge
and experience of the medical officers are essential for the proper understanding
of such matters, and that a copy of this resolution be sent to the Provisional
Secretary of the National Council of Institutions for the Treatment and Care of
the Mentally Afflicted, and to all asylum authorities in England and Wales.”

(2) Proposed by Dr. Turner and seconded by Dr. Turnbull —“ That whilst this
Association is in sympathy with reducing the hours of work so far as possible for
the asylum nursing staff, it is opposed to the principle of a uniform standard of
hours of work per week with payment for overtime as contrary to the ethics of the
nursing profession.”

(3) Proposed by Dr. Steen and seconded by Dr. Robertson —“ That a special
committee be formed to watch all movements of asylum management, and to be a
general advisory committee to be appointed by the chairman, treasurer, and
general secretary, together with the chairmen of the Educational and Parliamentary
Committees.”

(4) Proposed by Dr. Rice and seconded by Dr. Robertson—“ That it be an
instruction to the above committee that the fact be constantly pressed upon the
Ministry of Labour and any industrial council formed to deal with asylum service,
that the National Asylum Workers’ Union is not truly representative of asylum
workers, since it debars from membership all officers, whilst admitting domestic
workers, artisans, and the most junior probationers, and makes no distinction
between the trained and certificated, and the untrained.”

Preliminary announcement : The annual meeting will be held at York on
July 22nd and 23rd, 1919. Council meeting on July 2tst, 1919.

IRISH MEETING,

The Spring Meeting of the Irish Division was held on Thursday, April 3rd,
at St. Edmondsbury, Lucan, by the invitation of Dr. Leeper.

Members present. —J. M. Colles, K.C., LL.D., Lieut.-Col. Dawson, Dr. J. 0 ‘C.
Donelan, Dr. Greene, Dr. Mills, Dr. O’Mara, Dr. Rainsford, Dr. H. R. C. Ruther¬
ford, and Dr. Leeper (Hon. Sec.).

Letters and telegrams of apology for unavoidable absence were read from
Lieut.-Col. Keay (President of the Association), Dr. Nolan (Downpatrick), Dr.
Drapes, Dr. Hetherington, Dr. Lawless, Dr. Revington, Dr. Redington, Dr. Harvey,
Dr. Fitzgerald (Clonmel), Dr. Irwin (Limerick), Dr. H. Eustace, Dr. Gavin, Dr.
Considine.

Dr. Colies having been moved to the chair, the minutes of the previous meeting
were read and signed.

A ballot was next taken for election of the Hon. Secretary and two representative
members of Council for ensuing year.

Dr. Mills and Dr. O’Mara having been appointed scrutineers, the Chairman
declared that Dr. Leeper was elected Hon. Secretary ; Dr. Nolan, District Asylum,
Downpatrick, and Dr. J. O’C. Donelan were elected representative members of
Council.

A ballot was next taken for election of two ordinary members of the Association.
Dr. John Murnane and Dr. Stanley Blake were declared elected.

It was decided to hold the Summer Meeting at Ennis Asylum by the kind
invitation of Dr. O’Mara.

The following dates were provisionally fixed for the meetings of the Division
for the ensuing year : Autumn Meeting, Thursday, November 6th, 1919 ; Spring
Meeting, Thursday, April 1st, 1920; Summer Meeting, Thursday, July 1st, 1920.

Dr. J. O’C. Donelan and Dr. Gavin were elected to the posts of Examiners for
the certificate of the Association for the year.

The Hon. Secretary stated to the meeting that the Royal College of Physicians
had invited two delegates from the Irish Division of the Association to form part

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of a deputation to the Chief Secretary for Ireland regarding the Ministry of
Health Bill and its extension to Ireland. As the time given was so short he had
secured the help of Dr. Nolan, who was very interested and fully informed with
respect to all matters in connection with the subject, and he and Dr. Nolan had
acted as delegates from the Division, and formed part of the deputation to the
Chief Secretary. The Hon. Secretary then read to the meeting the statement
handed in on behalf of the Division as part of the deputation.

Statement to the Chief Secretary for Ireland, March 24 th, 1919.

‘'As representing the Irish Division of the Medico-Psychological Association
of Great Britain and Ireland, we notice that in Sub-Clause 1 of the Clause of
Ministry of Health Bill extending the same to Ireland the duty is laid on the
Chief Secretary inter alia to take measures for the treatment of mental defects.
We also notice that on the proposed Irish Public Health Council there is no
representative of the Irish Asylum Service. We are strongly of opinion that no
such measure should be undertaken without full consultation with the Irish Lunacy
Department, without prejudice to the independence of the latter as a department,
the powers of which should in our opinion be amplified in any event.”

It was proposed by Dr. Mills, seconded by Dr. O’Mara, and passed unanimously :
“That the action of Dr. Leeper and Dr. Nolan in acting as delegates by attending
the deputation to the Chief Secretary and submitting the views, as stated, of the
members of the Irish Division, be cordially approved of.”

The meeting next proceeded to discuss this important matter, and the following
resolution was proposed by Dr. Rainsford, seconded by Dr. O'Mara, and passed
unanimously, and the Hon. Secretary was directed to forward same to the Lord
Chancellor of Ireland, the Chief Secretary, the Attorney-General for Ireland, Sir
Edward Carson, M.P., Sir Robert Woods, M.P., J. Devlin, M.P., Sir Maurice
Dockrell, M.P., the Inspectors of Asylums, and to the Secretary, Parliamentary
Committee of the Medico-Psychological Association, with the request that Dr. Cole
would give it all possible support.

Resolution.

“ That the Irish Division of the Medico-Psychological Association, having read
the Clause of the Ministry of Health Bill, in which the treatment of mental defects
is mentioned as one of the objects of that measure, respectfully suggests that in
the appointment of an Irish Public Health Council due representation should be
given on that Council to that branch of the profession specially concerned with
the treatment of insanity in Ireland.”

A vote of thanks to Dr. Leeper for his having entertained the Division terminated
the proceedings.

REPORT FOR THE YEAR 1917 FROM THE LUNACY DIVISION,
EGYPT, BEING THE TWENTY-THIRD ANNUAL REPORT ON
THE GOVERNMENT ASYLUM AT ABBASIYA, AND THE SIXTH
ANNUAL REPORT ON THE ASYLUM AT KHANKA.

This Report again provides ample material for full consideration. As usual
Dr. Warnock’s Report is a model of what such reports should be. It really
represents, or is equivalent to, the Report of our Board of Control. It is divided
into two parts, one concerned with the central establishment at Cairo, the other
with the branch at Khanka.

Again we notice that there is great need for other asylums, the present ones
being crowded, and the criminal lunatics being also retained in the general
asylum.

The Report is a complete record not only of the medical but also of the
financial sides of the lunacy work in Egypt. Beside the general Egyptian lunacy
a considerable amount of work has had to be done in consequence of the war.
Dr. Warnock established a special hospital for all the military cases occurring in
officers connected with the British contingent.

Many points of special interest are reviewed, to which we shall refer in detail -.
for example, the serious effects of pellagra, and the different class of patients
received into the central asylum and in the country one.

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During the year Dr. Warnock had a short but much-needed holiday, during
which time Dr. Dudgeon very efficiently took over the work. Dr. Dudgeon has
special work, and under particular and trying conditions. He is away from Cairo,
with difficult approach ; he has to develop a kind of farming annexe to provide
to a great extent the two establishments with vegetables. He, too, is overcrowded,
and has no facilities as to water and electric supply. He has faced and mastered
his difficulties. Later we shall refer to his special Report.

It is not easy to consider the Report as a whole because of the alteration of the
date of issue, which is made to fit in with the financial year. The Report, there¬
fore, covers the period from January ist to March 30th, 1917, and from March, 1917,
to March, 1918. It will suffice, however, to consider the full Report more in detail.

The number of patients in residence has risen from 2,104 to 2,118. There is
accommodation in the two asylums for 1,550. The excess in residence at the
time of the Report was 568. There were 1,062 Egyptian admissions during the
year and 125 soldiers were received in the special hospital, the admissions being
1,062 and 1,219 f° r the years 1917 and 1918 respectively. The increase of
admissions is partly due to the fact that more insane patients are now sent direct
to the asylums instead of being detained in local general hospitals, pellagra being
chiefly a disease met with among the fellahin ; and as these patients are now
more freely sent to the Khanka Asylum, this contributes considerably to the
increase of admissions to that asylum. Patients are now taken to the asylum
by private motor; this obviates the troubles which used to arise when they were
taken by public conveyances. The war has prevented the building extensions
needed for female patients, and it has also prevented the repatriation of European
lunatics. It is essential that other asylums should be built—one certainly at or
near Alexandria.

Regarding discharges, of 672 Egyptian cases r 12 were recovered, 23 were
found not insane on admission, and 537 were handed over to their friends, being,
though still insane, no longer dangerous. They were discharged in order to
make room for more urgent cases. This, as we have often pointed out elsewhere,
is one of the serious results of deficient accommodation. Many of these patients
are re-admitted with relapse, or else as criminal lunatics.

The death-rate at both establishments is very high ; but this is accounted for
to a certain extent by the retention of patients at home as long as the friends can
manage with them at all, as there is still a considerable though decreasing dread
of an asylum. The second cause of the increase of deaths is the number of
chronic aged cases that have slowly accumulated at Abbasiya. Certainly there
is a need for a large asylum or hospital for chronic or mentally-defective patients,
as well as one for criminal lunatics. But, as Lord Cromer expressed to the writer
of this review some years ago, lunacy legislation must wait on finance. The
large death-rate at Khanka led to a consideration of the causes, and among these
it was decided that the diet of the patients was insufficient, especially for the
patients at this asylum, many of whom are occupied pretty fully on the farm.
The subject of diet was referred to Prof. Wilson at the Department of Public
Health. It was found that the native cheese, which formed an important article
in the diet, was almost valueless. Accordingly the diet was considerably changed,
several additions being made to it, and the improvement in the health of the
patients and the reduction of the death-rate was considerable.

The contrast of the death-rate between the pauper patients and the paying class
was very marked, the diet here again having an important influence.

The details as to building repairs do not need notice in this review, but we may
say that as usual they are most complete, and, for the administrating superin¬
tendent, very interesting. It is hoped to make a better provision for the Egyptian
medical officers, some of whom have spent many years in the asylum, and many
of whom have to live either in Cairo or in inadequate quarters.

General practitioners in Egypt are even more given to make mistakes in preparing
certificates than are their English brothers, and these general practitioners have
a pleasantly calm way of sending troublesome or dangerous patients to the asylum
uncertified. A good number of patients who were not insane were sent to the
asylum and several who were only delirious and suffering from fever.

The relative cost of maintenance, which is given in Turkish currency, is very
similar to that in England.

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Kindly reference is made by Dr. Warnock to the admirable work which was
done by Lord Cromer when he was in Egypt.

In Part II of the Report a short account of the special hospital which was
prepared for the Expeditionary Force is given. The patients as a rule were only
resident here for a short time—in fact, till they could be repatriated. During the
year 126 patients were admitted, and of all, 132 were discharged. No deaths and
no accidents occurred there. At present more of the military cases are sent
direct to the Citadel Hospital, thus relieving considerably the stress upon the
temporary hospital which Dr. Warnock had prepared. Of the admissions to this
hospital 25 were suffering from dementia prscox, 19 from delusional insanity,
only 4 from general paralysis ; 16 suffered from melancholia and 10 from mania.
Other forms of insanity were also represented, but the number of cases of dementia
prascox and of feeble-mindedness was certainly most remarkable, pointing to the
fact that a very large number of thoroughly unsuitable soldiers were enlisted.
Shell-shock was hardly represented by any of the cases admitted. As to attributed
causes and relapses, conditions of military service and congenital defect were most
marked. Forty-six of the 114 insane soldiers were said to have insane heredity.

Part III contains the special Report of the Abbasiya hospital, and is very full
of medical and social interest. The cost of each patient works out at about
1 2s. i\d. a week. Baskets and mats were made in large quantities by the patients.
The utmost care was taken in regard to the general sanitation of the institution.
A daily milk analysis was made, and photography was carried out also in relation¬
ship with all patients by the dispenser.

A more satisfactory system of drainage has been started.

There are now three grades of paying patients, and this adaptation for paying
patients is answering well. Fourteen patients who had been prematurely dis¬
charged were re-admitted as offenders.

An analysis of the forms of insanity of the 72 male and 8 female patients
admitted as accused of crime is given. This shows that pellagra was the most
common attributed cause. Chronic dementia came next, but beyond pellagra
nothing special is noteworthy as to causation of criminal lunacy. Thefts were the
most common faults, but assaults and murderous attacks were rather common.

Of the general admissions to the parent asylum, pellagra is given as the most
common associated cause. There were under care during the year, 2,367. Of
these, 99 Egyptian patients were discharged well, 446 relieved. Pellagrous
insanity produced 121, general paralysis 58, hashish produced 19. It is interesting
to note that, on the whole, the number of general paralytics was considerable,
being 58—47 male, 11 female—this proportion of female general paralytics being
greatly in excess of what occurs most commonly in England. In the country
asylum very few general paralytics were received. Over 10J per cent, of the male
patients admitted into Abbasiya were general paralytics. Pellagra accounts for
nearly 23 per cent, of the female admissions, and nearly 32 per cent, of the female
deaths.

Tables, of local interest only, are given as to the relationship of pellagra, hashish,
and alcohol to the residence of the patients admitted. Of course, as already said,
general paralysis and alcohol are much more commonly met with in town dwellers
than in those admitted from the country districts, whereas pellagrous patients
came chiefly from the country districts.

The great increase of mortality in 1917 is difficult to explain, but the following
considerations throw some light on the matter. The number of female pellagrants
admitted rose from 59 in 1916 to 73 in 1917. Another cause was the over-crowd¬
ing of the harem. The increased number of deaths of lunatics admitted suffering
from senile decay and advanced heart disease also was noteworthy. The increase
of 16 male deaths in 1917, as compared with 1916, is partly explained by the
increased deaths of general paralytics—49 against 39 in 1916. An analysis of the
deaths is given, and one may say that post-mortems were not infrequently made.
Most of the tubercular cases had evidently become infected while resident in the
asylum in consequence of the overcrowding. Artificial feeding by the stomach-
tube was performed frequently. Seclusion, of course, had also to be adopted.

The list of doses of hypnotics given is interesting, there having been during the
year 6,775 doses of hypnotics used at night. This seems to me certainly not
excessive.

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NOTES AND NEWS.

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No successful attempt at suicide occurred. Scabies was epidemic for a time.

Of the patients admitted, 8 had cut throats. In all, 54 post-mortem examinations
were made.

Very good and useful work was done by the laboratory. The services of a
medical officer were available for four months ; during the rest of the year the work
was done, in intervals from clinical work, by the rest of the staff. 408 stools were
examined, and 57 were found to contain ankylostoma and ankylostomatous eggs.
Many contained ova of other worms, and a few revealed bilharzia. 734 specimens
of blood were taken and sent to the Department of Public Health Laboratory for
Wassermann test. Thirteen specimens of sputum were examined for tubercle
bacilli, 5 being positive. The results regarding the bilharzia examinations were
interesting, and details are given of the special results.

A table is included giving the statistics of 625 cases of insanity admitted to
which the Wassermann test was applied. Thus a large number of cases suffering
from insanity of all forms were subjected to this process, and it seems to me that
it is worth while to reproduce this table.

Diseases.

Total number
tested.

Positive cases.

Percentage of !
positive cases. j

Males.

Fem.

Total.

Males.

Fem.

Total.

Males.

Fem.

Total. 1

G.P.I.

36

9

45

28

9

37

77

IOO

88

Pellagra

50

46

96

'7

IO

27

34

21

27

Adolescent insanity

47

>4

6l

I 1

4

15

23

28

30

Mania ....

61

6.1

124

14

'7

3i

23

27

25

Chronic dementia .

55

18

73

12

6

18

22

33

27

Hashish insanity .
Weakmindedness and

10

—

IO

I

—

'

IO

IO

imbecility .

33

9

42

6

3

9

18

33

25 j

Alcoholism .

29

4

33

4

4

8

*4

fioo

70

Puerperal insanity

8

8

2

2

—

25

25 1

Melancholia .

3‘

3 6

67

7

8

15

22

22

22 1

Post-febrile delirium

2

2

I

—

I

5o

—

5° !

Senile insanity

'3

IO

23

2

3

5

15

30

22 |

Epilepsy

IO

9

19

—

3

3

33

16

Paranoia

13

13

2

—

2

15

15

Organic dementia .

2

2

4

—

—

—

Delusional insanity

3

I

4

I

—

I

33

—

25

Confusional insanity

I

—

I

I

—

1

100

—

IOO

Total .

396

229

625

IO 7

69

176

27

3 o

28

Thus there is evidence of the admirable work carried out by Dr. Warnock,
both from the practical and scientific points of view.

We must make a special note of some of the work which was done by Dr.
Dudgeon.

At the Khanka Asylum there is accommodation for 400 patients. They
received 700, many of whom were direct admissions not passing through the
parent institution. There were considerable difficulties in reference both to fuel
and food. The admission number during the year was 266, the total number in
residence during the year being 956. The death-rate, 134, was very high. This
has been already referred to in reference to the imperfect diet, and also to the
serious condition in which many of the patients were admitted. Again reference
is made to the excess of fellahin among the patients, also to the very large pro¬
portion of patients suffering from pellagra. Hashish also produced a much larger
number of patients in this asylum than in the parent one. There were, as we have
already said, only three cases of general paralysis, and in all these there was

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135

a positive Wassermann reaction. In the cases admitted to Khanka, alcohol and
hashish were more common than in Abbasiya.

Elaborate notes are given of the general medical and surgical cases under
notice. Particulars are given of the operations and the surgical lesions, many of
which were of a trivial nature. There is a very careful and ingenious diagram
dealing with the death-rate in the asylum. Unfortunately at Khanka there is no
mortuary, and there are many other things required besides a great extension, which
will have to be made as soon as possible. Among the recent patients admitted the
recovery-rate was high. No mechanical restraint was used, and the employment
of narcotics was much reduced.

Among other collateral products was the cultivation of henbane, also of
guinea-pigs for the public institutions in Cairo. Altogether this Report by Dr.
Dudgeon is a very satisfactory one.

Besides the Report already noticed, there are a series of statistics referring to
the shorter period already alluded to, i.e., three months before the statutory year
commenced; but there is nothing essentially different in that report from the one
to which attention has been drawn.

The Report concludes with an appendix, giving the medico-legal instructions,
but these do not really interest the English reader of the Journal. Asylum diets
are also given, but in that respect also the Report is so peculiarly local that it
does not seem necessary to go into it.

We can only conclude this review by saying that, once more, it bears out what
has been evident.'so long—that in the hands of Dr. Warnock the treatment of the
insane is being most efficiently carried out under very arduous and trying
conditions.

CORRESPONDENCE.

Enquete de la Ligue Polonaise de l’Enseignemknt sur les Enfants

Anormaux.

To the Editors of the Journal of Mental Science.

Monsieur, —J’ai l’honneur d’attirer votre bienveillante attention sur I’enquete
organisde par notre Ligue et dont les resultats pourront 6tre du plus haut interdt
pour l’organisation des ftcoles en Pologne.

(1) Historique de l'ficolc ou de l’lnstitut consacrd & Federation des enfants
anormaux. Organisation. Initiative (privde ou publique). Nombre d'enfants.

(2) Provenance des enfants et mode de recrutement.

(3) Description des principaux types d’anormaux se trouvant h l’dcole.

(4) La fa<;on dont ils sont classds par 1 ’instituteur ou l’institutricc pour les
besoins de I’enseignement.

(5) En quoi consiste l’instruction donnde aux anormaux et arridrds ?

(6) En quoi consiste leur dducation ?

(7) Procddds employds par l'dcole pour adapter les enfants & la vie.

(8) Education morale. Moyens de discipline.

(9) Les mdthodes gdndrales d’enseignement et les mdthodes particulidres (la
lecture, 1’dcriture, Ie calcul, les travaux manuels, etc.).

lid) Les exercices des sens et de l’intelligence.

(11) L’education physique.

(12) En quoi consiste l'inspection et le traitement mddical ?

(13) Quel pourcentage d’enfants arrive h passer dans les classes pour normaux ?
Quel pourcentage arrive 4 gagner leur vie ? Quel pourcentage reste des non-
valeurs ?

(14) L'avenir de l’dducation des anormaux aprds la guerre. La ndcessitd de cet
enseignement ne va-t-elle pas grandir ?

(15) Pridre de nous indiquer :

(1) Quelques donndes bibliographiques concernant le ddveloppement de

l’dducation des anormaux dans votre pays.

(2) Quelques adresses des meilleures dcoles pour enfants anormaux dans

votre pays.

Pridre de vouloir bien envoyer les rdponses avant le i° mars, 1919, & Mile. M.

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NOTES AND NEWS.

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[April,

Grzegorzewska, secretaire de la Ligue polonaise de l’enseignement, 8, Rue
Monge, Paris 5 0 .

Dans l’espoir que vous voudrez bien collaborcr k notre ceuvre, je vous prie
d’agrcer, Monsieur, l’assurance de mes sentiments Ies plus distingu^s.

Marie Grzegorzewska.

Paris ;

Janvier , 1919.

[Replies to the queries in above letter are solicited, and should be sent to Dr.
Boulenger, Darenth Industrial Colony, Dartford, Kent.]

RETIREMENT OF DR. SOUTAR.

Dr. Soutar’s resignation of the position of Medical Superintendent at Barnwood
House has evoked expressions of appreciation of his work there which must be
very gratifying to him, and in which we wish to join.

Possessing in an unusual degree the qualities which characterise the ideal
medical superintendent, and having had the advantage of being trained by an able
and inspiring chief, Dr. Soutar was elected in 1892 to the position which he has
recently relinquished.

That the confident hopes which were then expressed regarding his future career
have been fully realised is evidenced by the terms in which the Committee of
Barnwood House have recorded how much they esteemed him. Further testimony
was forthcoming at a dinner given in his honour by medical men from all parts of
the county of Gloucester. The speeches made on that occasion manifested the
high regard in which he was held by his medical brethren, and their deep sense of
the loss they would sustain when he left the county. We realise that Dr. Soutar’s
retirement must have been a sorrow to his patients, to whom he has always
unsparingly devoted himself, and who regarded him not only as a physician, but
as a friend ; for his personal influence and his great gift of sympathy enabled him
to give to them the help and support so largely needed.

The officers, nursing staff and the employes of the Hospital asked Dr. and Mrs.
Soutar’s acceptance of a piece of plate and of an address in which they expressed
their sorrow at his resignation, the esteem and affection felt for him by all, together
with the hope that both he and Mrs. Soutar might enjoy long life, health and
happiness.

Those of us who had the opportunity of entrusting patients to Dr. Soutar’s care
at Barnwood House cannot but share in the widely-felt regret at his resignation.
At the same time we trust that, having been relieved of his onerous duties, he will
be able without detriment to his health to render to our Association, and to the
medical profession generally, services which he is so admirably fitted to perform.

OBITUARY.

Dr. George William Mould.

By Sir George H. Savage, M.D.

In giving an obituary notice of Dr. George William Mould, I shall first include
an outline of his personal history, contributed by his son; later, I shall give an
appreciation of his work, and also a full reference to his address as President
of the Association.

Born at Sudbury, Derbyshire, in 1835, he was the only son of his father’s first
wife. His father was a tenant-farmer and land agent; his mother, Miss Bakewell,
belonged to a local family, also occupied on the land. His grandfather held the
same land and the Rectory farm, and acted as land agent. He came from
Sandilacre, Nottinghamshire, where his family had been yeoman owners of the
same land for 300 years.

Dr. Mould was apprenticed to a firm of chemists at Derby at the age of 15,
acting at the same time as dispenser to Dr. Fox; but then he left to be apprenticed
to a surgeon, a Mr. Fletcher, at Uttoxeter, who many years after took charge of
Loxley Hall, under Dr. Mould. While a student he won the Warneford
Scholarship and Gold Medal at Queen's College, Birmingham, together with

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NOTES AND NEWS.

137

other medals in medicine, surgery, and midwifery and allied subjects, including
the Linnean Medal, also a prize for an essay proving the Divine origin of the
world. General Anson, Commander-in-Chief in India, wanted him to go out
on his staff, but his father would not consent. He was asked, also, to take
temporary charge of a private asylum in the Midlands. This chance directed him
to lunacy, and he was appointed Assistant Medical Officer at Prestwich. He then
married Miss Spencer, a local lady, who died in childbirth two years after the
marriage.

He was appointed Medical Superintendent of Cheadle in 1862, succeeding
Dr. Maudsley, who held the superintendency of this hospital for only a short
time. Later he became Lecturer on Mental Disease at Owens' College, Man¬
chester. This appointment he held for many years, when the College became
affiliated with Victoria University. At about this time, Holloway, of pill and
ointment reputation, became a friend of his, as they were associated with the
sport of coursing. He stayed with him at Cheadle, and Holloway formed so
high an opinion of his abilities and was so struck with the establishment at
Cheadle that he determined on building the Sanatorium at Virginia Water, and
taking counsel with Dr. Mould wished him to become its first superintendent.
This offer, however, he declined, though he accepted the compliment of being
made a Life Governor. Among other things, he was offered a Lord Chancellor’s
Visitorship, but this, again, he looked upon as likely to interfere with his real
interests in life, and, of all things, he seemed to dislike the restrictions that an
official position would force upon him. He became President of the Medico-
Psychological Association in 1880, and delivered an address, to which I shall refer
later.

In 1864 he married Caroline, daughter of the Ven. Edward Woolnough,
Archdeacon of Chester and rector of the neighbouring parish of Northenden,
who predeceased him. By her he had two sons and three daughters. He
subsequently married Edith, the daughter of Mr. Henry Sharp, manager of the
Bolton iron works, who survives him.

During all his life he was devoted to field sports, and he used to say that his
father took him out fox-hunting when he was only three years of age, and the
father would set his children off and with bloodhounds drag-hunt them, and on
occasion they might have to climb trees for safety. His fondness for sport and
his determination to enjoy it is proved by the fact that when he was Assistant
Medical Officer at Prestwich, with a salary of £80 a year, he nevertheless managed
to keep a horse and ride to hounds. At Cheadle he was quite one of the hardest
riders with the Cheshire and Meynell hounds. He also played polo—in fact, he
claimed to have played the first game which was played in England, on the asylum
ground. He also rode in a few steeplechases. He was especially delighted,
however, in coursing, getting second in the Waterloo Cup on one occasion. In
later life he took to fishing and shooting, which he followed up to the age of 70.
In politics he gave unswerving support to the Conservative Party. In religion
he held, without reservation, the beliefs of the Orthodox Party in the Church
of England.

So much, then, for the son’s narrative. By the death of Dr. Mould there has
been removed one of the oldest of our members. For some years he had retired
from all active work, and has not been seen at our meetings, so that the majority
of members did not even know him by sight. Those of us seniors who knew
him will always have a very warm and kindly recollection of him. Small in
stature, with the most untiring energy, he planned and carried out great designs
for the development of the treatment of the insane. His real life-work was
connected with the Royal Asylum at Cheadle, near Manchester. He found it
a small institution, and left it a model mental hospital. He had very strong
views on developing the personal interests of patients and making the hospital
a success. He enlarged its scope by adding country and seaside branches and
convalescent homes.

As already stated, he was a man of iron constitution and most unusual powers
of endurance. In the earlier days of the Association he was one of the leaders
in visiting the institutions controlled by other doctors, and very pleasant were the
reunions which then took place. Dr. Mould’s hospitality was of the most gracious
kind : welcome and good cheer made visitors feel happy and at home.

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I38 NOTES AND NEWS. [April,

As already remarked, he was a keen sportsman, and for years coursing was his
favourite pastime, and he was an excellent judge of both dogs and men.

He was too busy a man to write much for medical papers. The only production
we have in the Journal by him is the address when he was President of the
Association. Writing of any kind he abhorred, and many amusing accounts
used to be given of the difficulties which arose from his ignoring the letters even
of the authorities. If I wanted an answer myself, I used to enclose a directed
post-card, with the information that this would be repeated until 1 did get an
answer.

The time is coming when men like Mould, I fear, will not be available. The
tendency is for the administration to be separated from the medical control, and
once more there will be a return to lay control and more medical research. Of
this 1 will not write more, but I recognise that such men as Mould have done
enormously good work.

Dr. Mould gave his address as President of the Medico-Psychological Associa¬
tion in 1880. As might have been expected, it was a very practical one, and in
many ways pointed to alterations in lunacy law, which have since been made or
are still under consideration. He referred to an agitation, which was then taking
place, against private asylums, and pointed out that there was no sufficient evidence
that there was neglect of patients or selfish interests in the management which
needed any drastic measures of reform. He referred to the development of
single cottages in asylum grounds, and also to convalescent homes. And here one
may say that although this has been established and recognised by the Board of
Control for some years, there seems to be a tendency on their part just now to
modify the permission. He pointed out the objection he had to certain lunacy
forms, and protested against the alleged necessity for the two doctors who had to
see the patient and sign the certificate being forced to see the patient separately,
as he maintained that in many cases a full, complete and accurate knowledge of
the symptoms of the patient and his condition was not to be derived by a single
independent inspection. He made the suggestion that the Board of Control
should not only arrange to visit asylums, but that it would be a good thing if
the committees of the asylums could see them personally, and confer on any
suggestions that they might make.

On the need for proper training of mental nurses, espeoially those to be pro¬
vided for the nursing of mental patients away from asylums, he insisted very
strongly. He urged, what was secured in 1890, some protection for the medical
men who provided the certificates of lunacy. He also directed attention to
pensions for doctors and nurses connected with the various institutions, and
pointed out that the service in such institutions should be regarded as continuous,
so that a doctor or a nurse moving from one county asylum to another should have
the service at the two asylums as contributing to the pension. A thoroughly
useful paper was given, which made quite clear the views derived by Dr. Mould
from a very vast experience.

An Appreciation.

By Dr. D. Nicolson, C.B.

Lord Chancellor's Visitor.

In 1862 Dr. Maudsley visited Prestwich Asylum and said to Dr. Mould, then
the Assistant Superintendent, “ You must come to Cheadle after me and you will
either mar it or make it. Dr. Mould went, and he made it. It was the home and
the centre of his activities for nearly half a century. Not only did he increase the
accommodation of Cheadle itself fivefold up to a population of over 300 patients,
but he was a pioneer in the establishment of villas, cottages, and outlying houses,
where individual inmates or limited number of inmates were provided with home¬
like surroundings, where more freedom of movement and association with the outer
world were encouraged, and where the sanction of visits by relations and friends
was greatly appreciated. More important and larger branches were started in
Staffordshire and North Wales and met with a success which was especially
gratifying to Dr. Mould, who had ever in his mind the well-being of his many
patients with their varied mental idiosyncrasies.

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It was not my privilege to know Dr. Mould well until about the year 1896
when I visited Cheadle officially and had an opportunity of realising the important
nature of the work he had done, and the wisdom which had guided him in catering
for the comfort and happiness not only of his Chancery patients but of the
inmates generally. After that, and more especially after his retirement from
active work, I saw a good deal of him from time to time, and could not fail to appre¬
ciate his strong and attractive personality, his general force of character, his san¬
guine temperament and his sympathetic and unselfish disposition—characteristics
which were knit together in happy union by a generously hospitable nature, and a
keen and all-pervading sense of humour.

Dr. Mould's shortness of stature was counterbalanced by a development of brain
which was proportionately large, and which provided him with a special intelligence
and intuitive ability for diagnosis and treatment.

His wiry physique was well adapted for the good all-round sportsman that he
was, and he never was in better form than when telling of his runs with the
Cheshire or the Meynell Hounds, or recounting his adventures with his fishing-
rod or on the moor. He was fond of coursing, and won steeplechases, and is
believed to have played on Cheadle Asylum ground in the first game of polo in
England. He was very successful with his pack of greyhounds and in breeding
mountain ponies. I have only recently heard that he served as a volunteer officer
in the days when we were expecting invasion by Napoleon III.

In lunacy matters Dr. Mould was a law unto himself and rather sketchy in his
interpretation of legal formalities; but I am not aware that he came to grief or
was other than successful in his independent schemes or methods. He had a
pleasant memory of compliments paid to him by Lord Shaftesbury, who was
a guest at his dinner as President of the Medico-Psychological Association in
1880; and he told me with a merry chuckle that when dining in London on one
occasion with Sir James Crichton-Browne he met Mr. Phillips, one of the Legal
Commissioners in Lunacy, who said to him: “I know you are a very good
fellow, but you have given me more trouble than all the other superintendents
put together.”

Outside his professional work and his sporting proclivities, Mould was a
raconteur whom it would be difficult to beat, and a keen Freemason and a good
fellow. His stories were very largely original and often told against himself.
Once when taking his University class round the asylum after his lecture—and
he was an instructive lecturer and good speaker—they happened upon a patient,
a gentleman of the philosopher type, who took the opportunity of orating for the
benefit of the students, and concluded by saying: “ Well, gentlemen, perhaps you
don’t know much yet, and they say a little knowledge is a dangerous thing, but
since I came here I have found a little doctor who is a damned sight more
dangerous.” The " little doctor ” was beloved by his students, but they enjoyed
the piece of banter. Space limits me to one more story. Mould used to relate
with some pride how he persuaded a jury to bring in a verdict of “ accidental
death ” in a case where one of his patients had deliberately stood up facing a train
and got run over. The coroner afterwards told him he ought to have been an
advocate.

On his retirement, eleven years ago, he for some time found life and its concerns
irksome and depressing, but he got over this stage and settled down in his easy
chair, reading novels and light literature, and welcomed his friends gladly up to
the good old age of 84 years, retaining his marvellous memory of his manifold
experiences to the end, when he 11 passed peacefully from sleep into uncon¬
sciousness.”

Dr. Mould was three times married. By his second wife he had two sons and
three daughters. The sons, Gilbert and Philip, are doing extensive work in
lunacy and diseases of the nervous system throughout the north and west of
England. His third wife, who was Miss Edith Sharp, of Manchester, and who
survives him, is a lady of much charm and sagacity, and did excellent work during
the war as Commandant of the Red Cross Hospital at Colwyn Bay. She was the
constant helpmeet of her husband and looked after him with untiring devotion.

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NOTES AND NEWS.

[April, 1919.

NOTICES BY THE REGISTRAR.

Nursing Examinations.

Preliminary Examination . . Monday, May 5th, 1919.

Final Examination .... Monday, May 12th, 1919.

An Examination for Certificate in Psychological Medicine will be held in
London first week in July.

Essays for Bronze Medal must reach Registrar not later than June 10th.

There will be an Examination for Gaskell Prize first week in July.

Particulars of above from Registrar, County Asylum, Hatton, Warwick.

THE LIBRARY OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

Members are reminded that the Library of the Association at 11, Chandos
Street, Cavendish Square, W., contains many books which are of great value for
the purpose of reference. Recent publications are bought from time to time, and
if any member desires the use of a book not in the Library, it can be obtained by
means of the subscription which is paid to Messrs. Lewis’s Lending Library.
Application for any book should be made to Mr. Geo. Bethell, II, Chandos
Street, Cavendish Square, W.

R. H. Steen,

Secretary to Library Committee.

APPOINTMENTS.

Townsend, Arthur, M.D., Medical Superintendent, Barnwood House, Gloucester,
vice Dr. Soutar, resigned.

Brown, R. Dods, M.D., F.R.C.P.Edin., Medical Superintendent, Royal Asylum,
Aberdeen.

Kennedy, Hugh T. J., L.R.C.P.&S.I., Enniscorthy District Asylum, vice Dr.
Drapes, resigned.

NOTICE TO CONTRIBUTORS.

N.B. —The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to Lix(a) of the
Articles of Association, “ all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Papers read at Association Meetings should, therefore, not be published in other
Journals without suck sanction having been previously granted.

Dr. Drapes having resigned office as Medical Superintendent of the Enniscorthy
Asylum, his address after May 20th prox. will be: Milleen, Dalkey, Co. Dublin,
where all correspondence in future should be addressed.

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JOURNAL OF MENTAL SCIENCE, JULY, 1919.

Joseph Wiglesworth, M.D., F.R.C.P.Lond.
Obiit May i6th, 1919. President, 1902-3.

A,Hard <5s Son <5r* West \ etvman , I . fd .

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 270 [

NSW BBRIIft

No. 234.

]

JULY, 1919.

Vol. LXV.

Part I.—Original Articles.

The Present Position in Clinical Psychology. Presidential Address
by William McDougall, Major, R.A.M.C.(Temp)., M.B.,
F.R.S., at a meeting of the Section of Psychiatry of the Royal
Society of Medicine held November 19th, 1918. [By kind
permission of the writer and of the Royal Society of Medicine ]

In choosing a subject for this address, I have felt at liberty to go
outside the boundary of psychiatry , and 1 propose to put before you a
slight sketch of the present position in clinical psychology. First, it is
necessary to explain what I intend to denote by this term. It may be
said that there is not and cannot beany branch or section of psychology
that can properly be so called ; for the clinician necessarily deals with
his patient as an entire organism, and cannot, in considering his mental
life, abstract from any one part or function of the mind to concentrate
his attention upon another; his psychology therefore must be concrete
and must deal with the mind as a whole. This is true, and it follows
from this truth that, when our knowledge of the human mind shall
have become an adequate and well-established science, that science
must be the theoretic basis for all who are practically concerned with
the working of the mind, whether they are chiefly and immediately
concerned with the normal mind or with minds in disorder.

But, as I shall presently show, it is just because we have hitherto had
no such psychology that there has been growing up of late years a
specialised form of mental science which may conveniently be desig¬
nated clinical psycholog)'. There can, I think, be little doubt that a
century hence the present time will be held to be remarkable for the
great advances made in our understanding of the mind, and it will be
recognised with gratitude that clinicians have played a great and
leading part in this achievement. My purpose is to attempt a rough
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sketch of the way in which this achievement of the clinical psychologists
will appear to the historian of science in that future age.

In order to understand the rise of clinical psychology as a semi¬
independent body of thought, we must glance at the state of academic
psychology in the later decades of last century. There is some
foundation for the jibe that there were then as many psychologies as
psychologists ; yet there were certain doctrines which, especially in
the psychologies that claimed to be scientific rather than philosophical,
dominated the scene.

The chief of these were: (1) Atomism, or sensationism; (2)

associationism ; (3) hedonism.

Sensationism, the theory that all mental states, broadly spoken of as
presentations or ideas, are aggregates formed by the compounding or
clustering together of smaller fragments of conscious stuff, the ele¬
mentary sensations ; one idea differing from another merely in the
number and variety of the units of sensation combined in it (hence the
name mind-dust theory).

Associationism, the theory that all this compounding and clustering
of units to form ideas, as well as all the succession and interplay of
ideas, was ruled by the one great principle of association.

These two great principles were natural complements, and, therefore,
were almost inevitably and everywhere combined. This combination
was very widely accepted, owing not cnly to the seductive simplicity of
the notion, but still more perhaps to the fact that it lent itself to
combination with the increasing knowledge of the structure of the
brain, to form a purely mechanical and materialistic theory of mental
life. For the mental elements were regarded as being functions of the
brain-elements or cells, as the sound of a plucked string is a function
of the string ; and the ideas or clusters of elements were likened to the
chord heard when many strings are plucked or sounded together.
Association was a function of the connections between brain-cells; and
all the play of mental life was but a matter of the ringing up of brain-
cells and groups of cells by the spreading of the nervous impulse
from group to group, according to the simple principles of mechanical
association.

British thinkers, Locke, Hartley, the Mills, Bain, and Herbert
Spencer, to mention only a few of the most distinguished, were chiefly
responsible for the immense success of these two principles.

To some thinkers these two principles alone seemed. sufficient to
account for all thought and all action ; for to will was to have an idea
of an action or movement, and these ideas of movement were, like all
others, subject only to the great law of association. This was the
theory of ideo motor action, dearly beloved of so many of our French
colleagues, and unduly emphasised by many of them.- But others

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could not overlook the fact iliat men commonly act, not merely because
an idea of action comes into their minds, but because they have a
purpose, seek some end, or strive to achieve some effect; and, looking
round'for some formula to define that end, they said—It is pleasure l
In acting, in seeking, in striving, men, they said, are always moved by
the desire of pleasure. There you have the third great principle of
hedonism.

The psychologies which did not base themselves upon these principles
were in the main highly metaphysical, and not such as to engage the
attention of physicians struggling with the problems of mental and
nervous disorder. And so we find that these physicians adopted,
almost without exception, the mechanistic psychology founded on
atomism, association, and hedonism.

This psychology, however, was wholly inadequate to the needs of
psychiatrists. Its specious principles afforded little or no help when
brought to the practical test of use in the interpretation of mental
disorder.

And the natural consequence of its acceptance by psychiatrists was
that those among them who were moved to research devoted themselves
almost wholly to the attempt to discover the material basis-, the neuro¬
pathology, of mental disease, this tendency being strongest where the
mechanistic psychology was best established—namely, in England and
Scotland ; while the practical physician used the psjchology of common
sense and common speech, supplemented by his own intuition and
large experience of men—a condition of affairs illustrated by the
majority of the older text-books still in use.

I will further illustrate the position by reference to the writings of
three leaders of psychological medicine, in Germany, France, and
England respectively.

Prof. Ziehen, whose works have enjoyed a wide circulation, repre¬
sents the pure principles of mechanistic materialistic psychology based
on the three principles mentioned above. His psychology claims to be
a physiological psychology; in reality it is a speculative and highly
dubious brain-physiology which for psychiatry is utterly sterile.
Psychology of this sort seemed at one time to have achieved a triumph
in its interpretation of the varieties of aphasia, but it is, I think, now
generally recognised that this triumph was illusory, and that in the main
it obscured and distorted the facts.

Prof. Pierre Janet may justly claim to be the father or founder of
clinical psychology. Starting with the principles of the mechanistic
psychology, and, like other French write s, attaching great importance
to the notion of ideo-motor action, he greatly developed the conception
of mental dissociation. But valuable as was this contribution, his work
would have remained on the purely descriptive plane had he not

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broken away from the mechanistic psychology by introducing a new
conception quite incompatible with it—namely, he conceived the mind
to be pervaded by a synthetic energy, variable in quantity, whose
function is to hold together in one stream of consciousness the various
sensory elements, and in defect of which dissociation of consciousness
into partial streams occurs.

In this country, the transition from old to new doctrine which I am
attempting to sketch is illustrated in the most striking way by the work
of Dr. C. Mercier. This brilliant writer, after having expounded the
mechanistic psychology with great force and confidence, has made the
discovery that in presence of all problems of action it leaves us utterly
helpless. Thereupon, instead of undertaking a radical revision of his
psychology, he announces our need of a new and distinct science—
namely, a science of conduct (which he proposes to call praxiology )—
and writes a new volume to lay the foundations of this much-needed
science. No happier illustration of the inadequacy and sterility of the
mechanistic psychology could be found. In taking this course Dr.
Mercier was unconsciously following the example of John Stuart Mill,
who began by adopting and expounding the purely mechanistic psycho¬
logy of his father; and then, discovering, like Dr. Mercier, that it
threw no light on problems of conduct and of character, sketched out a
new science to fill this gap, proposing to call it ethology. Thus does
history repeat itself even in the realm of science.

These three thinkers I have cited fairly represent the many others
who have vainly striven to bring the mechanistic psychology to the aid
of medicine. No wonder, then, that others have thrown aside all
academic psychology in approaching the problems of the disordered
mind; and it is perhaps well that they have done so; for their relative
freedom from the paralysing shackles of the mechanistic psychology has
enabled them to make progress; but their repudiation of all academic
psychology has inevitably resulted in those peculiarities of the clinical
psychology of our time which mark it off from the main stream of
psychological tradition and development.

This method of approach and these consequences are best illustrated
by the work of Prof. S. Freud, who, whatever verdict may ultimately be
passed on his psycho therapeutic methods, will certainly rank as one
who has .given a great impulse to psychological inquiry, Freud’s
psychological work may be said, from the logical point of view, to
have begun from the wrong end. Without any preliminary attempt to
consider first principles of mental life, to analyse consciousness, or even
to define the terms which he uses, this daring and original inquirer has
wrestled at first hand with the problems of conduct, and especially with
the problems of disordered conduct as presented to him by his patients
in all their concreteness and complexity. Thus approaching, he has

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been deeply impressed by the great fact that much of human conduct,
both normal and abnormal, proceeds not from consciously reasoned
motives nor from any chain of association of clear ideas, but from a
great impelling force that works within us, expressing itself only very
obscurely in consciousness as vague feeling and uneasiness. This he
has recognised as the sexual impulse; and, having been deeply
impressed by the far reaching effects of this upon conduct, and by the
obscure and devious modes of its operation, he has gone on to bring
under the same heading whatever other forces of a similar nature he
has seemed to detect as co-operating with and subserving it, or which
the vagueness of common speech seems in any way to connect with it.
In this way, in his reaction from the mechanistic psychology, he has
brought to light two great allied facts: (1) The impulsive, demoniac,
illogical nature of much of human thought and conduct; (2) the very
partial and inadequate way in which consciousness or self-consciousness
reflects or represents the workings of this impulsive force. Freud’s
insistence on these two facts is his fundamental contribution to psycho*-
logy; and it is the recognition and emphasis of them, thanks largely to
his labours, that is the key-note of clinical psychology at the present
time.

Freud’s development of these two truths has been marred by several
errors : First, his attribution to the sexual impulse of much of conduct
that is not properly so attributable, and his consequent exaggeration of
the role of sex; secondly, he has not wholly freed himself from the
errors of the mechanistic psychology, in spite of his detachment from
tradition, so natural are these errors to the scientific mind; two
especially he has retained— (a) instead of repudiating the mechanistic
determinism, he claims that he has for the first time established this
principle in psychology ; ( b) instead of repudiating hedonism, he has
made it his own and attempted to combine it with his recbgnition of
the impulsive nature of conduct, as what he calls the pleasure principle ,
in a very confusing way that largely vitiates his thinking. A third
great blemish is, that, having repudiated the traditional terminology of
psychology and having neglected to define his own terms by careful
analysis, his terminology is often obscure and misleading, and, as a
further consequence, the large unanalysed conceptions with which he
operates tend to become anthropomorphic agencies—the unconscious,
the censor, the foreconscious, etc.

But in spite of these large blemishes and beyond the two funda¬
mental principles we may, I think, see in his work permanent contribu¬
tions to psychology which are of especial value to clinical psychology
and are playing a great part in its development. Notably (1) the
conception of active continued repression of distressing memories—a
conception distinct from and much more fertile than the dissociation of

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Janet ; (2) the conception of conflict in the mind going on below the
threshold of consciousness and capable of giving rise to disorder of
thought and conduct; (3) the symbolical significance of some dreams
and of some forms of waking thought and conduct, and the value of
these as indicators of conflict and repression ; (4) the conception of
the “ affect ” as a quantity of energy that attaches to ideas, and gives
them their impulsive force in the determination of thought and conduct.

Let us now glance at the way in which others have contributed to
the further development of these lines of thought. I refer first to
Adler, who, working by methods similar to Freud’s, has diverged widely
from h'm. His chief contribution has been to secure recognition by
clinical psychology of two great impulses which seem to have escaped
the notice of Freud. He has recognised the great pait in human life
of an impulse of self-assertion, and of one of only less importance, an
impulse of self-abasement or submission ; and, applying to these what
may perhaps without impropriety be called the Freudian method in
psychology, he has assigned them an immense rd/e, and seeks to show
that their distoited working is the source of all the neuroses, just as
Freud finds that source in the sex-impulse. And, though he has without
doubt exaggerated their role in the neuroses, we mu>t forgive this natural
exaggeration in gratefully recognising that he has secured recognition by
clinical psychology of these two important impulses.

An English clinician has in a similar way secured recognition for
another great impulse. Mr. W. Trotter has discovered the gregarious
impulse, and, in a brilliant and persuasive little book, has treated it by
the Freudian method , that is to say, postulating this impulse, without
first stopping to inquire—What is its nature? What are the limits and
scope of its action ? But, sweeping into its province whatever human
activities are social or in any way dependent upon or related to the
social groupings of mankind, he has made it appear as the mainspring
of well-nigh all human activity, normal and pathological.

An American clinician has performed a similar service in regard to
yet another fundamental impulse of the human mind. Dr. Boris Sidis
has, by applying the Freudian method, sought to show that fear is the
source of all the psychoneuroses, all those troubles of thought and
conduct which Freud attributes to the sex impulse, and Adler to the
self-assertive tendency and its opposite. And though, like them, he
must be judged to have overdone his part and proved too much, he yet
may claim the credit of having given to fear a secure place in clinical
psychology. But this place has been overwhelmingly established by the
observations of a large number of physicians upon the psychoneuroses
of war; for they have learnt that many, if not all, of the modes of
neurosis may be generated by the terrifying experiences of the battle¬
field—that is by fear, or, as they commonly prefer to call it, by the

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instinct of self-preservation. Thus tear takes its place alongside sex,
self-assertion, and the gregarious impulse, as one of the great impelling
forces of thought and conduct which work independently of the
promptings of pleasure and override the principles of mechanical
association.

We may, I think, assume that clinical psychology has not yet come
to an end of its advance along this line, and may confidently expect
that there remain other fundamental impulses of like nature to be dis¬
covered by it playing their parts in the genesis of mental and nervous
disorders.

Now, it is of the essence of these great fundamental impulses, thus
revealed as the underlying motive powers of so much of thought and
action, both normal and abnormal, that they are purposive or teleo¬
logical, and are not to be deterred by pain, nor turned aside from their
biological ends by pleasure. They override and dominate for their own
purposes all the mechanisms of association and the hedonistic influences.
Therefore their recognition in clinical psychology necessarily leads to
a complete break with the mechanistic psychology. Freud’s own
teachings show clearly the purposive character of much in human
conduct that had been regarded as merely the fortuitous outcome of
mechanical haphazard association ; that, in fact, is rightly claimed by
his disciples as one of his greatest achievements. Thus he has himself
undermined both the mechanistic determinism and the hedonism
which he professes to maintain. And although clinical psychologists
commonly use the phrase “ mental mechanisms,” this is only for lack
of a better mode of expression; and some of them have grasped the
radical transformation of psychology that must result from the recog¬
nition of the great role of these primary impulses—a transformation
from the deterministic mechanical psychology to a teleological and inde¬
terministic psychology, a radical transformation, because, in spite of the
ingenuity of German metaphysicians, mechanical process and purposive
action remain utterly and fundamentally different. Most notable
among these is Dr. C. J. Jung, who in his Analytical Psychology has
forcibly shown the practical clinical importance of this revolution,
insisting that so long as we regard the symptoms of our nervous patients
as wholly and mechanically determined by the past, we miss their true
significance and render our psycho-therapy relatively sterile ; he insists
that we have constantly to bear in mind in all our procedures the fact
that conduct is determined by ideals of the future that we strive
towards as well as by the events of the past.

Jung also has made a further great step of a more speculative kind.
Repudiating the excessive sexualism of Freud and insisting upon the
importance of the food-seeking impulse, especially in childhood, he
regards all the primary impulses as differentiations of one fundamental

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energy, the life-force which sustains all our strivings, both conscious
and unconscious, thus approaching, but from a very different direction,
the conception of the Han vital which the greatest of contemporary
thinkers, Prof. Bergson, has so eloquently expounded.

Turn now for a moment to that other distinctive feature of clinical
psychology—the increasing recognition of the part played in conduct
and mental life by processes that remain hidden from consciousness.
It is difficult to make any general statements about this, because the
greatest obscurity and confusion still reign. The facts have not been
brought to light by clinical psychologists alone. Others have been
impressed by their importance and have prepared the way—Schopenhauer
and Hartmann, and F. W. H. Myers notably.

Janet, with his conception of dissociated sensations and ideas, has
attempted to give greater precision to the conception of unconscious
mental process; and others who, like Janet, have made large use of
hypnosis, have brought forward as justifying the conception all the
striking facts of post-hypnotic suggestion. Morton Prince especially,
following in the line of Janet, has striven to introduce some clarity into
the vagueness which enshrouds this region, by his demonstrations of
co-conscious personalities and co-conscious ideas; and to my mind he
seems to have made out his case for the truth of these conceptions in
certain abnormal cases. But his conception does not cover the whole
ground ; it does not cover the unconscious or subconscious operations
of normal life ; and on these Freud has rightly insisted.

The reality, the richness, and the importance of these subconscious
operations of the mind have been brought home to many of us with a
new force by our experience of the functional disorders of warfare; for
no one working among these cases can have failed to come across many
instances in which the symptoms, both bodily and mental—amnesias,
war-dreams, phobias, anxiety states, paralyses, contractures, epileptiform
seizures, headaches, tics—have been undeniably traceable to emotional
conflicts and repressed tendencies and ideas, which have operated
wholly or partly beneath or without the clear consciousness of the
patient.

But Freud and most of his disciples have followed in the line of the
“ unconscious ” of Hartmann, of Myers’ “ subliminal self,” and the
“ unconscious mind ” of other authors—that is to say they have tended
to confuse together in one unanalysed mass whatever contents and
operations of the mind are not clearly conscious at each moment, and
to make of this an anthropomorphic entity, a demon, a god in the
machine, whose nature and powers remain entirely unlimited and
incomprehensible. And Jung and his followers seem to me to fall in
some degree into the same error. I say “ error ” because this way of
treating of “ the unconscious ” seems to me unscientific; it tends

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towards a vaguely mystical attitude which, however much in place in
religious or metaphysical thinking, does not directly promote, but
rather checks, further scientific inquiry into this problem.

I venture to think that this error is again the outcome of the
contamination of clinical psychology with the fallacies of the mechanistic
psychology which it professes to repudiate. For that psychology all
mental life was a succession of clearly conscious ideas. It ignored the
fact that these ideas are but the eddies and ripples on the surface of a
stream, deep within which are the currents and forces of which those
eddies and ripples afford only very imperfect indications. This truth is
manifested all down the scale of animal life—the instinctive strivings
of the animals generally bring them surely to their biological ends,
without clear consciousness either of those ends, or of the means by
which they are achieved, or of the objects which, by impressing their
senses, guide their successive steps. And it is not otherwise with man :
he also is borne on to his biological ends, for the most part but dimly
conscious of those ends or of the mental forces and processes by which
he achieves them.

Just because the mechanistic psychology had ignored these surging
hidden streams of the life force, those who, revolting from its inade¬
quacies, have found themselves confronted by evidence of their reality
in man, have been startled by the revelation and have seemed to see
beneath the only form of mind recognised by the older psychology
another system of forces greater and more mysterious, which they have
thus been led to regard as a distinct mind or entity—the unconscious,
the subliminal, or subsconscious self.

A third way in which clinical psychology is diverging widely from the
mechanistic psychology is by its discovery of the mind’s wealth of innate
endowment. The mechanistic psychology inherited Locke’s dogma
that each mind starts out upon its course of individual experience as a
tabula rasa —a blank sheet on which experience writes as chance
determines.

The recognition of the primary or instinctive impulses, of which we
have already spoken, carries clinical psychology a long way beyond this
primitive and untenable position, showing the strong native bias of the
mind to select and react upon impressions from the outer world, not
only according to its individual past experience, but also and chiefly
according to its inherited constitution. But among clinical psycho¬
logists there is a strong tendency to go further than this, to believe that
much of the development of the individual mind is literally a recapitu¬
lation of the racial mind, a gradual unfolding at the touch of experience
of modes of thinking and feeling and doing gradually acquired by many
generations of ancestors. Only by this assumption can they explain the
striking uniformity of symptoms which characterise certain mental

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disorders, and the equally striking uniformity of thinking and feeling
revealed by primitive myth and custom among the most diverse races of
mankind.

This line of work in clinical psychology promises to contribute very
importantly towards two of the greatest problems that confront the
human intellect—one strictly biological, the other of more general and
philosophical import.

The one is the problem of heredity. If that wealth of inherited
forms of thought and feeling, towards which clinical psychology seems
strongly to point at present, should be further substantiated, this result
will decide the issue of the great controversy between those who deny
and those who affirm the inheritance of acquired characters. For
while it may, perhaps, be plausibly maintained that a few simple
instinctive modes of feeling and action may have been impressed upon
the race by natural selection alone, every demonstration of a greater
richness of this inherited structure of the mind renders this explanation
more hopelessly inadequate, and drives us back upon the Neo-Lamarckian
view that the experience of each generation impresses itself enduringly
upon the race.

The other great problem is that of the constitution of mar., the age¬
long controversy between materialism and what in the widest sense may
be called spiritualism. For so long as it is held, w'ith the mechanistic
psychology, that congenitally the mind is a tabula rasa , and the brain
little more than a mass of indifferent nerve-tissue waiting to be moulded
by impressions from the outer world, it may seem plausible to hold
that all mental potentialities are somehow comprised in the material
structure of the germ-plasm. But, with every addition to the
demonstrable wealth of innate mental powers and tendencies, this
hypothesis becomes more impossible and incredible. And it may
safely be affirmed that, if anything like the wealth of innate endow¬
ment claimed now by some— e.g., by Jung in his latest w r ork—should
become well established, then all the world would see that the
materialistic hypothesis is outworn and outrun, and that each man is
bound to his race and ancestry by links which, conceive them how
we may, are certainly of such a nature that in principle they can never
be apprehended by the senses, no matter how refined and indefinitely
augmented by the ultramicroscope or by the utmost refinements of
physical chemistry. I venture to insist upon this contribution of
clinical psychologists towards the solution of these great problems,
because few of them seem to have adequately realised the bearing of
their work on these issues, which so far transcend in interest even the
fascinating and important questions with which they are more directly
concerned.

There are many other features of interest in the present position on

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which I might dwell if time allowed. I have had time to touch only
on these few which seem to me the most significant. I have said
nothing of the burning questions of method in psycho-therapy, and to
do so would perhaps be presumption on my part. But I would like to
say one word in the nature of a warning criticism. We are repeatedly
asked to accept satisfactory clinical results not only as evidence of the
value of the therapeutic methods applied, but also as evidence of the
truth of the psychological doctrines on which they claimed to be based.
The whole history of medicine seems to me to show the danger and
the fallacy of this claim. How many accepted therapeutic procedures
have been shown to be worthless ! How many others, whose value has
been proved, have been founded upon, or held to prove the truth of,
hypotheses which are for ever dead. And we are relieved from any
compulsion to accept such evidence when we notice that the exponents
of different methods, based upon different psychological doctrines, claim
equally brilliant therapeutic results in the same class of cases; and how
even the same clinical worker continues to a< hieve equally brilliant
therapeutic results before and after a radical change of doctrine and
procedure. I insist on this as a warning against dogmatism, as an
appeal for mutual tolerance and the open mind in this great field
where we all wander, groping more or less blindly, among the deepest
mysteries of Nature.

I have tried to hint that clinical psychology, now launched upon a
great career, is in the position of a brilliant and wayward child, which,
throwing aside the traditional wisdom of its parent as of no account,
sets forth to acquire a new wisdom ab initio , and which, though making
great strides, is hampered through retaining all unawares some of ihe
prejudices and errors that it believes to have put off. And this brilliant
child, as it advances, will inevitably find that there was truth as well as
error in that parental wisdom. For the mechanistic psychology was not
the whole or even the better part of psychology : it was the work of a
sect, a series of persuasive and brilliant writers, who evolved it by
deduction from principles set up by physical science, rather than by the
patient and detailed study of human and animal life; and it enjoyed a
great vogue because it harmonised with the materialistic tendencies of
the great age of physical discovery.

But we are now in the age of biological discovery, and since Darwin
initiated this new age there has been growing up a biological and
inductive psychology, a science not springing full blown, like the psycho¬
logy of James Mill, or of Herbert Spencer, from the reasonings of one
powerful mind, but a science, based like other sciences, on a vast mass
of minute and careful observation, a slowly growing product of the
co-operation of a multitude of workers.

This science is showing the same main tendencies, the same trends,

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MENTAL WARDS WITH THE B.E.F.

[July,

as clinical psychology. And it is a bigger thing than clinical psychology .
because it is based upon a wider field of observation and induction; it
is greater as the whole is greater than the part. Clinical psychology
cannot afford to ignore this greater stream and to remain in splendid
isolation. It is to be hoped that it will renounce the effort to do so,
that the brilliant child will return to the parental fold, bringing rich
gifts, but gaining in return a greater breadth of view, a greater sanity
and balance, a more precise terminology, a greater clarity of thought,
and with these, a greater power of dealing effectively with those most
distressing of the disorders that afflict mankind—the nervous and mental
diseases.

Menial Wards with the British Expeditionary Force: A Review of
Ten Months’ Experience. By W. D. Chambers, M.A., M.D.,
Senior Assistant Physician, Crichton Royal, Dumfries (late temp.
Capt. R.A.M.C ).

During the period from March ist, 1918, to January nth, 1919, the
writer held the appointment of Mental Specialist to Boulogne Base, and
was in charge of the mental wards for that area. These were located at
No. 8 Stationary Hospital at Wimereux, and received all the mental
cases developing in or brought to the Boulogne and Calais areas. In
addition a number of cases were sent for report from the local standing
medical board, and many cases were seen at other hospitals.

Staff .—At the time of my appointment the staff consisted of myself,
two nursing sisters by day and one by night, a ward-master, twelve
nursing orderlies, and one general duty orderly. The nursing orderlies
worked eight-hour shifts, one shift relieving the other for meals, and
taking night duty in rotation. All twelve had had previous mental
experience, but in March, 1918, seven of them, being of category A, were
removed and replaced by men of low category and having no experience.
As there were frequently sixty or seventy acute patients in the wards
this made their management difficult at times.

Accommodation .—At first this consisted of two huts at right angles,
one containing forty beds, the other twelve beds and a day room, which
served as overflow dormitory. There were four cubicles, only one of
which had a door, two baths, three w.c. seats, and the usual
offices. The other two sides of the square were formed by a corrugated
iron fence, seven feet high, enclosing an airing court. All windows to
the exterior were not only heavily barred, but covered with heavy iron
mesh, immovably fixed and impossible to clean. The dayroom and
cubicles were lit only by skylights.

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Theoretically the accommodation was for fifty-six, but on my
arrival I found ninety-two patients. The excess slept on mattresses on
the floor. Fortunately a new hut containing forty-four beds opening from
the day room was ready for use by May, 1918. The more oppressive of
the bars and iron-mesh window-guards were removed, making the wards
lighter and more airy, and towards the end of the year windows were
provided in the day rooms, greatly diminishing the prison-like aspect of
the place.

After urgent application a space of 35 by 40 square yards on the
seaward side was obtained for exercise. It was surrounded by a forbid¬
ding fence of barbed wire, but allowed room for more free movements
and some games, and afforded an unsurpassable view of the Channel and
its traffic, and on a clear day of the cliffs of “ Blighty.” There was no
verandah, but the bed-patients were taken out whenever possible. Their
number varied from six to forty, but averaged twenty.

Admissions .—During the io£ months under review there were 893
admissions, in addition to the 92 patients I found in the ward. This
number included, besides men from Britain and all the Dominions, 12
Americans, 14 Portuguese, 2 French, 12 West Indian Negroes, 3 Indians,
3 Russians, 4 Poles, 1 Serbian, and 16 Germans. No officers were
admitted. The admission-rate was always lower during active fighting,
but this diminution was more apparent than real, and was largely due
to mental cases being detained in other units when the trains were busy
with wounded. The rate tended to be higher before a battle, as a result
of units clearing out inefficients and hospitals near the line freeing beds.
The additional stress and strain of a battle undoubtedly precipitates the
symptoms of the psycho-neuroses in those already sickening, but I was
unable to detect any notable increase in the incidence of insanity at
such times. It appeared that a larger number of defectives broke down
during heavy fighting, but my numbers were not conclusive. Cases
from any part of the Front may be sent to any Base, and only the
statistics for the whole battle-line could be of value in this connection.

General Management .—Another hospital at the base was appointed
to take all cases of neurosis and psychoneurosis, and it was intended
that only “ mental ” patients should be sent to my wards. A large
number, however, of patients of the former classes were sent in. Some
of them were greatly upset to find themselves in a mental ward, the fear
of insanity being ever close to the psychoneurotic, but after I got a
second ward I was as a rule able to keep them away from the worst
cases and save them this anxiety.

All cases found to be suffering from a psycho-neurosis or from mental
disease or deficiency were transferred to the United Kingdom. The
doors of the convalescent ward were open all day. Parole was freely
given and was only abused on one occasion—Armistice night. I was

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fortunate in only having one escape, a syphilophobic psychasthenic, not
on parole, who spent a night in the local venereal hospital and returned
voluntarily. He had gained a knowledge of the symptoms of the
dreaded disease which did him good. There were no suicides.

On the whole I found the soldiers extraordinarily good patients, and
incredibly more amenable than similar civilian patients. The Army
and its methods make their mark on a man soon. On two occasions
when the wards were crowded and the weather bad, a few malcontents
threatened to attack the orderlies and break out—there was always a
considerable proportion of prisoners uneasy about their fate—but both
threats fizzled out. Care was taken to avoid oppressive “ militarism,”
especially in dealing with neurotics, but no man was permitted a degree
of slackness which would diminish his self-respect.

Air-raids were rather a problem. We were situated unfortunately on
a convenient landmark—the coast from Gris-Nez to Boulogne—and the
enemy aircraft, though they seldom dropped bombs very near, frequently
passed overhead, meeting there the local barrage. All electric light was
cut off on the merest hint of a raid, and we were dependent for light in
the observation ward on three hurricane lamps turned very low. The
first considerable concussion put these out, leaving a ward full of unreliable
patients of various tendencies perilously free scope for their activities.
Fortunately no accidents happened. Defectives and hysterical cases
and the negroes were most alarmed on these occasions and needed
encouragement. Maniacs and general paretics were the envy of all.
Cases of depression and confusion, stuporose and delusional cases were
unaffected as a rule. I used hypnotics rather freely on fine nights when
a raid might be expected.

Prisoners .—Of the admissions, 125 were prisoners, either convicted
or waiting disposal, including 22 cases of self-inflicted wounds. In most
cases the offences were purely military in nature. Charges of desertion
and absence without leave were, as might be supposed, particularly
common. Cases of theft, insubordination, and assault also occurred,
mostly in defective and paranoic cases. I was required to examine
one murderer, in whom I failed to find any signs of mental disease or
deficiency.

In the Army a very slight variation from the normal in conduct
quickly attracts attention. In many cases the earliest attention takes
the form of committal to the guard-room, but the occasional individual
unfairness of this procedure is more than counterbalanced by the
advantages of having the incipient psychotic put under treatment at
once. I had never any difficulty in protecting a man from the
consequences of an offence committed while he was not responsible for
his actions.

Of the cases of desertion and absence without leave—the distinction

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is delicate but definite—the majority were the subjects of simple
hysterical fugues. All degrees of dissociation were found. Some after
a comparatively prolonged absence were clean and tidy, apparently well
fed, and in no way likely to attract attention. Others were dirty and
exhausted, and had obviously been less able to look after themselves.
Some on admission were completely dissociated and disorientated;
others, except for slight retardation, behaved and conversed naturally,
and said they had, for a time, forgotten their name and unit and had
been wandering about. Others in an intermediate condition were still
unaware of their identity, showed some confusion, had no conscious
insight, yet accepted a hospital bed without surprise.

As was natural, considering the psychological mechanisms at work,
the majority of these cases made for Boulogne, and were arrested in or
near that town. Some, however, wandered aimlessly about the country.
The French peasants fed them, and they got stray meals in British
camps and billets. The fact that so many profoundly dissociated cases
managed to elude the numerous and inquisitive military police as long
as they did is astonishing, and argues a very considerable degree of
unconscious alertness and cunning. In many of these fugues the amnesia
was absolute only for the act of leaving the unit, and a gradually
diminishing haziness of recollection covered the remainder of the period.
In other cases the amnesia was clear cut at both ends. In some cases
the offence occurred while the patient was on leave in England—usually
after he had left home for the return journey. Few of these cases were
of longer duration than a few days, and they differed in no way from
those which took place in France.

I had had little previous experience with this type of case, and found
that some of them gave me considerable difficulty, particularly those of
longer duration with few symptoms on admission. In some of them
the restoration of the amnesic period led to an unfeigned emotional
outburst. In some I was able to obtain a history of definite physical
or psychical shock. In some the fugue was apparently motiveless and
unlikely to be of service. One case, presenting practically no other
symptoms, had frequent terrifying battle dreams. In almost all analytic
conversation revealed the activity of a complex. A common symptom
was a fixed local feeling of painful pressure or tightness in the head,
which varied with the degree and extent of the amnesia. Many also
showed listlessness or apathy, which with the headache vanished wdien
the memory became complete.

Panic flights by defectives accounted for most of the remaining
absentees. Absences in this category tended to be shorter and there
was no real amnesia. The diagnosis was easy.

The estimation of responsibility for crime in the case of men who
plead amnesia is highly important, and has not received very much

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attention. Even admitting the amnesia to be genuine, in the absence
of other psychoneurotic symptoms can responsibility be denied ?
Amnesia is a result of dissociation and repression which are by no
means pathological processes, but are in minor degrees normal and
natural to all. Wishes, tendencies or thoughts which are unpalatable
or unacceptable or antisocial are being harboured by most of us, and
are constantly being repressed and kept from consciousness by the
psychic censor, and their continued repression and powerlessness to
affect our consciousness or our conduct is due to the watchfulness and
strength of this censor. The psycho-pathological explanation of the
crimes we are discussing is that a wholly or partly repressed complex
eludes or overcomes the psychic censor, and becomes sufficiently power¬
ful temporarily to suppress consciousness and to gain control of the
bodily activities. The mechanism is the same whether the desired end
be trifling and unimportant, or antisocial and an infringement of law
and custom. The difference is solely one of degree. The man who
abstractedly burns or loses his tailor’s bill, and he who unconsciously
leaves his regiment on the eve of an attack are actuated by the same
driving force working in the same way. The conduct is favourable to
the individual but unfavourable to the herd. In some people the
instinctive individualistic wishes are very completely suppressed, and are
never able to influence conduct. In some the suppression is less
thorough, and activities incompatible with conscious control may be
aroused and displace consciousness. In others the altruism demanded
by herd instinct is feebler or non-existent, and a more or less consciously
deliberate career of crime is chosen. Excepting certain outstanding
cases, who are called moral defectives, and incarcerated in asylums
instead of prisons, members of this third class are commonly regarded
as being in all respects responsible for their actions. It would appear
difficult to justify the universal exoneration of wrong-doers of the
second class, whose psychic censorship is powerful enough to entail a
temporary dissociation of consciousness during their anti-herd activities,
but not to prevent those activities altogether. The force of example
afforded by the condemnation and punishment of others will assist and
reinforce the censorship that is inclined to waver. Those cases,
however, who have offended against the herd, but who, as a result of
prolonged and stubborn resistance to the tendencies of individualism,
exhibit pathological symptoms of the conflict in the form of insomnia,
anxiety, terrifying dreams, etc., appear to be entitled to exoneration
and to removal if possible to an environment where the psychic control
may be able to cope with the desires of the individual.

In three cases of absence I was satisfied that the offender was in all
respects responsible for his actions.

Pte. H— was found near the docks in Boulogne, clean and tidy

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and behaving naturally. He was without pay-book* identity disc, or
papers, and a portion of the side pocket of his tunic on which a
soldier commonly writes his name had been recently cut away. He
complained of nothing, but stated he could give no information
whatever about himself, or any part of his history. He had no
physical signs of disease. During examination he seemed uneasy
and on his guard. He had no headache, showed no confusion or
retardation, and gave his answers quickly. In a long conversation
it was possible to trap him in inconsistencies. His “amnesia” was
unusually resistive, and the order in which he eventually “ remembered ”
his particulars, etc., was unnatural. He had a bad record with his
unit.

Pte. S—, also with a bad record and charges of desertion and prison-
breaking both in England and France against him, was sent in com¬
plaining of “ loss of memory and not knowing what he was doing.” I
found his amnesia capricious and variable, and quite unsupported by
other symptoms or by a suggestive history. I was unable to hypnotise
him. After prolonged observation I discharged him as fit to stand his
trial.

Pte. P— had, among other charges, one of desertion to the United
Kingdom for twelve months against him. On admission he feigned
symptoms which he conceived to be psychotic ; later he pretended to be
a defective, and finally, after his medical board, he stated lie had
recovered. At no time did he show signs of mental or nervous disease.
It was only after great hesitation I decided he fell outside the class of
moral defectives and sent him for trial. From this man and from one
or two others I gained some knowledge of the remarkable trade in
pay-books, passes, leave-warrants and other evidences of identity carried
on in soldiers’ hostels and clubs.

Other offences were rare and as a rule unimportant. I shall allude
to them elsewhere.

Self-inflicted, wounds .—Of the 22 “self-inflicted” cases, 3 were
definitely not suicidal in intent, 1 being deliberate to avoid duty, 1
the result of a drunken fight, and 1 following the attempt of a general
paretic to kill rats with a Mills’s bomb. The suicidal wounds comprised
the following: 14 cut throats, 2 gunshot wounds, 1 bayonet wound, 1
precipitation from a train, and 1 man who threw himself under a lorry.
None of these patients were responsible for their actions. The very
small proportion of cases in which firearms were used is striking, and in
my opinion results partly from the probability that when a soldier attempts
suicide by shooting he is almost invariably successful, and so rarely
gains a place in statistics. There is no doubt that in heavy fighting
under adverse conditions, as at Passchendaele in November, 1917
numbers of men kill themselves. I agree with Stanford Read that mere
mechanical difficulties in the use of the rifle are quite insufficient to
explain why it is neglected. The choice of means is undoubtedly due
to some unconscious psychic factor or factors, and I suggest a loathing
of everything military as one possibility. It is also probable that the
LXV. 1 I

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daily contact of the razor with the throat in shaving exerts unconscious
but cumulative suggestion on a mind torn asunder by hidden conflict,
and revolting to the end from the rifle—that ever-present symbol of the
hated environment. The two cases of gunshot wound which reached
me were of the lower jaw. They illustrate incidentally the comparative
absence of explosive effect resulting from close proximity of the muzzle
of the modern rifle. In both cases the chin bad been resting on the
rifle, and there was a compound fracture communicating with the mouth.
One man was an epileptic imbecile, four months in France and four days in
the trenches, who ascribed a scolding from his sergeant-major as a cause
for his act; the other was a “ persecuted ” paranoiac, ast. 38.

Of the cut-throat cases, 3 were due to hallucinations of alcoholic
origin, but in one there was an obvious underlying psychosis, which was
the cause of the alcoholism. In these cases the wounds were very
severe. Six occurred in acute “ persecuted ” paranoiacs with hallucina¬
tions. It was remarkable how the mental condition of these cases
improved in hospital. Two were cases of more or less pure depression,
and the remaining three showed hysterical dissociation with dream
delirium. In only one was there admitted conscious premeditation, and
it is interesting to note that one of the dissociated cases was awarded
the Military Medal for an act of gallantry performed a day or two before
his suicidal attempt. In addition to these two men who attempted
suicide by drowning in a state of dissociation were admitted, and two
similar cases made resolute attempts by hanging and strangulation in
the ward.

Almost all the suicidal cases showed amnesia for the event. This is
the rule in civilian cases too, and is the natural consequence of the
cleavage of the personality necessary before an act of self-destruction
can be achieved. It would seem that such a reversal of the great
primordial instinct of self-preservation could only result from some
very profound disturbance of the mind. Yet that in certain cases this
instinct can be apparently without difficulty neglected and set at naught
is obvious. Defectives, and in some countries children, commit suicide
on wholly inadequate and trifling grounds. The double suicides of
lovers which occur almost weekly are remarkable instances of the—one
might call it—levity with which this step may be taken. The common
combination of murder and suicide is equally notable in its apparent
absence of sufficient motive. The hara-kiri of Japan, the suttee of
India, carry the strong approbation of the herd, and are less difficult to
conceive, yet they are notable perversions. Epidemics of suicide such
as have occurred at intervals in the world’s history are in this class.

The psychological basis of the act is in all cases conflict, represented
by psychic pain. Idiosyncrasy, the product of previous experiences,
alone can explain the reactions of individuals to certain situations.

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Suicide is reaction of an individual to a psychic conflict which may be
partly conscious or wholly unconscious. This conflict may be compara¬
tively superficial and recognisable as such, in the form of a feeling of
inadequacy, of inefficiency, of failure. It may be ignored and concealed,
but recognisable under a web of rationalisations. It may be buried and
repressed and active only through distorted and fantastic hallucinations.
It may be of intolerable pitch, yet so repressed that it betrays itself not
at all. But whatever its relation to consciousness, this mental conflict
may at any time attain sufficient momentum to over-ride the self-preser¬
vation instinct and provide its own final solution.

The following case illustrates the intensity of the conflict occupying
the minds of some of the men who are driven to self-destruction, and
the manner of its distortion in presentation to consciousness. In this
case the content of the dream-delirium was remarkably vivid, and con¬
sisted of illusory distortions of the actual surroundings and not of
hallucinations. The memory of it persisted very strongly during
convalescence.

Pte. S—, aet. 38, two years’ active service. Admitted in a state of
terror and apprehension—restless and confused, not hallucinated, able
to give his particulars. He had a long incised wound across his throat,
not very deep. He soon became more dull and almost stuporose;
apprehension diminished ; had a fairly good night. Wept at intervals
during the following day, but was obviously improving. Beyond feeding
him and dressing his wound no notice was taken of him. On the third
day he gave me the following account of himself. He said lie had
been one of a machine-gun detachment of four, guarding a road. (It
was on the Somme during the German advance in April, 1918.) There
were two other detachments near, all three under an officer. He
illustrated the relative positions and the direction of the Germans, and
he knew the names of his comrades. There were some shells passing
over. Suddenly it dawned on him that his companions were Germans
disguised in British uniform. One of them appeared to be a “ nigger ”
as well. (He was hazy about this.) He realised it was his duty to
inform his officer. He tried to steal away to do this, but was seized by
the “ Germans ” and knocked down. He then became aware that the
officer and men at the other posts were Germans also, and realised he
had been captured. He was taken away and put in a bell tent with a
“black German” guard, and given straw to lie on. He heard voices
without, saying the straw was to be set alight and the prisoner burnt
alive. There was loud mocking laughter. Then he heard the ticking
of a time-bomb, which was concealed in the straw'. He searched
frantically but fruitlessly, and finally to end his misery he took his razor
from his pocket and cut his throat. Finding he did not die, he burst
from the tent and tried to escape. He was pursued and dragged back
among laughter and jeers. He “ remembered ” vividly the remarks and
chaff to which he was subjected. He was hazy as to how he got back
to the British lines.

No notes had come with him and for some days I believed he had

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been in German hands and escaped. Many of our men had this
experience in the open fighting of this period. I was able later,
however, to ascertain the facts, which were as follows: He had had
little rest or food for some days. He suddenly became very excited and
uncontrollable while in a machine-gun post as he described. There
was little shelling going on, and the Germans were not near. Two men
took him to the aid-post, where he was put in a tent by himself and
seemed to settle down. Presently he broke from the tent with his
throat cut, and fled. He resisted capture and fought fiercely. For
a few weeks he was depressed and dull, ate and slept poorly, stuck to his
story without variation, but became unwilling to talk of it. At the time
of his transfer to the United Kingdom he remembered his dream
experience, but had little or no confidence in it, though he still had
partial amnesia for the actual events.

Classification of cases .—In the classification of cases dealt with the
nomenclature of mental disorders as laid down by the Army Council
was necessarily followed in all official records. In view, however, of the
extremely incomplete investigation possible in most of the cases, dia¬
gnosis was out of the question, and a temporary label for the patient’s
condition was all that was aimed at. Under the circumstances such
records are almost valueless, and it is only with a view to indicating the
types of mental disorder more prominently met with that I include

the following table covering the 966 cases dealt with.

Feeble-mindedness . . . . . . 153

Nervous debility ........ 29

Mental instability.26

Moral imbecility.4

Confusional insanity, including exhaustion psychosis . 136

Delusional insanity ....... 94

Mania.82

Melancholia.98

Dementia prsecox ....... 101

General paralysis. . . . . . . .21

Alcoholic psychosis.12

Stupor.5

Constitutional psychasthenia.7

Epileptic psychosis.27

No appreciable mental disease.22

Psychoneurosis . . . . . . . -134

Various.15

As regards disposal, 763 were sent to D. Block, Netley; 127 were
transferred to England as functional neurological cases ; 39 (Americans,
Portuguese, etc.) were transferred to other mental hospitals in France;
12 were evacuated as ordinary medical cases ; 22 were discharged

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direct; and there were 3 deaths. I will now proceed to discuss the
different classes in more detail.

Feeble-mindedness .—Mental deficiency accounted for 153 of the cases.
In many the degree of deficiency was amazingly high, and one wondered
whether recruiting boards had any conception of the conditions of active
service. Stigmata of degeneration were common, and many displayed
infantile characters in greater or less degree. There was one striking
case of physical and mental infantilism. About half of the defectives
were sent to me for opinion by the classifying medical board at
Boulogne, and belonged to the Labour Corps. Their average service
in France was a few weeks, and in many cases they showed already
early signs of psychosis, usually confusion or depression. These cases
were particularly numerous in the early summer after the much-needed
reinforcements had been hurried out from England. Numbers of these
men were back in England within a fortnight of their original sailing.
It is perhaps comforting to note that one U.S. soldier, a low-grade
defective, was admitted within a week of his landing at Calais and within
two months of his enlistment, with the history that his feeble-mindedness
had been recognised before leaving America, but the procedure for
leaving him behind worked so slowly that his unit was compelled to
bring him.

The other type of defective, of a higher grade, had a belter average
length of service, and had made an effort towards adaptation. Many
had two or three years’ service in France with a labour unit, or even a
regiment, though in the latter case seldom carrying out the duties of a
fighting man. In all these cases psychotic symptoms gradually deve¬
loped, confusion, stuporose states, and persecutory paranoiac ideas being
the most common. It is unnecessary to dwell on the objections to
placing such types in positions so full of possibilities of danger to them¬
selves and others. Among the cases I had to deal with were one of
attempted murder by shooting, one of indiscriminate shooting under the
influence of hallucinations, and one of attempted suicide by shooting.
All were definitely feeble-minded, with a tendency to the formation of
delusions of reference and persecution. I have great sympathy with the
units which are compelled to retain such types, as I have had personal
experience of the difficulty in getting rid of them before the onset of
psychotic symptoms. Even employment at a base or on the lines of
communication is unsatisfactory and unsafe. The hours are long, con¬
ditions are hard, military discipline makes few allowances, and the
“ Gotha ” and its kind provide thrills and shocks enough to unsettle at
times the most stable. The defective, uprooted from the limited and
comparatively simple environment he has known all his life, finds com¬
plete adaptation in his new state quite impossible, and his breakdown is
but a question of time. On the other hand, the high wages some of

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these men had been able to earn in civil life amazed me. A vocabulary
limited to two hundred words with general knowledge to correspond
does not prevent a Lancashire cotton spinner from earning his ^3-^4
a week.

As might be expected many of the defectives had got into trouble and
were admitted as prisoners. I do not think the authorities who send
such types abroad realise how conduct which in a civilian would be
unimportant may on active service constitute a serious technical mis¬
demeanour, and lead to heavy punishment. The most common offence
in this class was absence without leave or desertion—a purely military
offence. The absences were as a rule short and often rather aimless.
Some of the patients had already been sentenced on admission, and a
few had even served part in a military prison. A Canadian soldier,
Pte. R—, set. 21, with nearly three years’service, was under sentence of
death for desertion. He showed marked retardation, was backward and
stupid, was undersized and poorly developed, and suffered from a
striking hydrocephalus, the circumference of his head being 24^ ins.
Some of the defectives attempted to assume psychoneurotic symptoms,
but they were poorly executed, and when ignored soon dropped without
remark. Pte. M—, set. 18, with three months’ service, was micro-
cephalic, had never been to school, and could not read or write. He
was a prisoner for desertion, pretended to the court to be completely
amnesic for his past, and was sent down as “? mental.” In reply to all
questions, he said, “ I dont know,” “ I forget,” etc. I satisfied myself
that he was feigning, and was able in a short interview to convince him
the game was up, after which he answered very willingly. Another
defective, a barefaced and incorrigible rogue, had in civil life been in
the habit of etherising himself with collodion-soaked cotton wool placed
in the nostrils.

Nervous debility .—In this class, which numbered twenty-nine, I
included those who, not being feeble-minded in the usual meaning of the
term, and without developing a psychosis, were unable to adapt them¬
selves to new situations and environment. Their symptoms were
constitutional timidity and diffidence, a tendency to hypochondriasis
and introspection, and an indifferent hold on their mental balance. A
few had had transient psychotic or psychoneurotic periods. They were
all men who would in all probability have been able to cope with the
problems of civilian life.

Mental instability .—I place next the class of those who, having no
permanent psychosis, were pathologically unstable. They numbered
twenty-six. In the main their condition was betrayed by increased and
exaggerated reactions of various types, most frequently a short bout of
excitement, and in many the differentiation from defectives was vague,
and one or two suggested epileptic equivalents. By some these cases

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are described as impulsive insanity. As a rule, however, the insane
conduct, though sudden in onset, is of the nature of a reaction to a
recognisable stimulus, marked mental enfeeblement being absent.
Their symptoms were repeated, but transient, and I was rarely able to
observe the patient during an attack. Such patients appear to escape
certification in civil life. Two were old soldiers with twenty-four years’
service and an alcoholic past, serving under N.C.O.’s of the new armies.
One was a remarkable man, whose hereditary profession was having
paving-stones, placed on his head, broken by blows with a sledge¬
hammer. His nottt de thiatre was “ Upper,” and his sub-title “ The
Human Pincushion.” He had apparently complete anaesthesia to heat
and pain, but not to touch, cold, or deep pressure, below the elbows and
on the face and neck. He stuck pins into these regions with
indifference and showed many circular scars, the result of pressing
lighted cigarettes into the skin. As side lines he broke bottles by
hitting himself on the head with them. He was a clever tumbler, and I
believe an expert at releasing himself when bound with ropes. He was
a powerfully built man, looking more than his age, which was 45.
He confessed that for many of his feats of endurance he fortified himself
with liquor, and it was a demonstration in a canteen with beer bottles
which led to his being sent to the mental ward. He stated that his
antesthesta had existed in its present condition as long as he could
remember. Sensation elsewhere was normal. The superficial and
deep reflexes were considerably increased, equally on both sides. There
was no atrophic change pointing to acquired syringo-myelia, no
spasticity or neuritis, and in view of the distribution the condition was
probably hysterical. The notes which accompanied him stated that he
was impulsive and violent-tempered, unduly susceptible to small
quantities of alcohol, and liable to spells of furious excitement on little
or no provocation. He was rational and lucid while under my obser¬
vation, and complained of no disability. He showed neither physical
nor mental signs of excessive alcoholism.

Moral imbecility .—There were four cases, in no way differing from
those met with in civilian practice.

Confusional insanity .—Under this heading 1 placed 136 cases.
They were of the most varied types, including all the degrees of
intellectual obfuscation and retardation found in civilian practice. At
one end they merged into delirium, at the other into stupor, and many
cases similar to those placed in this group are classified with the
“ confusion ” sub-group of the psychoneuroses.

The cases of pure confusion fell into two vaguely defined types, the
toxic cases and those showing hysterical dissociation, but no definite
differentiation can be made—in fact the psychological basis is probably
identical. In the lattei* disorientation appeared to be more complete,

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and the patient was part of, and living among, his hallucinatory sur¬
roundings. In the toxic cases the patient was, on the whole, less
inaccessible, and his hallucinations were more superficial and affected
his conduct less. In some of the hysterical cases imperception was so
marked that the motions were passed into the bed, yet within a few
hours reintegration took place, leaving no symptom but slight retarda¬
tion and amnesia. Evidence of toxic origin, influenza, trench fever,
etc., was obtained in about 20 per cent, of the cases, and in many of
the others a septic condition of the alimentary tract was obvious. I
had an opportunity of observing considerable numbers of severely
wounded men suffering from delirium. All were gravely toxic, but
some showed quite clearly a delirium of the hysterical type. Many of
the cases were probably passing through a confused phase of manic
depression or dementia pnecox.

It appears that many very different conditions are commonly
included under the heading of exhaustion psychosis or confusional
insanity. As stated above, in about 20 per cent, of my cases a toxic
element appeared to operate as a cause. But other patients displaying
the same or similar symptoms brought a history which seemed to exclude
toxaemia, and pointed very definitely to psychic trauma, prolonged or
sudden. The influence of physical exhaustion as a cause of psychosis
seems to have been greatly over-estimated. The pathological processes
by which these varying causal factors produce the same syndrome are
obscure. Kraepelin’s opinion that nutritive changes occur with produc¬
tion of toxins, and neuronic poisoning does not throw much light on the
question. The theory of Jelliffe and White seems of more value.
They believe that the symptoms which a damaged neuron can produce
during dissolution are limited in number and complexity, and depend,
not on the nature of the destructive agent, but on the function of the
neuron, and that minor variations are the result of individual make-up,
not of differences in the agent. This theo.y, however, also predicates
the existence of a toxin or metatoxin in all cases of marked confusion—
a hypothesis which does not appear to be proved.

I will describe a case of dissociation illustrating a type of case which
I returned under this group in which the causal factors were partly
physical, partly psychic.

Pte. G—, tet. 21, service three and a half years—three years in France.
Wounded once. Sound heredity and normal youth. No neurotic
symptoms observed. Was noticed to be “run down ” and sleepless for
a few days only. Was sent to a forward rest-camp, where he received
a wire informing him of his mother’s death. Disappeared for four
days, and turned up again dirty, unkempt, and starving. Was unable
to speak, and was confused and restless. Sent to casualty clearing
station he became agitated, apprehensive, terrified of the orderlies,
etc., sleepless, refused food, habits dirty, and began to verbigerate
“ Back to my Army,” and “ 100,000 black men in the north.”

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During this stage he was evidently suffering an acute and vivid
hallucinosis. On admission was exhausted and weak, stared unsee-
ingly about, had marked imperception and disorientation, was not
restless, allowed himself to be fed, etc. In answer to all questions he
said “ Back to my Army ” again and again in a terrified and later in
a pleading way, as if trying to make me understand. In a few days he
lost all his apprehension, and began to sleep well and look well and
content. Mentally, his condition was one of very profound impercep¬
tion. If put to bed, and his eyes closed, he went to sleep. Pin pricks,
loud, sudden noises, the sound of his own name or nickname entirely
failed to attract his attention, but if one stood in front of him he could
hear and repeat single words, and later he learnt the meanings of a few,
such as bed, smoke, eat, etc. When given food he was able to feed
himself tidily, he could wash and dry himself, he went quickly and
directly to the w.c. when necessary and made his arrangements
perfectly when there, but he never learnt to adjust his clothes or his own
bed, and would get into the first open bed he saw. He showed a
curious degree of apraxia. He smoked cigarettes very efficiently and
with enjoyment, but he would make earnest attempts to draw smoke
from pencils, pocket-knives, etc. He could close a pocket-knife—
taking infinite precautions—but could not open one. He learnt to
strike a match if given one from a box, but he never learnt to open the
box. He lit his cigarette well, inspected the burning end in the most
typical “Tommy’s” way, but was unable to lay down or blow out the
match, and watched it burning down to his fingers with a growing look
of horror. When it had burnt out he was able to place it in the ash
tray. He appeared to enjoy cigarettes, but made no attempt to take one
from his pocket, etc. He showed great delight when the canaries sang
if he was looking at them, but he would sit for hours with hi»back to
them, taking no notice whatever. His sense of possession was feeble.
Anything he was given he tried to put under the nearest pillow. The
predominance of his mental automatism was shown in his games with
other patients. He could catch a slowly moving ball, but he invariably
returned it with the hand he used to catch, and to the man who had
thrown it to him. Nothing would induce him to depart from this.
He slept unmoved through air-raids. Except in going to the w.c. I
never saw him display any initiative. Taken out for a walk, he would
walk straight on indefinitely. He experienced emotions of joy and
sorrow, but very seldom and very superficially. His expression was one
of happy idiocy, with an indescribable element of reproachful amaze¬
ment. I was unable to hypnotise him or get in touch with him during
sleep or by automatic writing. He was in the state described when
transferred to England.

This case illustrates the combination of profound dissociation with
absence of hallucinations, showing a condition distinct from the more
typical “ exhaustion psychosis ” on one hand, and from the oneiric
delirium with an hallucinatory or illusory system on the other. It is
akin to the aprosexic form of confusion described by Rhoussy and
Lhermite.

Delusional insanity .—I found a delusional state the most prominent

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feature in ninety-four cases, excluding those who appeared, fairly
conclusively, to be paranoid dements. Delusions of course occurred
in all types of psychosis, but in a number of those returned as melan¬
cholia urgent delusions of a persecutory type, at times supported by and
based on auditory hallucinations, were so marked as to render their
classification doubtful. In some the condition was quite transient
(notably in some of the defectives returned as such); the delusions were
of a reasonable nature, not held with much conviction, and probably arose
from a conscious or unconscious feeling of inferiority or inadequacy, and
these cases responded well to rest and encouraging suggestion. The
majority of the cases seemed to betray more or less distinctly the
paranoiac disposition, and though only one-third had a well-fixed system
of delusions, it appeared likely that many of the others would eventually
develop the same. A type, showing fairly rapid development and the
most intense conviction, frequently hallucinated, with delusions of
persecution and reference and great suspicion, was strikingly evident.
In most war-colouring, if present at all, was quite superficial; as a rule
the sergeant-major or some officer formed the nodal point of the
persecutory system. Homosexual ideas were distinctly more obvious
than among civilians, and in this connection Stanford Read makes
the interesting suggestion that “ it would be suggestive to investigate the
theory that the herding of men together in the Army where heterosexual
intercourse is mostly excluded tends to arouse a latent homosexual trend
against which the personality defends itself by ‘ projection.’ ” It appears
to me, however, that the mechanism of projection, without necessarily
a homosexual foundation, will satisfactorily explain this acute perse¬
cuted state, with ideas of suspicion and reference, and early support
from hallucinations. In an army at war a soldier lives close to the
essentials; the comforting minor rationalisations permitted in times of
peace are denied him; the “mitigating circumstance” has little sway;
if the other man is the better of the two, it is likely to be publicly
proved beyond argument and with cruel directness. Intellectual talent
is at a discount, and physical powers are predominant, and it is
remarkable that the average man bears disparagement of the latter
with much less equanimity than of the former. Projection then comes
to the aid of the discomfited, and protects his peace of mind at the
expense of his reason.

Almost all observers of the war have noted an unusually high
proportion of such cases, and it is interesting that a similar psychosis
was reported as common in the Russo-Japanese war. The patient in
some cases reacts to his painful ideas by over-indulgence in alcohol.
Similar mental states in civilians are almost invariably associated with
alcoholic excess, and in these authorities differ in assigning the relative
importance of cause and effect.

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One or two interesting cases at an early stage passed through my
hands.

Pte. P—, ret. 24, four years’ service. No history of neurotic
symptoms. Wounded once, sent down suffering from an (admittedly)
self-inflicted wound, not as a mental case. Displayed the most intense
and unfounded pessimism and distrust, without actual construction
of delusions. No hallucinations or confusion. Irritable, unruly,
difficult to control, reasonably polite to me only with an effort, insolent
and objectionable to sisters, etc. Threatened suicide, though had
numerous facilities. Took ungraciously and without thanks all privileges
and attentions. No complaint of disability. Displayed no motion
during air-raids.

Pte. H—, ret. 38, three years’ service. Two self-inflicted wounds
(denied, but certain). Symptoms as above.

Were these merely cases of the “ fed-upness ” of the average soldier
carried to an extreme, or were they early stages of a progressive delusional
nature ? They suggested the delire chronique of Magnan. In favour
of the latter theory was the unaltered scowl with which they greeted the
first stage of their journey to England.

Dementia prcecox .—One hundred and one cases presented symptoms
which appeared to point to one or other of the types of schizophrenia.
Their differentiation from hysterical and exhaustion cases was very
difficult on a short period of observation. The resemblance was
particularly close in cases showing mild stupor, with general retardation,
motor and ideational inertia, emotional apathy, flexibilitas cerea,
agreeable hallucinations, etc., combined with good orientation and
grasp of the surroundings. Some such cases cleared up apparently
completely in a few days in a way I have not seen precocious dements
do. Most of the deluded types had made use of scenes and material
of war for their delusions; for example, an army signaller said he
received messages in Morse code from enemy aircraft on his teeth, and
that he sent them false information in the same way. I was struck by
the advanced stage of disease shown by some of these paranoid dements
on admission, with vivid and abundant hallucinations. The disease
had been developing in some for many months, and yet the patients had
been able to carry on their duties without exciting remark. In this
they differ from the paranoiac, whose delusions, even though unsupported
by hallucinations, gain publicity more forcefully and at a much earlier
stage. The enviable apathy of the schizophrenic during exciting air¬
raids was remarkable and occasionally indicated the diagnosis in a
doubtful case.

Melancholia .—There were ninty-eight cases in which depression was
the most important feature. About half were involutional or pre-senile
melancholia, and were in no way different in pathology or sj mptoms
from the cases met with in civilian asylums. The remainder were of a
type not so common. They were younger men, ret. 25-35, and the

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MENTAL WARDS WITH THE B.E.F.

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symptoms tended to merge either into “ persecuted ” paranoia or
anxiety neurasthenia. The latter was the more striking symptom, and
was almost universally present in the younger depressed cases. Fatigue
seemed indicative as a causal factor in the anxious depressed group
because of the remarkable improvement which took place in many of
them after a week or two in bed, indicated not only by abatement of
the symptoms, but also by ability to stand air-raids with comparative
composure. It is probable, as Stanford Read points out, that most of
the cases in which delusions are at all prominent should be regarded as
primarily paranoiacs, with a secondary emotional depression. Domestic
unhappiness or trouble was a common cause in this group. The
soldier would appear to react to distress of this kind by depression and
to occupational worries by paranoia.

Mania .—There were eighty-two cases in which manic excitement
occurred. They included fourteen severe cases of classical acute
mania, two of them associated with wounds, and twenty-six cases of
acute excitement with more marked confusion and hallucinations. The
remainder were subacute and more transient. Some cases in this group
were probably hysterical dissociations with illusory dream states, but
their violence and unreliability rendered it justifiable temporarily to
label them as cases of mania. The two wounded were both severe
cases, and showed wonderful recuperative powers. One of them, a
most powerful man with an enormous sloughing wound of the calf, ran
about the ward, and at various times scrubbed his wound with a nail
brush and filled it with fseces. He made a good recovery. The
hallucinated cases merged with those I have classified as confusional.
Many of the milder degrees of excitement would no doubt turn out to
be katatonic in nature.

Among the subacute cases were three curious cases of exaltation, with
perfect orientation and lucidity, no motor, and little mental acceleration,
no evidence of hallucinations, suffering from fairly severe mustard-gas
burns. They were quite accessible, had no delusions, felt no pain or
discomfort from their burns, as a rule most uncomfortable, and simply
lay in bed and smiled approvingly at everything.

General paralysis .—I diagnosed general paralysis in twenty-one
cases, all but one having globulin and a pleocytosis in the cerebro¬
spinal fluid. The signs of general paralysis are liable to be closely
simulated by commotion neuroses. In my cases the average age of onset,
thirty-eight years, was not earlier than in civilians, but the symptoms
showed unusually rapid progress, most of the cases having a history of
only a few days’ illness. Probably the early moral deterioration was less
noticeable in the Army than in home surroundings. One man had
been a competent N.C.O. on a supply train, broke down completely
after three days of the stress of the German advance in April, 1918,

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left his unit, and was arrested walking among a group of peasant
refugees wearing a pair of civilian trousers with his uniform, and
carrying a dead fowl. He was markedly expansive on admission, and
during the three weeks he was under my observation his speech became
almost unintelligible, and general mental dilapidation became extreme.
Stanford Read, working with a very much larger number of cases,
states that he found the average age of incidence in soldiers very much
earlier, and that a very short period existed between the syphilitic
infection and the commencement of symptoms. As it appears that in
very many cases of quite early syphilis the central nervous system is
seriously affected without symptoms, one might expect to find that the
stresses of war would increase and hasten the syphilitic cerebro-
pathies.

Alcoholic psychoses .—Cases in which the symptoms were wholly due
to alcoholic excess were very few. In twelve of my cases, or i'25 per
cent, only, was alcohol the immediate causal factor. Acute halluci¬
natory states, developed while on home leave or during the return
journey to France, accounted for six, and the remainder were chronic
intoxications. Eager found the percentage of alcoholic cases from
the B.E.F. to be ri over 1,652 cases, which agrees closely with my
figures, whereas Hotchkis estimated that 18 per cent, of 831 Expedi¬
tionary Force cases were of alcoholic origin. The figures of other
observers show similar striking disparity. Stanford Read, reviewing a
very large number of expeditionary cases received at Netley, found the
percentage of alcoholic cases “ very small,” but quotes Lepine’s figures
for 6,000 cases in the French army, in which he ascribed to alcoholic
excess the astounding proportion of 50 to 66 per cent. Other French
writers agree closely with these figures. Obviously the personal
equation enters largely into the question, and different observers adopt
different points of view. That alcoholic excess is a protection against
imperfectly repressed mental pain is revealed by the most superficial
analysis of the vast majority of so-called alcohol cases. In these
alcoholism and its symptoms are secondary. Perhaps the most ele¬
mentary example is that afforded by the self-conscious man, who takes
a few drinks to render his social manner easy and confident, and to
anaesthetise his feeling of inefficiency. The same applies to intoxica-
cations by other narcotic drugs. Temporary or prolonged absorption
of such substances produces definite syndromes, which obscure the
real psycho-pathological process. I would except only certain defectives
who probably seek the elementary pleasurable sensation of intoxication
for its own sake. The acutely hallucinated alcoholic cases provided
three of the cut-throats. All the acute cases showed some depression
and a distinct tendency to the paranoiac temperament and outlook. The
chronic cases were all past middle age, and all rather pathetic failures:

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T70 MENTAL WARDS WITH THE B.E.F., [July,

a private soldier of twenty-one years’ service, a master mariner of twenty-
four years’ standing cleaning motor bicycles, etc.

Epilepsy. —Of thirty-six cases who had had fits, I was of opinion
that twenty-seven were epileptic. These included three defectives, two
cases of head-injury, four cases of petit mal , eight cases with psychotic
symptoms. Five of the cases had had pre-war fits. I judged the other
ten cases to be epileptic from the nature of the fit, the time and manner
of its occurrence, etc.

Modern observations point convincingly to the very indefinite
differentiation between epileptic and hysterical fits. As the distribu¬
tion and intensity of the motor discharge may be identical, it is not
easy to see how a diagnosis may be made on such signs as cyanosis,
extensor plantar response, etc. Many authorities base their diagnosis
on the accompanying mental symptoms only, and others assert that the
conditions are continuous with one another and not to be rigidly
separated, which appears to be most probable. In certain cases of
trauma, sometimes somatic, sometimes psychic, resulting in the blocking
or closing of many paths of outlet, either structurally or by inhibition,
according to the theory of White and Jelliffe, there occurs a periodic
discharge of energy of a certain intensity, and accompanied or followed
by a certain degree of dissociation. This dammed-up and suddenly
liberated energy may be of the most elementary type, or it may be
sublimated and take a more purposive form, such as oneiric delirium,
furor epilepticus, or any epileptic equivalents. Epileptic automatism is
in itself indistinguishable from hysterical somnambulism. It is probable,
too, that petit mal, tremors, tics and habit spasms differ only in degree
from the major manifestations, and constitute vents for energy denied
its proper outlet. The objectionable egocentricity of the chronic
asylum epileptic is merely another aspect of the fit—equally mis¬
directed.

Psychasthenia. —I have included in this class only the constitutional
psychopaths, of whom there were seven. They presented no features
of interest.

Stupor .—There were five cases which appeared to be manic-stupor.
There was no history of concussion, undue emotional stress, or fatigue ;
there were no hallucinations, and recovery was gradual, without dipping
of consciousness. Two of them, apparently in deep stupor, trembled
violently during air-raids. A number of cases exhibiting greater or less
degrees of stupor are included under the headings of “dementia
prtecox ” and “ neurasthenia.”

Various. —In addition to the above, I had one case of senile
dementia, an Irishman, ret. 68; one case each of tubercular and
cerebro-spinal meningitis (the former died); two cases of varicocele
with hypochondriacal and psychasthenic complaints; three cases of

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chorea; three of tabes; two of cerebral syphilis; one of severe
cranial neuralgia of uncertain origin ; and one chronic morphia
taker.

No appreciable mental disease. —Twenty-two cases were admitted in
whom no nervous or mental disease was discovered. Of these, in my
opinion, only five were deliberate attempts to feign insanity, or 5 per
cent, of all admissions. Two were deserters and have been mentioned
under the heading of prisoners. One stole a sum of money from a
comrade, posted it to his fiancee, and had a good time on his next leave.
He pleaded amnesia for the theft, and stated he had suffered from and
had treatment for similar losses of memory all his life. On reference
to his relatives this was shown to be false. One while waiting
discharge from hospital tied a handkerchief to a stick and marched
about in a foolish way. On examination he was tremulous and on his
guard, and soon broke down and became ashamed and repentant. One
charged with desertion and theft, after spending some weeks in prison,
suddenly reported that he had suffered all his life from headaches, and
that at the time of his offence he was unconscious of what he was doing.
He had no amnesia or signs of nervous disease. He was unable
satisfactorily to explain why he had not reported sick sooner (he had
served other sentences without complaint), and I was satisfied he was
exaggerating his disability.

In none of these cases did I lay a charge. Four already had
sentences to face, and the other appeared so genuinely ashamed that a
scolding appeared to meet the case. Five more in this group had been
guilty merely of silly or unusual conduct which was not in my opinion
pathological in origin. One case, perhaps, deserves mention. He was
a youth, set. 19, only son of a widow, his father, a drunkard, having
died sixteen years ago. The boy had been sent to a good school and
took every possible prize, but he had never played a game or had a friend,
or spent an hour, except at school, away from his mother. He was a
voracious reader, and had a really good education, though his know¬
ledge of affairs was poor. He was living at home completely wrapped
up in his mother, when he was hurled into a conscript camp. He was
reserved and sensitive and could not bear the rough ways of the men,
nor join them in their work or pastimes. He had flickerings of a desire
to improve his wretched condition, but wept when one spoke of
manliness, etc., and pleaded to be sent back to his mother, with whom
he corresponded almost daily in very affectionate terms. Physically he
was slight and poorly developed, but neither infantile nor effeminate. I
have never seen the cedipus-complex so near the surface. As the
armistice had been signed and there was little chance of his coming to
harm, I sent him forth to look for his manhood once more. The
remaining twelve cases in this category were transferred to medical

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172 MENTAL WARDS WITH THE B.E.F., [July,

wards on account of minor physical ailments. 1 was unable to discover
on what grounds they had been sent to a mental ward.

The psychoneuroses .—I returned 134 of my patients as suffering from
psychoneuroses. These were nearly all fairly severe cases, as only those
exhibiting psychotic symptoms were supposed to be sent to my wards.
I would further classify them as follows :

States of anxiety.52

States of confusion, delirium, and stupor . -34

“Neurasthenia”. 13

“ Psychasthenia ” . . . . . . . .10

Conversion hysteria . . . . . . .16

Hysterical “ fits ” ..9

These groups are by no means mutually exclusive. Many bringing a
history of temporary dissociation presented symptoms only of anxiety,
and others made this change under my eye. All the “conversion”
cases and some of the “ fit ” cases displayed greater or less anxiety.
Further, the cases shown here merged with those returned as
melancholia, confusional insanity, etc.

The setiology and psychopathology of the war neuroses have engaged
much attention, and many different views receive support. Exhaustion
per se as a causal factor would appear to be definitely excluded not
only by the experience of Bonhoeffer with the Serbian Army, but by
the observations of Maitland, Farrar and others with our own. The
other materialistic theory of causation, that of commotion or trauma,
advanced principally by Mott, does not appear to afford a complete or
satisfactory explanation for the multiplicity of neurotic phenomena
which occur. The unimportance of concussion and fatigue factors is
also generally supported by German experiences as given at the Munich
Congress of 1916 and elsewhere. Evidence is growing on every hand
of the paramount importance of the psychogenic factor, but it is
probable that fatigue and exhaustion, commotion and emotion partici¬
pate in varying proportions in the aetiology. MacCurdy, who gives first
place to the psychogenic factor, distinguishes between physical and
mental fatigue, and gives due place to commotion. Hurst differentiates
between cases the result of exhaustion and those following prolonged
emotion, but it appears unlikely that the latter can be separated from a
considerable degree of fatigue.

In my experience many cases ascribed to each of these causes
occurred, supported by evidence of varying degrees of value; a man’s
own statement as to how near he was to a shell burst is wholly untrust¬
worthy, and the greatest caution is required in the interpretation of the
word “ buried.” I was quite unable to trace any connection between
the apparent cause and the form of the neurosis. For example, two

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173

cases admitted as “N.Y.D. ? Mental” and showing typical anxiety
states, were afterwards classified as “ shell concussion ” by the official
Army form, made out by neurologists in the front area after reference to
the patient’s units ; and as stated above, the symptoms of individual
patients altered completely while under my observation.

I will now discuss separately the various groups into which I
subdivided the psychoneurotic cases.

States of anxiety or “Angst .”—In this group I placed 52, or 39 per
cent, of the whole. Their symptoms have been exhaustively described
by McCurdy and others. All degrees occurred, from simple “jumpi¬
ness ” without conscious fear—a state well recognised by all soldiers—up
to a condition of agitated melancholia. Some had developed gradually
and without incident, others showed marked exacerbation after an
unpleasant episode, others followed a phase of confusion or stupor. In
all evidence of prolonged and increasingly powerful emotion was to be
found. Insomnia, painful hypnagogic hallucinations, battle-dreams and
nightmares were common. The terror shown by some during air raids
was pitiful and out of all proportion to the conceivable degree of danger,
and was, I think, due to conscious or unconscious abandonment of all
attempt at control. I have noticed that all soldiers tend to make more
fuss about an air raid at the Base than about the same degree of noise
and danger at the Front.

Distortion occurs very rarely in the battle-dreams and deliria of
neurotic soldiers, but in two cases—both young boys—dreams of
amorphous black and green monsters occurred. In the case of Pte. S—,
described under “ suicide,” slight distortion was found. When the
neurosis is at its height the patient is always defeated in his dream
combats, but as he recovers he begins to turn upon his nightly attackers,
and in the end to drive them before him in flight.

Physical signs of hyperthyroidism occurred in just half of the anxiety
cases and were extremely prominent in a few’. The apparent degree of
hypersecretion by no means corresponded to the severity of the mental
symptoms. Exophthalmos and enlargement of the gland were rare,
but tachycardia, sweating, the pilomotor reflex described by Hurst,
tremors and hyper-excitability were common. In mental symptoms
these did not differ from the cases showing no signs of increased
secretion, which had probably been present at an earlier stage. Some
of the more severe cases had obsessive ideas towards suicide, and all
had a dread of insanity.

Few of these cases made any real progress while in my ward. As
regards treatment, I cleared up amnesias when possible, and in most
cases made use of therapeutic conversations and superficial analysis,
but the presence of definitely “ mental ” patients, the air raids, and the
loss of self-control shown by so many made my results poor. Such
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cases should be retained in the Front area, or evacuated completely out
of reach of the alarms of war.

States of confusion , delirium and stupor .—Of these I had thirty-four
cases. They merge with cases described as confusional insanity, and
include a large number of conditions difficult to distinguish clinically or
causally. Simple retardation, simple confusion, confusion with stupor,
and confusion with a vague and imperfect dream state are among the
phenomena observed. As regards the forms produced by concussion,
I place so little reliance on the histories of most of the cases that I am
unable to venture an opinion. The patient himself is naturally unable
to distinguish between an amnesia and a period of unconsciousness
following a blow. MacCurdy states that low mental tension and dipping
of consciousness are pathognomonic of concussion types, but I found
both symptoms where concussion could with reasonable certainty be
excluded. In the following cases concussion and physical exhaustion
do not seem to have occurred, and the syndrome resulted solely from
prolonged emotion :

Pte. L—, ret. 29, four years’ pre-war service. In October, 1914,
was on patrol with three others. They realised they had got too far
ahead and were among Germans. They lost their heads and kept
pushing on, gradually divesting themselves of kit, concealed in ditches,
etc. After going some distance they found some civilians and succeeded
in getting into plain clothes. They had now some idea of getting
across country to Antwerp. They had some hair-breadth escapes—
once lying on a haystack while a German party lunched at the foot—
and got separated. The patient pushed on alone and got into Lille.
He could speak no French, and was taken in by some French people
and sheltered in a garret. He was fairly well fed, and later a forged
billet didentity was obtained for him. He had once been a cobbler,
and was able to earn some money repairing boots, occasionally got out
and had some exercise. He lived naturally in a constant state of dread
and anxiety until the British entered the town. With other escaped
prisoners of war he was sent to hospital. Early next morning he
passed into a dream state, got up, partly dressed, and began musketry
exercises, presenting arms, etc. He remained somnambulistic till
admission, when he was apprehensive, disorientated, and quite imper-
ceptive, inclined to resist attention blindly, and was suffering from
retention of urine. He lay with eyes fixed unseeingly, periodically
raising his chest in opisthotonos, and rolling slowly round to the left till
he would have fallen from the bed. He was able to swallow. He
slept at intervals for forty-eight hours, and then began to have short
lucid intervals, but with considerable retardation. He took some
interest and was able to give his particulars. He cursed the Germans
with violence. The stuporose condition kept recurring, when the same
opisthotonic movements were repeated. After several days only was I
able to get his history, and during his account he passed into a somnam¬
bulistic state, going through in pantomime the experiences of his
original flight, crawling about the floor, peeping over tables, etc. He
remained unstable till his transfer to England if questioned about his

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captivity. A complicating causal factor was his fear that he might be
regarded as a deserter and punished.

The following case of hysterical dissociation with hallucinations
appears to be worth recording at some length :

Gnr. W—, a Canadian, set. 21, service two and a-half years ; precocious
boy and youth. Studious, clever, eccentric, not a social. Worked with
father, who was an analyst, etc. Learned French, chemistry, etc.
Quarrelled with father and twice ran away, getting employment as “ boots ”
in hotels. Precocious sexual experiences. Ran away from university and
enlisted. Got on well; was promoted to sergeant. Transferred to Uni¬
versity unit as gunner and came to France After eleven months with
battery was rendered unconscious by a bursting shell. Had had no
premonitory signs of neurosis, and had felt happy. Seemed shaken, and
was sent to his transport lines for a rest. Began to have impulses to do
silly, senseless things; these he recognised as abnormal, and was, as a
rule, able to resist, but committed some profitless petty thefts. Began
to have the idea that he had been a spy. At first realised the absurdity
of this, but later conviction became intense, and hallucinations and a
state of anxiety developed. Could hear his chums saying he was a spy,
and ought to be shot. About this time he was sent down to a neuro¬
logical hospital. He began to consider himself a martyr, thought
what a fine thing it would be to be shot as a spy, how all his friends,
and especially his father, would be startled, and think more about him,
and so on. He also enjoyed the idea that someone would get into trouble
if he was shot unnecessarily and the mistake came to light. At this
point he reported himself as a spy, giving a most circumstantial account.
He stated that as a “ boots ” he had got into the power of a German
agent, who had used him for years. He described how he sent his

information to a Mons. F-in Paris. (By a remarkable coincidence

a German agent named F-happened to be known in Paris at this

time.) He attracted considerable attention. After a few weeks the
hallucinations ceased, and the patient realised his position. He con¬
fessed to his fabrications, and after some delay was sent to the base.
Consciousness was complete on admission, and he had no amnesia. He
gave me his history in an ashamed and humble way. His conduct was
natural. He was still liable to impulses, however, usually to petty
thefts, and on two or three occasions rifled the lockers, replacing the
plunder shamefacedly later. He had an impulse to poison himself,
partly to be a martyr, partly to cause a fuss. He had several dis¬
sociations with hallucinations, in which he heard me describing him
to the sisters as a spy, and saying he would have to be shot. These
attacks began with headaches, and passed on into deep sleep. It is
interesting to note the recrudescence of the “spy” idea with a totally
different emotional colouring. Between them the patient showed an ego¬
centric vain temperament; he was proud of his knowledge of French,
etc .; fancied himself as a writer of prose and poetry and as a lady-
killer, and on the whole was rather pleased with his illness and the
attention it had attracted.

A case similar to the above is described by Dr. W. S. Dunn, in which
the patient made two attempts at suicide, and my own case, Pte. S—,

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described under the heading of suicide, is of the same type. Unfortu¬
nately the probable degree of dissociation, as shown by resolution in
the suicidal attempts, is not discussed by Dr. Dunn, nor is the degree
of amnesia. All these cases sought to appear in a romantic and
interesting light, and to attract attention and notability. In a case
reported by D. K. Henderson the same object is visible, but in this case
there was apparently no dissociation or somnambulistic state at all.

There would appear to be an infinite gradation between a true
somnambulism followed by amnesia and a simple paramnesia, with
pseudologia phantastica occupying an intermediate position. It is also
probable that somnambulisms also show degrees according as their
content is purely delirious or hallucinatory, or distorted and illusory.
Towards the lower end of the scale one finds such cases of confabula¬
tion as that described by Henderson—the “white lies” of children, and
the genuine distortions of memory which are familiar to all. (The
externally changing paramnesite of an alcoholic probably arise from a
different mechanism.) The degree of conviction or self-deception in
all these grades is a most interesting problem. Obviously it is
inadequate to call a man a “liar” who is willing to stake his life on his
beliefs. I do not know if the psychopathology of the lady who con¬
fabulated the story of the “ Dundee nurse,” or of the journalist who
“visited” the Russian armies in Belgium in October, 1914, has been
reported, but they seem eligible for inclusion in this class.

In the following case the dream-content took an unusual form, the
patient’s attitude being very like that of the acutely hallucinated
“ persecuted ” paranoiacs. Probably similar mechanisms were at work.

Pte. B—, French-Canadian, one year’s service, one month in France.
On his first trip to trenches a few' shells passed over and burst some
considerable distance away. He fell down, look wildly round, trembled,
refused to speak or walk, and was finally carried to an aid-post. In
the C.C.S. he became very excited and violent, attacked orderlies and
other patients savagely, and was hurriedly transferred to the base,
labelled “ mania.” On admission he was extremely suspicious, glared
around, resented any attention, but did not resist, and remained silent.
He seemed to have a severe headache. He was microcephalic, and had
a low, cunning, vicious face. He paid no attention to the sisters, was
suspicious of orderlies and other patients, and glared furiously at
anyone who went near him, but allowed me to examine him, occasionally
answering in a low monosyllable. He lay beneath the bedclothes, ate
and slept well, smoked, kept himself clean, would not help to carry
out his own bed to the garden, refused all information about himself.
He was put on small doses of bromide and aspirin for his headache,
which seemed severe. After a few' days he made a violent and quite
unexpected attempt to strangle me, and it taxed the strength of four
men to control him. His lips were retracted till his incisor teeth were
entirely exposed, he shook violently, and his face was contorted with fury.
He made several other attacks upon me, but was always more easily

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mastered. Fortunately he relaxed his suspicions of the orderlies
correspondingly. He made attempts on two occasions to assault a
distinguished visitor, a Lieutenant-Colonel, R.A.M.C., who was interested
in him. He was in the same mental condition when transferred to
England. I failed to get into touch with him, but I should like to have
known with what he identified me in his illusory world.

In the majority of these cases the delirium, etc., was of short
duration, and disappeared in a few days. Active interference was
impossible, and there was nothing to do but wait. Some of them, as
the integrity of their consciousness was restored, tended to develop
states of anxiety or “ conversion ” symptoms. The latter were easily
dealt with and prevented, but as a rule little impression could be made
on the former.

In four of the cases in this group the stupor was deep enough to be
considered narcolepsy. In others the stupor was less, and was combined
with confusio n. In all recovery was quite sudden.

“ Neurasthenic” states .—Using the word in its popular sense, in this
group I placed thirteen cases complaining of headache, fatiguability,
weakness, and general bodily ailments. Two were cases of neurasthenia
proper. Both were over forty, had suffered for many years, had had
light comfortable billets at the base. In the others the occurrence of
battle-dreams showed them to be true war neuroses lying intermediate
between the conversion hysterias and states of anxiety.

“ Psychasthenic" states .—These are to be distinguished from consti¬
tutional psychopaths. There were ten, the symptoms being diffidence,
indecision, loss of concentration, etc.

Conversion hysterias .—I had sixteen cases of conversion hysteria, all
mutism, three with deafness. Tremor is a common conversion symptom
but is usually associated with anxiety. Stammering was rare, and
appears to be a symptom of late development. Five were relapsed
cases, and all responded at once to treatment. They displayed more
distress at their condition, and greater relief at its removal. Two were
cured by hypnosis, and the rest by persuasive suggestion.

In addition to these I had two cases of hysterical vomiting, combined
with other psychoneurotic symptoms.

The following case illustrates the combination of conversion and
delirious symptoms in the same patient:

Pte. B—, aet. 19, service three years eleven months. Married.
Professional boxer. Exceptionally well-built boy. Blown up four months
previously, with mutism, deafness and an amnesic period. Recovered
voice and hearing by suggestion, but still stammered badly. Relapsed
after air raid while in convalescent camp. Admitted in a state of great
terror and excitement, confused and disorientated, shouting and crying
aloud. Vivid hallucinations and illusions of Germans advancing on
him with rifles, etc. Fought and struggled violently, and was given
hyoscine and morphia. Had some hours’ sleep and woke apprehensive,

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but more composed, and deaf and mute. Hallucinations returned at
intervals, but illusions ceased. Orientation returned, and we were able to
approach and soothe him. On the third day I restored his hearing and
speech, but he had a violent inspiratory spasm, which made the latter
most painful. Later I was able to remove this, so that he could speak
freely in a low voice. His delight was unbounded. He had amnesia
for his excitement on admission. For two days he seemed stable and
well, then suddenly and for no apparent cause his dream-state returned,
he had the same terrifying hallucinations, and he had to be held down.
He cried out, showing the same severe stutter. After half an hour he
came to, with a hazy memory. After this he was uneasy, nervous and
apprehensive, and needed constant encouragement. He had a restless,
suspicious night. He told me he kept seeing Germans everywhere,
pointing rifles and bayonets at him. These were not illusions, but
pseudo-hallucinations. He improved steadily, but for some days was
subject to the pseudo-hallucinations with short intervals of dissociation
and real hallucinations. I have not seen these combined in this way
in any other case. A few nights before he left for England he went
through a noisy air raid tremulously, but without ill-effects.

Hysterical fits .—I have already discussed these cases under the
heading of “epilepsy.” There were nine cases of convulsive attacks,
obviously hysterical in origin.

Conclusions. —(i) A consultant psychiatrist, understanding and having
sufficient. authority to protect the interests of those suffering from
mental disorders, is essential. Such a post, held up to 1917 by
Lieut.-Col. C. S. Myers, R.A.M.C., was afterwards abolished or left
unfilled. The accommodation in the mental wards at Boulogne com¬
pared unfavourably with that provided for surgical and medical cases,
and when seven out of the twelve trained mental attendants were
combed out in 1918 no attempt was made to replace them by trained
men of lower category, numbers of whom were available, but totally
inexperienced men were sent. This obviously increased very con¬
siderably the risks in the safeguarding of three score acute mental
patients, apart from the fact that only one single room, provided with a
door, was available.

(2) No special “ war-psychosis ” was evident, but the proportion of
acutely suspicious and persecuted delusional cases noted by various
writers was certainly higher than in the same number of civilian cases.

(3) The patients were admitted at a much earlier stage than is usual
with civilians, and their psychotic symptoms were, as a rule, corre¬
spondingly more responsive to treatment. On the whole, however, I
found soldiers in acute excitement, confusion, etc., very much more
amenable to external influences than the same types of patients in a
county asylum. The ideas of discipline and rank are thoroughly
stamped in during training, and are slow to disappear. It is difficult
to see how such drastic interference with personal liberty as compulsory

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detention in a mental hospital could be arranged in civil life without
some safeguard analogous to certification, but there is no possible
doubt that earlier treatment of mental disorders is urgently called for,
and must be made more easily available than at present. Further,
curative mental hospitals should be kept completely distinct from
repositories for the defective and the organic dement. The influence
upon the temporary and curable psychoneurotic of daily mixing with
the gravely deteriorated chronic insane cannot but be harmful.

(4) Little psycho-analysis was done, but all cases were interrogated
in private, simple explanations of psychological mechanisms given
where suitable, and superficial analysis on the evidence of dreams,
association tests, etc., were carried out, with satisfactory results. Many
of the depressed and deluded cases had little conviction, and were
remarkably susceptible to persuasive suggestion. Hypnosis was used
rarely and less frequently in later months. Other means of over¬
coming psychic resistance, if slower, are more satisfactory. All patients
were in the open air every possible hour—labour was plentiful, and
the beds were light—and everything was done to foster the hospital
atmosphere. I was fortunate in being able to maintain a spirit of
orderliness, of self-control, and of “ will to recover,” which was of the
greatest possible assistance, and which of itself was responsible for most
of the improvement which occurred in the patients.

(5) Neurotics and psychoneurotics, if allowed to leave the Front
area for treatment, should be sent out of risk of all the alarms of war.
Their treatment in a base, exposed to air raids at short intervals, is
extremely difficult.

(6) Defectives, if enlisted at all, should be retained strictly for home
service

References.

Read, Stanford.—“A Survey of War Neuro-Psychiatry,” Mental
Hygiene , vol. ii, No. 3, July, 1918.

Jelliffe and White.— Diseases of the Nervous System , London, 1917.

Rhoussy and Lhermitte.— Psychoneuroses of War, London, 1918.

Armstrong-Jones, Sir Robert.—“The Relation of Alcohol to Mental
States,” Journ. Ment. Sci., April, 1918.

Fildes, Parnell and Maitland.— Brain, vol. xli, pt. 3, 1918.

Hotchkis.—“A War Hospital for Mental Invalids,” Journ. Ment.
Sci., April, 1917.

Eager, R.—“Admissions to the Mental Section of the Lord Derby
War Hospital,” Journ. Ment. Sci., July, 1918.

Farrar, C. B.—“War and Neurosis,” Amer. Journ. of Insanity, April,
1917.

MacCurdy.— War Neuroses, Cambridge, 1918.

Babinski and Froment.— Hysteria or Pythiatism, London, 1918.

Mott.—“Shell Shock,” Proc. Roy. Soc. Med., February, 1916.

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1 80 PSYCHIC SECRETION, ' [July,

Dunn, W. S.—“Pseudologia Phantastica,” Journ. Ment. Sci ., July,

i 9i8.

Henderson, D. K.—“ Pathological Lying in a Soldier,” Rev. Neurol,
and Psych., July, 1917.

Wholey.—“Revelations of the Unconscious in a Toxic (Alcoholic)
Psychosis,” Arner. Journ. Insanity, January, 1918.

Henderson.—“War Psychoses: Analysis of 202 Cases,” Journ. Ment.
Sci., April, 1918.

“Psychic Secretion: The Influence of the Environment." {}) By Lieut.
Col. E. P. Cathcart, M.D., R.A.M.C., Professor of Physio¬
logy, London Hospital Medical School.

Mr. President, Ladies and Gentlemen, —Probably most of what
I shall say to you this afternoon will be well known to you; indeed,
many of you may think the information self-evident and trivial, but in
spite of this I hope that what I say may serve to re-emphasise in your
minds the fact that we are all very subject to our environment.

Consciously or unconsciously we are all inclined to look upon
mankind as a superior caste of living organism—a something which
occupies a place apart in the kingdom of the living. But this assumed
divergence from all other life arises solely from the fact that some few
of mankind think or pretend to think, and therefore have not unnaturally
arrived at the view, that mankind is a class apart. We recognise and state
in a superior sort of a way that the lower living organisms are subject
to their environment—are indeed at the mercy of their environment, that
their actions and manner of life are governed by their surroundings.

Yet in spite of our superiority we, too, as a class are subject to, and
in fact one might almost sayare victims of, our environment. We respond
to the various types of stimuli which affect the despised lower members
of creation, but unless we respond in a way divergent from the conven¬
tional social standard of conduct, we pursue the even tenor of our way
almost blissfully unconscious of the fact. On the other hand, if we
respond irregularly, or too actively, we immediately attract the notice of
.our friends, mayhap of the alienist, and sometimes even of the police.

Now, some of you may quite correctly inquire what has all this wordy
preamble to do with the subject of my lecture, “ Psychic Secretion.” I
wbuld reply that it has everything to do with it. The so-called psychic
secretion is only a demonstration of one of the simplest of the relations
which we have to the outside world. The commonly used term
“ psychic secretion ” is really a misnomer ; all it is, in reality, is a reflex
secretion in which the stimulus is not the usual commonplace one.

Let us for a moment consider the type of secretion to which the term

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“ psychic ” has been applied. It is common knowledge that under certain
conditions, quite apart from the taking of food, our “ mouths water.”
This mouth-watering was not considered worthy of the attention of
physiologists until Pavloff—in whose laboratory at Petrograd I had the
honour of working—took up the matter, and thoroughly investigated the
conditions associated with salivary secretion. Pavloff first of all showed
that it is not the mere flow of saliva which has to be considered : the
composition of the saliva which results is also under control. If you
tempt a dog with a mass of raw meat it gets very excited, but no saliva
is secreted from the parotid gland. But show it dried meat powder,
or dry bread, and immediately there is a free flow of watery saliva
from the parotid gland. If, on the other hand, you are making
observations on the submaxillary gland, and you show the animal
the raw meat, a free secretion results. Pavloff then demonstrated that
the different salivary glands are very sharply differentiated as to the
conditions necessary for their activity; they show a marked selective
action in the choice of an adequate stimulus. A very interesting point
is, that the mechanical stimulus in the form of a material object is not
the only potent stimulus.

The psychic stimulus is not confined to the salivary glands. Pavloff
has demonstrated that the gastric glands react in the same way, thus
confirming a very early observation of Bidder and Schmidt, who had
noted that the offering of food to a hungry dog evoked a flow of gastric
juice. The interesting fact about the gastric psychic secretion is, as
Pavloff has clearly demonstrated, that the latent period of secretion is
identical— viz., five minutes—with that which follows the normal stimula¬
tion of the buccal mucous membrane. Pavloff further showed that the
temperament of the animal tested plays a large part in the flow of the
gastric juice. Lazy or impatient animals do not act as good subjects.

One of the practical results arising from these experiments was the
conclusion that the taking of food is, or should be, a serious function ;
unless the meal is eaten with interest and enjoyment the full value is not
obtained. Hence we are, indeed, at the mercy of our environment. It
is not the mere food which is of primary importance; there are many
additional factors which play an important part in this question of the
taking of food. The refinements of life in our prandial ritual have
gradually assumed a position of primary importance. Under normal
conditions most of us make certain demands in connection with our
meals : spotless linen, bright silver, a well-decorated table, and everything
set in a special room. Unless we get this, along with well-flavoured,
well-cooked, and well-served food, our appetites are apt to fail. Hunger
is indeed the best sauce, but indoor work is not the best stimulus for
the creation of hunger.

But there is still another side of the question, and this is an aspect

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which you here will appreciate perhaps more fully than I can, and that is
the effect of mental strain or emotion on the appetite. We all know how
often, when we are deeply interested in a piece of work, the usual meal-
hour can come and go, and yet we are indifferent; or, on the other hand,
how strain and worry literally destroy the appetite—the food may be
taken, but it is eaten without enjoyment or interest, and the all-impor¬
tant psychic secretion fails. Or still further, we may be heartily
enjoying a meal when some emotional storm sets in—say a quarrel
starts, the temper is raised, and as a result of the violent emotion the
digestion is actually brought to a complete cessation. Truly we are
at the mercy of our environment. We respond to stimuli which of
themselves play, and can play, no first-hand part in the secretion of the
digestive uses, but yet which, in conjunction with a very early reflex,
can be gradually converted into true stimuli of the first order. In other
words, we form secretory habits, and unless the particular concatenation
of events is present, or unless certain well-defined specific stimuli are
present, the result is failure. You, above all other workers, appreciate
the true importance of these apparently subsidiary factors in the realm
of psychopathic studies—how certain individuals must have certain
stimuli before what may be regarded as a perfectly normal act can be
performed. Take for example a certain well-known speaker. What
would he do if coat-lapels went out of fashion and his tailor failed to
provide them ! Then take those individuals who cannot speak without
having something to play with. The stimulus of the coat-lapel or the
piece of string, in themselves perfectly indifferent, and perfectly incapable
of forming adequate stimuli for thought and speech, yet play a very
real part in the smooth flow of thought and speech.

The facts underlying this reflex secretion have been investigated by
Pavloff and his pupils, using the secretion of the salivary glands as the
test. Pavloff carried into the realm of the central nervous system the
methods of experimentation which had given such successful results in
connection with mere glandular activity. The particular methods which
he employed he has called the formation of “ conditioned reflexes.”
He divided the salivary reflexes into two classes ; he spoke of the “ con¬
ditioned reflexes ” and the “ unconditioned reflexes.” Pavloff would
say that the so-called psychic secretion which resulted from a stimulus,
perhaps indifferent in itself, was a conditioned reflex, whereas the
ordinary stimulation of the buccal cavity on the taking of food—the
normal way in which saliva is caused to flow—he calls the unconditioned
reflex. From a study of these two reflexes Pavloff has evolved a
wonderful method of gaining information about our relationships to the
external world, that is, of our relationship to our environment.

In developing this relationship there are two fundamental mechanisms
involved. The first is by what he called “ temporary association ”—that

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is to say, the bringing of external phenomena into relation with the
reactions of the organism, this connection becoming more and more
complex and the more subject to modification or influence as evolution
of the higher centres proceeds. The other fundamental mechanism
is that associated with the “ analysers ” usually called the sense-organs,
ie., the eye, the ear, etc., the organs which sort out the many and
complicated stimuli which bring us into relation with the external
world.

As one of the simplest and most primitive of our relationships to the
external world is the necessity of procuring food, in the course of the
quest for a suitable supply of nutriment the means by which food is
detected increase in number and complexity as the analysers are
differentiated. As a result the variety of phenomena which gradually
become associated with food increases in number, so that in the end,
owing to the variety and number of the adequate stimuli, the impos¬
sibility of other than mere temporary or evanescent association is
obvious.

How is the conditioned reflex—the formation of the temporary
association—brought about? How is an indifferent stimulus converted
into an active one ? Why is it, for example, that one man reading in a
newspaper—an indifferent stimulus—that coupons are no longer required
for meat in a restaurant has, if he is a lover of a well-grilled steak, an
anticipatory flow of saliva, whereas a man who is a vegetarian is left
cold, except, perhaps, for a feeling of disgust that more meat is to be
liberated, by the same announcement.

Pavloff showed that if a new indifferent stimulus be presented
sufficiently often in conjunction with one which is known to cause a
secretion, in the end the indifferent stimulus presented alone will evoke
a response. It means that the reflex arc has taken on a new afferent
neuron, but it has not taken it on unconditionally; the path is not yet
beaten down hard : no right-of-way has been formed.

I shall now give you an account of how an indifferent stimulus may
become a true reflex, lake, first of all, an example of an unconditioned
reflex. As you know, if you give an animal food saliva will be secreted.
Suppose, now, that every time food is given to a dog—for example,
meat powder thrown into its mouth, so as to leave out the factor of
chewing—a bell is rung, or a light shown, or a single note sounded on
an organ, or the dog has its skin scratched on a particular spot. If
the giving of the food and the application of the particular stimulus
selected be made to synchronise a number of times—the actual number
varies a good deal with' the individual dog—it will be found that one
day the superimposed indifferent stimulus, the ringing of the bell, if
that were chosen, used alone, will evoke the secretion. In other
words, a conditioned reflex to a specific stimulus has been created.

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This is an example of the genesis of a conditioned reflex, and similar
reflexes can be generated by practically any phenomenon of the external
world, provided the animal possesses a suitable analyser or receptor—
that is to say, if it can form temporary associations between the external
phenomena and the mechanism for the salivary secretion.

The point that is thus emphasised is that, provided a well-established
primitive unconditioned reflex exists, by suitable treatment a previously
indifferent external stimulus can be brought into intimate relationship
with it.

The investigation would be very simple if it all ended here, but
Pavloff has definitely shown that the problem of inhibition must be
considered : that not only can one inhibit either externally or internally
these reflexes, but in the end an inhibition of the inhibition may be
brought about. Any external phenomenon may act under suitable
conditions as an inhibitant. This fact is of serious import when the
conditioned reflex is being developed in the laboratory : the experi¬
ments have to be carried out in dead silence every day; each time one
has to use the same movements. Very frequently the very slightest
outside disturbance—the banging of the door in another laboratory, for
example—is enough to upset the experimental dog for the day.

The question of internal inhibition is much more subtle. When a
conditioned reflex is properly developed, i.e., when the indifferent
stimulus alone evokes a response, if the animal is not presented on
several successive tests with the food which it has learned to expect on
the application of the stimulus, the conditioned reflex ceases to be
effective. As a rule this type of internal inhibition is merely temporary,
the conditioned stimulus being effective at a later period.

At the same time actual inhibition of secretion can be developed by
suitable treatment—that is to say, we can build up reflexes for non¬
secretion or non-activity just as easily as we can build up a reflex for
activity. It is a matter of training, and of the utilisation of special
methods.

In one animal under observation we had developed on its fore leg a
little active spot which, when brushed, caused active salivary secretion.
In the middle of its back, on the contrary, by a similar process we had
developed an inactive cold spot, and when that spot was chilled inhibition
of secretion took place ; it was a spot trained for non-secretion. If the
non-secretion reflex is first evoked, naturally there is no flow of saliva ;
if the active reflex is now called in there will still be no flow—active
inhibition has taken place. The active stimulus, however, soon becomes
effective again. You get the same thing if you try to present two
different active reflexes simultaneously, or if an attempt be made to
superimpose an active stimulus during the period of secretion produced
by another active stimulus.

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BY E. P. CATHCART, M.D.

.85

It can also be demonstrated that the time element may play an
important part. I have mentioned that in regard to the gastric flow
there is a normal latent period of five minutes. A similar latent period
may be developed in connection with conditioned reflexes. For instance,
if in building up a conditioned reflex the food be not given until a
definite constant period—say two minutes—after the application of the
stimulus, it will be found that when the new conditioned stimulus is
given alone there is a latent period of the duration established during
the formation of the reflex, viz., two minutes. During these two minutes
of latency an active inhibition is going on to prevent the secretion of
saliva. If, during this latent period, you throw in another perfectly
indifferent stimulus—a stimulus which of itself would not produce a flow
of saliva, one which the animal has not been trained to respond to—an
active flow of saliva takes place ; the indifferent stimulus has broken the
spell, it has inhibited the inhibition, and an active flow of saliva ensues.

In dogs at least the development of a conditioned reflex is a very
sensitive affair. Supposing you train an animal to the stimulus of an
organ note of exactly ioo vibrations per second, that animal will be
indifferent to a note of ninety-six vibrations on the one hand and to a
note of 104 vibrations on the other ; but as soon as the 100 vibrations
are resumed the saliva flows again. Again, take the skin. One does
not look upon the skin as in any way too sensitive when spacing it out
with an resthesiometer ; yet the removal of the stimulating electrode or
brush to a distance of only 1 cm. from an active spot will suffice to do
away with the whole reflex.

Even painful stimuli can be used for the building up of conditioned
reflexes. Thus an electric current strong enough to cause signs of
pain in an animal may be built up into an apparently non-painful
conditioned stimulus. If each time such a stimulus is used the dog be
given food, it will be found that after a few repetitions all signs of pain
from the stimulation have disappeared and a free flow of saliva occurs :
the stimulus has lost its power as a painful agent. But move the
electrode even a centimetre away from the spot and the dog will again
show every evidence of violent pain. It must be admitted it is only
with difficulty and under special conditions that you can develop these
painful stimuli into good conditioned reflexes.

I think you will now see why I have insisted that we are victims of
our environment—of the daily routine which is so dear to us ; how it is
that as we “ get used ” to a certain setting, we work better and more
happily, we enjoy our food better—in general we are more comfortable.
All these little amenities of our social life which we have come to look
upon as more or less essential to our comfort and well-being are
but indifferent stimuli, which, through constant application, have been
converted into conditioned reflexes. Our environment plays such an

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PSYCHIC SECRETION.

I 86

[July,

enormous part in our happiness and well-being simply because we have
physiologically developed conditioned reflexes.

Sir Robert Armstroxg-Jones said this paper was a very difficult one to
discuss. It was ex cathedrd, and in attempting to discuss it one was apt to
wander off into platitudes. It was well known that if one's morning letters brought
bad news, one did not want ond’s breakfast. As the Psalmist said, one’s tongue
clove to the roof of one’s mouth, and altogether there was an inhibition of psychic
secretion. He felt very grateful to the reader of the paper for having introduced
a very charming phrase, which he hoped Colonel Cathcart would not regard as
his copyright—namely, “ the prandial ritual.” It described very aptly all the
social amenities and conventions which appertained to the taking of food. He
had always said that the poor man and the rich man drank for two opposite
reasons—the poor man because he mistook the feeling of stimulation imparted by
a glass of beer for the satisfaction produced by a well-grilled chop, whereas the
rich man drank in order to make his meal a better meal. The latter had all the
assthetic reasons around him—the charming napery, the brilliant silver, the flowers
arranged before him—he had practically all the nice amenities, and there was also
the sight of the champagne bubbling in the glass. All those were points which
had to do with psychic secretion. He was greatly interested in the fact that man
was so much looked upon as a creature of environment. Man, however, was
only an ordinary creature, not a superior mortal, but he had five or six windows
to him, through which boundless energies came to him from without. We
were, no doubt, deaf or blind or insensitive to many of the forms which came
in, but we were open to others. He maintained that one was kept going by
one’s environmental stimuli coming from without. He had seen many men who
retired at 60, having made their pile, and he had seen them “ drop out of
life,” so to speak ; they had become members of an asylum population merely
because they had retired and no longer had the customary environmental stimuli.
But there was one point he could not harmonise with what the reader had said.
Dementia prascox was the unemotional type, but the subject of this never failed
to secrete his saliva and never failed to grow fat in the early stage of his dementia
prrecox. He also appreciated everything which came before him. If humanity
was so much the creature of psychic secretion, why was it that in this charac¬
teristic form of insanity all the functions of the body seemed to go on satisfactorily
for a time ? It had been a most excellent psychological lecture, touching on simi.
larity, contiguity, the power of appeal to the cortex to inhibit all these things-
One heard and read of various stigmata produced by thought and by suggestion.
There was the question of the fine balance kept between the internal secretions.
Perhaps it was the want of that balance which made Napoleon grow fat and sleek,
and develop adiposis dolorosa. The same thing probably obtained in abnormal
conditions of the thyroid. He had heard it said—and he had no reason to doubt
it—that certain cases of goitre had been brought on by mental stress. Not
infrequently he had seen neurasthenia in a shell-shocked soldier who had had
goitre produced, perhaps by nervous influences. We had in our hands the creation
of our own internal arrangements, and perhaps gigantism, acromegaly, goitre and
similar conditions could be controlled if the inhibition were exercised. He had
been well rewarded in coming to hear the lecture.

(') Read at the Quarterly Meeting of the Medico-Psychological Association
held in London on February 20th, 1919.

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1919-] THE GENESIS OF DELUSIONS : CLINICAL NOTES. I 87

The Genesis of Delusions : Clinical Notes. By Colin McDowall,
M.D., Medical Superintendent, Ticehurst House.

Men and women hold to and have faith in certain opinions as the
result of long thinking around and along certain lines. Our social and
political tendencies are the outcome of an analysis more or less critical,
and believed by the individual to be impartial. A scattered phrase or
an apparently insignificant incident may attract attention, and be the
beginning of a prolonged mental conflict which is finally determined by
a definite line of thought. It does not follow that the reasoning is
always logical, or the argument conclusive to people of other opinions,
but nevertheless a conclusion is arrived at, and it is final.

How this is borne out in every-day life may be seen in the following
narrative: A boy of Scotch descent, bearing a distinctly Scotch name
but born in Ireland, was sent to a school in Scotland. His school¬
fellows pronounced him an Irishman at once. His accent was Irish,
and he lived in Ireland, so his Scotch school companions would not
admit him as a Scot though his parents had always fostered the idea
that he was one. The view of his school mates was a rude awakening.
When the International Rugby matches take place national feeling
runs high in a Scotch public school. He found he was expected to
support the land of his birth ; the land of his name rejected him with
scorn. This result had its lasting effect. The boy against his inclina¬
tions and early teaching had to range himself against what he thought
was his own country. Years passed and the man remains the same : he
supports the land of his birth, and when the character of the Scots is
discussed, though admiring much in silence, he takes a partisan side
and brings out all that can be said against the country that years ago
rejected him.

A thoughtful and apparently honest man arives at a conclusion which
another equally thoughtful and honest man will inform you is wicked, and
nothing but the road to ruin for all those who think similarly. It is not
necessary to pursue this subject, but it is mentioned because in those
mental states in which distinct abnormality exists the mind of the
patient works along the same lines, and false beliefs arise as the result
of thought directed irregularly to experiences in the lives of the indi¬
viduals. An incident may or may not have an abiding effect upon the
course of anyone’s life. Just as a chance phrase or sentence may
influence for a lifetime the opinions of thinking persons, so may an
incident be misunderstood and its effects misconstrued owing to lack of
the sense of proportion in the mind of the psychopath.

Abnormal mental states arise in persons with a varying personal and
family history. Probably the presence of hereditary taint is the most

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important factor in the preparedness of anyone to become mentally
disturbed or actually insane. Heredity is therefore important, as
also are other predisposing factors, but these agents alone do not
determine the course which the disability will take. The tendency to
insanity exists, and it is the personal experience which goads the
intellect along an illogical and unreasonable path. Just as reasoned
thought, stimulated originally by an expression or form of words,
produced a complicated line of thought which was held through life as
an opinion or belief, so in the psychopath an incident may start a
complicated system of delusions. The result is, after a space of time,
a state of affairs very unlike the original condition. Delusions and
hallucinations do not arise accidentally ; they have a definite basis, the
foundation of which is in the personal experience of the sufferer.

It is the duty of the medical man to analyse the mental processes by
which the abnormality has arisen and work back to what may be called
the taking-off point. It is not my general experience that these causal
factors are always difficult to bring to light. A great step towards
removing the difficulty is to gain the complete confidence of the
patient, and there is no easier method to attain this end than to have
the subject of one’s examination constantly intermingling with patients
in whom treatment has previously been successful. Some of my most
interesting cases have been encountered in dealing with enlisted soldiers.
Whether the soldier is more readily made to talk than the civilian may
not be easy of proof, but it is probable. In men the cause underlying
a psychosis is often reached very quickly, whereas women are more
reticent. Not only is this so, but I remember well a case in which a
woman of good education deliberately invented what to her appeared to
be a very satisfactory collection of dreams and association-tests merely
to deceive me so that I might pronounce her recovered, and thus
provide her with a suitable opportunity for suicide.

I have said that the determining factor in the mental abnormality may
not be far from the surface. It may indeed be so insistent that it is
always present in the thoughts of the patient. The after-results of the
personal experience may conceal the relationship of the cause and the
effect in the patient’s mind, and he may describe his symptoms and
almost in the same breath give the cause of all his troubles. The
patient does not realise the relation of the one to the other, and cannot
be expected to do so ; and here it is the necessary duty of the practitioner
to explain to the patient his symptoms and educate him by showing the
interconnection of cause and effect. The means placed at our disposal
is through mental analysis. By that I mean an examination which will
not only investigate the conscious problems of the patient, but also
bring to light the factors of subconscious origin.

When dealing with numbers of men suffering from war neuroses it

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1919.]

I 89

was noticeable that as a general rule the functional condition required
a great deal more probing to arrive at something satisfying than was
necessary in the more organised state of mental inability. And it may
be added, paradoxical though it may seem, the functional condition is
much more easily treated than the state in which delusions or hallucina¬
tions have begun to assert themselves. The mere elucidation of the
cause is not enough to effect a cure, and the patient should be taught
to follow in their logical sequence all the ideas which he had mis¬
interpreted and misunderstood.

A man was admitted to Maghull Military Hospital showing all the
signs of acute depression and considerable confusion. He had been in
the trenches for four months in the early part of the war. There had
been a mental breakdown nine years previously, in consequence of
which he was invalided out of the Navy. He was a married man with
three children. In addition to the general signs of depression there
were delusions; he said he had only half a body, that the food he took
did him no good as it ran out of him. When questioned as to what
these ideas meant he explained he had had diarrhoea in the trenches
and it had so weakened him he was only “ half his old self.” The food
could not be retained as he thought his rectum had “ dropped out, I
suppose.” The idea that his diarrhoea persisted was incorrect. He had
a stool once a day as a matter of fact. Further inquiry elicited the
following facts: He was an old naval man living at a seaside town and
yet he had not rejoined his old service. He did not try to rejoin: he
“ wanted nothing more to do with the Navy.” He complained he
heard a voice saying, “You ought never to have done these things.”
The patient for a time would say no more about himself. Later he
related how he had joined the Navy at fifteen, and had received money
regularly for allowing certain practices to take place. The clear
relationship of the acts of his youth and the delusions of manhood is
evident. The patient had begun to rationalise his bowel sensations
and to misinterpret the normal bowel action. After a certain amount
of instruction, and the explanation and interpretation of his symptoms,
improvement set in. He said to me the voice was no more than his
conscience—a correct estimate of the condition.

The hallucination was a very helpful hint that there was more in the
case than a superficial examination would show; he thought his food
did him no good, that his rectum had dropped out. The man’s
explanation of his delusions was only a rationalisation, and might have
been considered satisfactory. He had passed through four months of
strain and stress in France; terrifying experiences disturbing to the
emotions would have had time to act upon a man who had previously
been insane, but the hallucinations at once pointed the path along
which further investigation should go. The patient was suffering from

LXV. 1 3

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remorse in an aggravated form. His attitude was one of shame. He
was unsocial and avoided others—even his own wife when she visited
him. The hallucination was the product of his own thoughts.

Hallucinations do not occur in states of depression at an early stage
of the malady; delusions develop earlier. A simple anxiety state with
depression may develop into a condition associated with delusions, and
this is the more likely to happen if the case is untreated. There are
quite enough causal factors associated together in modern warfare to
cause a psychosis to develop. The patient, already tormented by a
state of anxiety, begins to revert to these gloomy and sordid experiences
of his life. Finally, one memory is able to take possession of all his
thoughts, and round this subject he will weave his net. The hallucina¬
tion, “ You ought never to have done these things,” cannot be said to
be in relation with a subconscious thought; quite the reverse. It is
in relation with a painfully clear memory. The hallucination as it
stands means nothing, and it is only when the man’s life episodes are
revealed, and the personal matters are sifted, that it can be made
intelligible. The presence of hallucinations may be taken as the
measure of the intensity of the causal memory image. Just as dreams
are helpful in the purely functional case, so hallucinations will surely
point to a causal factor of the first importance. The subject of this
case made a good recovery, although during his convalescence his wife
died somewhat unexpectedly.

The case just recorded may be said to be one in which the personal
experience acted as a secondary or indirect agent in the production
of the psychosis. In the story which follows the experience was the
direct factor, and the mental state arose from looking at the occurrence
from an altogether wrong point of view’.

The patient was a man iet. 41—a north countryman. He had
taken alcohol in the pre-war days rather freely. A reservist, with no
previous experience in warfare, he went to France in August, 1914.
He was invalided to England with rheumatism in February, 1915, was
sent to France a few weeks later, but returned, as the rheumatism
recurred in Havre. After some time in an English hospital he w r as
given leave. He remembers getting his papers, but nothing after
that.

I did not see the patient until he had been in hospital some weeks.
On examination he showed considerable uncertainty of memory, and
was obviously depressed, of anxious countenance, his forehead deeply
furrowed, the face thin and haggard. He was solitary, avoided his
comrades, went for long walks alone, and in short showed all the signs
of a man brooding over some occurrence recent or remote.

For three months this man was with me. Any attempt at progress
on my part was frustrated by an obstinate silence, or word manipulation.

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He was not improving mentally, but after much persuasion the facts of
the case were disclosed.

In the winter of 1914 he was sent out one night on a patrol. He
was the leading man of six others. Suddenly he felt that he had lost
touch with his companions. He was alone, but almost immediately he
heard a voice say in English, “ Give me your rifle.” He could see
nothing, but when the order was repeated he bent down and was able
to make out against the sky-line the spike of a German officer’s helmet.
He had little time to make a decision, but holding his rifle in the
middle, he drove it upwards at the man in front of him. The officer
gave a “dirty laugh, a sarcastic, scoffing laugh.” Our patient naturally
enough thought he had struck into the lapel of the officer’s greatcoat.
The next moment the officer fell dead at his feet. He had stabbed
him through the floor of the mouth and the bayonet stuck in the skull.
The officer carried a sword in one hand, a pistol in the other. The
movements and voices of an enemy patrol were heard and our man
escaped to his trench. The telling of this story takes time, but the
actual occurrence was all enacted in a moment.

Many emotions were stirred in this brief experience. The setting
was fitting for a memory which can never leave the soldier. Fear
firstly at finding himself isolated, the sudden voice asking for his rifle,
the fearful thought that he had missed his man, as evidenced by the
scoffing laugh, and lastly, fear of discovery as he attempted to regain
his trench.

The soldier from the beginning took an altogether false view of
his action. On his return to his trench he only told one man what had
happened. He was ashamed of what he had done. He said to me
“ he would not have minded if it had been a fair fight in the open,” and
“if he had cursed me I should not have minded, as he would have
deserved what he got.”

Depression and confusion followed some months later. At night,
when in a state between sleeping and waking, he would see the whole
incident. The laugh would waken him at night. He would hear the
sarcastic laugh also in the daytime. He could not sit in the billiard
room of the hospital, as men often laughed in the same sarcastic way
when a player failed at a shot. He went away by himself so as to
avoid the possibility of having the image recalled by a comrade’s laugh.

It is not quite easy to explain the sequence of events in this man’s
depression. Much would depend upon the mental make-up. He
appeared to be a simple, kind-hearted man, but in no way a senti¬
mentalist. He had lived a normal life of boyhood and youth, and
joined the Army, as many men do, in order to see the world. On going
on the reserve, he had married and worked on the railway.

The event in every-day life which to my mind is perhaps analogous

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to this war episode is one connected with association football. In
football, when a player within a certain area infringes the law, a penalty
kick is given against him. That means virtually a certain goal to the
opposing side. In popular football, with the thoughts of the crowd
interested more in bets and points than in the play of the game, a cheer
goes up at the decision of a penalty kick; but in a truly sporting crowd
there is no such demonstration; the feeling created is rather one of
resentment against the offending player. The true sportsman would
rather not gain a point under such circumstances. Once the decision
is given the penalty must be taken, and the player, however much he
may have the sporting instinct, must do his best. Reverting to the
soldier, he merely did what was his duty. To have done nothing
would have meant his own death; he acted under enormous stress.
There was at first uncertainty as to the nationality of his opponent, but
once he had made a decision on this point he had to act. The common-
sense conclusion is that he did right.

The method of treatment adopted was by explanation of his symptoms
a comparison of his act with that of the football incident, and a strong
appeal to the man’s own common sense. The unburdening of himself
of the long-kept secret had an immediate effect. The dreams stopped
almost at once. Following the first interview after the facts had been
obtained, the patient had the best night’s rest he had had for months.
Ultimately he lost all his depression and was sent home.

I have used this case as it shows what results can be obtained by
mental analysis in a patient in whom there is no connection with sexual
matters. It is unfortunate that to many mental analysis should have
reference to this subject of necessity. Many cases, when analysed, no
doubt, have to do with sexual things, but in very many the reverse is
found.

Finally, I would record another example of the close connection
between memory of an action in boyhood and the fully developed
delusion in manhood. The patient was a soldier, ret. 24. When he
came under notice he was acutely depressed and was under the
impression that people were accusing him of being a murderer.

His father was an alcoholic, and he himself had drunk very
considerably. He has never been able to stand the sight of blood
When twenty-two he was sick when he saw’ an ox killed. He went to
France in August, 1914, and felt sick and faint when he saw a man
blown off a horse and killed. He was returned to England within
a fortnight with rheumatism. In March of the following year he went
to the Dardanelles, and there worked with his battery for four months.
He became confused on Gallipoli, and wandered about aimlessly, so
that he was sent home. His memory of the events of the voyage home
is very incomplete.

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When examined he was highly emotional, wept whenever addressed,
and went on his knees praying for forgiveness of his sins.

A word analysis was tried, and it gave some interesting reactions.
Many of the tests are omitted, and a few selected ones only given.

Tired—very, thinking how he has always to be pushed on to work.

Forget—never, the lessons he has had, all his past misdeeds. .

Breath—holy, the breath given to us all is given by God.

Fire—hell, hopes to keep out of hell fire.

Mouth—river, after a considerable interval “no fastings.” The need
of fasting on account of his wickedness.

Happy—very, he should like to be very happy.

Broken—often, refers to his promises.

Hope—always, to do his duty and live another life.

End—never, world without end.

Death—an interval of twenty-four seconds, and then, “ Death did
you say?” Sting, later he said his first thought was “Beautiful,”
then “ Envy,” then “ Happy ” (these all refer to a sister’s death).

It will be seen at once how the idea of self-reproach and unworthi¬
ness is running through many of the associated words. Some replies
indicate his religion, and the tendency to seek relief from his present
oppressive thoughts by an appeal through his spiritual beliefs. He
shows in the words “ end—never’’that his outlook must indeed be
terrible if his present misery is to last everlastingly; or possibly he
means that his fate is unending as his sins are unforgiveable. Lastly,
the reaction-time for the stimulus word “death” produces thoughts but
no spoken word, except after a long interval. “ Death ” and “ sting ”
are a normal reaction, and had the reaction-time not been taken the
associated word would have caused no criticism. The man admitted,
however, under pressure he had thought of three words and rejected
each, as he did not want to talk about them.

He heard people calling him a murderer, and he said he was the
wickedest man on earth. In addition, he said he often thought of his
home, of his sister who died, and he had heard her say to him at night,
“ I am happy.”

His youth had been a disturbed one. His parents were not of the
same religion, and though he had embraced his mother’s religion, his
father often quarrelled with him about it. His sexual life was an
unhealthy one. Living in the same room with two sisters, he had had
incestuous relations with one and had attempted similar things with the
other. His sister died of lung disease at a time when these practices
had not ceased. She was quite young. He thinks that by these
practices he had so weakened her that lung disease overtook her. He
used a forcible expression, which I cannot repeat here, of his belief in
this subject. He was an ignorant boy, poorly educated, and running

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wild with little control as a youth. He had read, however, in pamphlets
of the dangers of sexual matters when carried to excess, especially in
the young and immature. He applies this theory to his young sister,
and blames himself for her death. The word “ beautiful ” refers to the
dead girl lying surrounded by flowers preparatory to burial. Happy—
he is expressing the hope that she is happy in Heaven, and the
hallucination, “ I am happy,” is nothing more than a wish fulfilment.
Envy—how he envies his sister in the pure state of the life hereafter as
compared to his miserable, sordid life on earth. Self-accusatory thoughts
are very usual in depression, and the word “murderer” is only an
exaggerated impression of his own view of the result of his own wrong
action. Unfortunately I lost sight of this patient, but when I last heard
of him the opinion prevailed that he was not likely to do well. His
psychosis, however, is interesting, and shows the relationship of the
human side of the patient’s life and the later development of the
delusion and hallucinations from which he suffered.

Without such a personal history nothing in these cases could be
understood, and the opportunities for treatment would resolve themselves
into improved hygienic conditions and rest.

Sir George Savage said the subject now under discussion had interested him
for about half a century. He would have preferred to see the paper bearing the
title he himself used many years ago, “ Morbid Mental Growths.” Taking it for
granted that in nearly all these cases there was a starting-point—often of a physical
or psychical nature—when one came to consider the growth of delusions it led one
back, as an Irishman might say, to the present time, because psychic analysis and
that kind of procedure led one back to the morbid mental growth. The develop¬
ment of former ideas from the subconscious was a very old subject of study. It
had been generally recognised that nearly all delusions had a starting-point, and
the influence the starting-point had upon any subconscious area was only that of
moving it one step backwards. In treating of this subject he had said there were
morbid mental growths which were simply inconvenient; probably most had
similar morbid ideas—some obsession which did not really interfere—but all had
seen individuals with one great dominant idea which influenced their whole life
and yet destroyed nothing. These were innocent morbid mental growths. But
there was another form of delusion—morbid growth it might also be called—which
not only interfered with utility but probably with mental action, yet was not
destructive. In the third group, however, there was destruction, so that the
morbid mental growth seemed not only to invade but to destroy faculties. The
manifestations varied according to whether there was hypochondriasis on the one
hand or delusional insanity on the other. The hypochondriacal person, who was
merely morbidly self-conscious, might yet not be mentally defective; but the
person with delusions of persecution probably had a form of disorder which was
very destructive. Most of the members knew, too, of the intermediate type, in
which an individual had delusions growing out of his hallucinations, and yet such
individual continued at his work. Thirty-five years ago, a gentleman who had
occasionally attended the Association’s meetings was acting as dispenser to a
doctor in the south of London. The doctor consulted me about him, and I
said to the doctor, “ Good gracious, he ought to be locked up 1 ” He had what
was called " clair audience,” “clairvoyance,” and occultism generally. That indi¬
vidual had not been in an asylum, but had been treating the poorer residents of a
suburb of London all this time. Here was a morbid mental growth which did not
interfere with the man's usefulness. Deafness had frequently been associated with
forms of disorder. He believed that one lady novelist was so deaf that she never

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heard anybody contradict her, and hence she had very exalted ideas of her own
power. It was, however, much more common for those who were deaf to have the
impression that other people were talking about them.

Dr. Hl'bert Bond, in obeying the President’s invitation, said he did not feel he
could add anything on the lines taken by the first speaker. During the reading of
the paper, and while Dr. Stewart was speaking, he was thinking of how many of
those present missed their revered confrere and former President, because of the
magnificent opportunity afforded by such a paper as this for his criticisms and
remarks on the relation between the branches of their work. As to the paper, he
had a sense of very great encouragement as the result of the treatment detailed.
There must be several men of standing in medicine present, and he assumed that
they, like him, were taught the futility, if not the inadvisability, of attempting to
reason with a delusional patient; that in a case of delusions and hallucinations
the mind was not deluded because of hallucinations, but that both symptoms were
the outcome of the morbid mental state. Was not that the case because the
physician had no means of getting at the right topics of conversation when
approaching the patient ? And was not the lesson which had been learned, not
only from Dr. McDowall’s vivid description of the cases but also from other
writings—some from war cases—that the profession now had before it the modern
means ? He was aware that some were inclined to scoffingly assert that there was
in this nothing new, and that it was what had been taught when they were younger,
but he did not feel it was so. The results of the last few years’ experience had
certainly taught him that they had now at hand modern means of attacking patients
on the right lines and instilling reason into some of the most—apparently—hope¬
less cases, and in that way promoting their recovery. It was that feeling of
encouragement which he wished to emphasise.

Dr. R. H. Steen desired to thank Dr. McDowall for his paper. He, the
speaker, wished to lay emphasis on the idea that delusions were often wish-fulfil¬
ments, and to ask if Dr. McDowall had noticed this fact in any of his cases. Of
course, distortion of the wish existed in the case of delusions as in the case of
dreams. A recent case which made a great impression on him he would relate,
altering, of course, the names of the persons: A patient, Miss Smith, came into
the institution, and he made a long and careful history of the case. It appeared
that, years previously, she had known a Mr. Jones, a clergyman, and she considered
that he was paying her special attention. But it could not be gleaned what form
the advances had taken. She had once shaken hands with him, but had seldom
conversed with him. She said that in his sermons he made remarks concerning
her. A few months later he, the speaker, was surprised to learn that she had
asked all to call her by the name “ Mrs. Smith Jones,” to emphasise what she
stated as a fact—that she was now married to Mr. Jones. He related that as an
instance of how the delusion came to be a definite fulfilment of a wish.

Dr. Carswell said he regarded it as a matter for great satisfaction that the
younger men were devoting themselves to fresh clinical studies. He was sure the
outstanding need of the specialty at the present time was for the men who had an
opportunity for seeing a large number of cases to make fresh clinical studies,
with minds free from the preconceptions of the past. By habit he had always
felt himself drawn intensely to the progressive side, yet he had a feeling that, after
exploring along the lines stated in this paper, they would come back to most of
the old views ; that they would not derive the satisfaction at present apparently
promised by their theories, which were based on the conception of a conscious and
subconscious mind. Nevertheless, good was bound to come of such studies as
those set out in the paper. Of course, all the phenomena manifested in the cases
related by Dr. McDowall could be explained without the nomenclature of the
newer psychological point of view. They had all been familiar, because it was true
to experience, with the fact that all delusional ideas had their origin in some
experience. There was nothing which came to any man in the form of a fresh idea
that had not had a basis in a previous experience of some sort; and the lunatic, or
the person who became afflicted with a morbid idea, was simply basing his morbid
idea on that past experience. To unearth that experience, to explain the road by
which the patient had arrived at his false idea, was a very valuable thing to do,
and he hoped it had been the usual practice, though he gleaned from the remarks
of Dr. Bond that it had been avoided. No one could run a hospital for the

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treatment of early mental conditions, before they arrived at the asylum stage, without
feeling forced to adopt the method of quietly, calmly, and persistently seeking to
explain to the patients the origin of their morbid ideas, and to surround them in the
hospital arrangements with the pervading idea that they were suffering from an
ailment, not a delusion in the sense of being a baseless alienation of the mind;
that it was a disorder arising from some experience, taking on special colouring
by some morbid emotional tone, and the whole associations connected with it
being such as could be suitably handled by hospital methods, and by the educative
methods so successfully adopted by the psycho-analysts.

Dr. J. G. Soutar said he thought one of the most interesting features of Dr.
McDowall’s paper was that he did not trouble his hearers very much with the sub¬
conscious, and he did not deal at all with what was termed “ psycho-analysis ” ;
rather he found a common-sense explanation of the growth of delusions in the
really conscious life of the patient; his analysis was the ordinary simple in¬
vestigation into the patient's life-history. In that way he had been able to
bring out not really the genesis of delusion, but he had shown why it was that
delusions took a particular direction and form. The author had not carried
members back to what they really wanted to know—why a man who had hitherto
been acting in what was termed the ordinary sound way, on the lines along
which all their minds went, should, either suddenly or gradually, take on a
morbid line of action, of which delusion was but one manifestation. The
recognition of the pre-delusional stage—of that condition of mind in which delusions
would be apt to flourish—was most important, for then it was that the patient was
most amenable to to atment. He looked upon the delusions and the hallucinations
as the later and obvious manifestations of an already unsound mind. The
delusions did not arise only as wish-fulfilments. He thought many of them
arose from the patient’s past experiences, failures which had not given any trouble
through a long period of life, but for some reason, some departure from health,
were keenly remembered, and there were crowded around them appropriate
emotional states. Dr. McDowall said delusions preceded hallucinations, though
he did not think it was laid down as a general statement. He (the speaker)
thought hallucinations often preceded delusions, and the latter took their form
from the hallucinations. A patient heard voices or had perception of unpleasant
odours—in fact, there were general sensory hallucinations. Then there came a
period of acute depression, followed by a period of questioning as to why he was
singled out for persecution. Then the other emotional state, one of exaltation,
followed, along with the definite delusion that the person was an individual of great
importance, otherwise he would not be so persecuted. With regard to the method
of dealing with delusions, the re-educating of a patient was, he considered, of
the greatest possible value. Dr. Bond referred to the old teaching that it was
not desirable to argue with a delusional case. That was true were arguing in
question. But re-education was a different matter, as that enabled a patient to
obtain an insight into his or her condition, and was of the greatest value. If one
could succeed, even to some extent, in modifying the baneful influence of a
delusion upon a patient, one thereby did a great deal towards getting that
person into a sound state of health, because a delusion was irritating and
worrying, and was consequently affecting the whole health of the patient.
Even simple worry produced a deleterious effect upon an ordinary person, and
if this worry could by some means be alleviated something was thereby being
done to break the vicious circle which was keeping up the ill-health of the patient.
Dr. McDowall had put his cases in the most vivid way, and he (the speaker)
would like to add one to the list of the cases which had to-day been related. A
lady, the only child of people who were in a very good position, but were in
straightened circumstances, when 22 years of age married a very old man, a
widower with no children, who, for his property's sake, was very anxious to have
a child. She married in face of her parents’ strong opposition. In course of
time both her father and mother died, as did also her husband, and there was no
child. When between 50 and 60 years of age the lady herself broke down, and
her delusion now was that she had got her father, her mother, and her husband in
her womb. The association was easy to see, but the important question was,
Why did that particular type of delusion arise? Indeed, why did she become
deluded at all ? What was the state of mind into which she had got ? It was

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true that the ordinary changes were taking place in her womb, but beyond that
there was no reason for it. Here there was no question of wish-fulfilment, but a
recognition of the painful episodes of her life. There had been no reconciliation
between herself and her parents, there had been failure to produce a child, and she
had crowded her failure into her womb. Past experience was not wish-fulfilment,
and almost any experience of the human mind was capable of being perverted
into a delusional condition.

Capt. Prideaux suggested that probably the treatment in the sense Dr. Bond
gave it was not really what was used by Dr. McDowall in the treatment of his
cases; it was really more the use of emotional processes. Persuasion was based
upon the use of these, and he thought that if one went back to the genesis of
delusions it was found in the derangement of the patient’s emotional life. That
emotion could produce dissociation in two ways—either suddenly, as in sudden
fear, or gradually as a result of a prolonged mental conflict. To his mind the
genesis of delusions seemed to be in the emotional sphere by subsequent dissocia¬
tion, and for that reason emotional processes may form part of the treatment
adopted. For instance, a state of fear was instantly changed by a state of anger;
as soon as the emotional state was changed there was set up a different arrangement
of mental processes: the association of mental processes was governed by the
emotional state of the person. Some of these delusions seemed to arise when
a man was in a state of dissociation already. He had one case in which the
patient, whilst undergoing treatment for shell-shock in a hospital in France,
developed the hallucination that he saw his brother walking about with his head
under his arm. This originated from a letter written to him by his mother describ¬
ing a similar hallucination she had had during a Zeppelin raid. After the origin
of it had been cleared up he got perfectly well.

Dr. McDowall, in reply, said he understood Dr. Steen to mean that many
delusions were wish-fulfilments. (Dr. Steen: Yes.) In regard to the case related
by Dr. Soutar, he (Dr. McDowall) thought that could be made out to be a wish-
fulfilment. Dr. Soutar asked what was the soil which would best grow delusions.
That was the great difficulty in the whole medical world. We did not yet know that.
His only idea in the paper was to give some examples of delusions and to point
out that they were quite capable of treatment along certain lines. Dr. Carswell
had referred to nomenclature, but he (Dr. McDowall) thought he had been very
discreet in avoiding many of the words in use at the present day. At the same
time they were all very useful words. His own view was that delusions did come
as a result of previous experience. With regard to the subconscious mind, it was
not always necessary to suppose that in insanity the subconscious mind should of
necessity contain the determining fact of the psychosis. In the first case he
referred to he tried to point out that the real disturbing element was far from being
subconscious; indeed, it was very much on the surface. But the subconscious
mind was, undoubtedly, a very important factor, and his view was that it had more
to do with functional cases than had the true psychosis. Dr. Soutar had asked
about hallucinations. The sentence he (Dr. McDowall) read about that was:
“ Hallucinations do not occur in states of depression at an early stage in the
malady; in depressions delusions develop earlier.” He believed that to be true.
In maniacal states hallucinations occurred before anything else. But in true depres¬
sion, simple depression came first, delusions followed and hallucinations came later.
That was his feeling, though he might be wrong. With regard to the case referred to
by Capt. Prideaux, the idea of the other boy who developed hallucinations regarding
his brother came merely as a suggestion, and a man suffering from functional
disorders such as he was was the very kind of case to be influenced by suggestion.
No doubt he was already being treated by means of suggestion by someone else.

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198 PROBLEMS OF ADMINISTRATION OF ASYLUMS, [July,

Some Present-day Problems Connected with the Administration of
Asylums. By Bedford Pierce, M.D., F.RC.P.Lond., Medical
Superintendent, The Retreat, York. A contribution to a discussion
on Administration of Asylums at the Spring Meeting of the
Northern and Midland Division.

In many respects the difficulties of administration are greater in
hospitals and private institutions than in public asylums maintained out
of the rates. The financial problems raised by the reduction of hours
and the increase in salaries, as well as the greater cost of all commodities,
are very serious when there is little prospect of increasing the income
to meet the increasing expenditure. What will happen if the present
tendency continues no one can foresee, but it seems quite clear that the
middle classes will soon be unable to bear additional burdens. Already
many patients with limited income cannot possibly pay increased
charges, and it would be cruel to discharge, for financial reasons, aged
patients who have been under care for years, and have no other home
than the asylum in which they live.

Serious as the financial problem is, there are other disturbing
questions of even greater moment. There is, I fear, slowly developing
a want of harmony with the staff and the management, and a deplorable
tendency to ignore the welfare of the patients. In the recent demands
of the Asylum Workers’ Union I could see no trace of any concern (or
the patients. There was no sign of any proper nursing spirit; all the staff
were counted equal in the Union, and demands were made for reduction
of hours quite irrespective of the duties undertaken. I only judge from
the printed circular, and I have not come into personal contact with
any of the leaders of this movement, and possibly I may misjudge
them to some extent. Still, there are many indications that the well¬
being of the patients is not the primary concern of members of the
Union.

But, as was remarked at one of the special meetings of the Medico-
Psychological Association in London, we physicians have also been to
blame to some extent, and we must not be surprised that the nursing
staff do not readily accept our point of view. Long before the war the
pay and the conditions of service of the mental nurse left much to be
desired. I, have always felt that men or women who devote their lives
to nursing the insane deserved much greater recognition than has been
given. The work, as we know well, is often very arduous, and brings
little reward beyond the satisfaction of doing difficult work well, the pay
has been miserably poor, and there have been few signs of appreciation
from patients, their friends or from managing committees. When we
think of the daily routine in many wards, the discouraging nature of the

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work, and the unpleasant duties that have to be performed day after
day and week after week, we admit that the conditions of service ought
to be good and the remuneration liberal. Yet we, who knew all this,
did not, I fear, press upon our committees in season and out of season
the urgent necessity for their giving attention to these aspects of the
question.

The situation seems to require some clear thinking, or I fear the
work of the Association to raise the level of mental nursing will be
undone. Hitherto the nurse who has obtained the certificate of the
Association has only received a small increase of salary, with the
result that in many asylums only a small proportion of the staff are
trained nurses. The training itself has not always been thorough,
so that the certificated nurse has frequently not been worth pro¬
motion to senior posts. The suggestion I would make is that the
Association renews its efforts to train nurses well, and also that every
effort be made to render the position of the certificated nurse much
better than those not so trained. The man or woman who takes up
this vocation should find that mental nursing is a career which brings
not merely adequate remuneration, but also a social stains quite removed
from that of the ward-maid or labourer.

I have always tried to teach our nurses at the Retreat that they w r ere
taking up a profession akin to that of the physician, and I have read to
them extracts from the Hippocratic oath referring to the sacred nature
of their responsibilities towards their patients.

Thus, on the one hand, I would urge a far greater improvement
in the conditions of service of the trained, experienced nurse than has
already been obtained, and on the other I should demand much greater
devotion to the work than seems to be compatible with the trade union
spirit.

I am quite certain that the more carefully we personally train our
nurses, and the more we can infuse a proper professional spirit, the less
we shall be troubled with disaffection and discontent. But at the same
time, the more we bear in mind the conditions under which our nurses
work and the more we understand and sympathise with them in the
discharge of their truly arduous duties, the less we shall be satisfied
with things as they have been in respect to hours, pay, and conditions
of service generally.

The practical difficulty is what to do with the many excellent persons
in our employ whose education and general qualities do not permit
them to reach a sufficiently high standard. I presume, for some years
at least, we shall have two classes—the partially trained and the trained
certificated nurse. At the Retreat we have begun to pay certificated
male nurses jQ 20 per annum more than attendants, and it is intended
this amount shall be increased. I look upon this only as a start, but

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it is a step in the right direction. On the other hand, it will be desirable
to arrange that special qualifications in the senior attendants should
receive recognition.

These proposals are only of value if the training the nurses receive is
adequate.

There seems to t>e room for considerable improvement in the present
system of training, and the regulations of the Association require
amendment.

Some years ago, when I was examiner for the Certificate, it was
clearly evident that many nurses who presented themselves for examina¬
tion were practically illiterate, whilst there was reason for concluding the
training they received was poor. The number of lectures allowed by
the regulations is far too few. There is no proper provision for
demonstrations and instruction in practical nursing. Invalid cooking
should be taught to all women nurses, and opportunities given for
instruction in massage. The class examinations should be compulsory,
and only those who succeed reasonably well should receive advances in
salary. In this way the illiterate who fail to educate themselves would
gradually be eliminated.

Lastly, it has been the practice at the Retreat for many years only to
take nurses who sign an agreement to go through a course of training
for four years. I consider this period for training necessary, and it
corresponds with the years of apprenticeship required in many trades.
Nurses learning their profession should receive only a comparatively
small initial salary, which should rise steeply as they progress, and when
qualified they should command, as I have already said, a salary
proportionate to the responsibility of their calling.

If it be found impossible to secure men and women to train on lines
such as these, then I suppose others must be engaged, but these would
not be trained, would not attend classes, and should never reach
responsible posts. They would be attendants and not nurses. Their
initial salary might be higher, but the advances would be more gradual,
and the final pay much less. This view of the matter is similar to that
in many trades : the man who begins as a labourer gets more pay than
an apprentice, but remains all his life in an inferior position.

It seems to me that the Medico-Psychological Association can do
much to help the nursing profession, and greatly benefit patients if
it steadily perseveres in its policy of training mental nurses, and sees
that the training given is really effective. This will inevitably result in
improved status and better remuneration for the nursing staff.

It may be interesting to give particulars of the introduction at the
Retreat of Departmental Councils, on the lines of Whitley Councils now
so general in industrial concerns.

Three departmental councils have already been started—(i) For male

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nurses; (2) for female nurses; (3) for the outside staff, including
artisans and engineers.

In each of these the staff concerned elect five or six representatives,
care being taken that all classes in the department are represented.
The management is represented by one or two members of the
Committee, the responsible officers of the department affected and
myself.

Each Council appoints a clerk, who keeps the minutes, and the
minutes are submitted each month to the Committee of Management.
The Councils meet monthly.

So far the meetings have been useful, the discussions have been
frank, and the impression on my mind is that they will promote a better
understanding. The attitude of all the Councils is thoroughly loyal to
the institution. No doubt in time questions will be raised which the
Committee may decline to take up, but there is a reasonable hope that
the interchange of opinion will lessen the risk of dissatisfaction and
discontent.

The relations between the management and the staff at the Retreat
have always been harmonious—indeed, it has been a sort of family
party ; but I encouraged the establishment of these Councils in view of
the tendency of the times, and if possible to anticipate the difficulties
which I knew existed elsewhere.

One question raised may be alluded to. It was asked whether the
Committee would object to members of the staff joining a trades union.
They received the formal reply that the Committee raised no objection
whatever, but they wished it to be understood that they would not
willingly retain on the staff any persons capable of leaving, and so
neglecting their patients, without giving adequate notice. Other
subjects referred to at these Councils have been the difficulty of
reducing hours when short-handed ; the proposed new time-table giving
fifty-three hours a week and a varying period of about three hours
weekly to games and entertainment of patients; the stokers’ hours of
fifty-six per week—three shifts of eight hours each ; the cultivation of
games amongst the nurses ; holidays for gardeners, etc. All these
subjects are discussed, but the final decision rests, as heretofore, with
the Committee of Management.

I cannot but think the old days of autocratic management are over,
and though some who think a beneficent autocracy is the best form
of government may lament the change, we can nevertheless look forward
without dismay to the new era of democratic control if the proletariat
recognises its responsibilities. The Works Councils are, I consider,
useful as a means of introducing the spirit of mutual understanding
and co-operation without which no institution can be successfully
managed.

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202 CLINICAL NOTES AND CASES. [July,

Clinical Notes and Cases.

A Group of Fits. By Alan McDougall, M.D., Director of the
David Lewis Epileptic Colony.

The patient was a girl, set. 13, who is stated to have been epileptic
from the age of five. The group comprised 3,231 discrete fits, and
occupied 17 days: 2,258 of these fits occurred in the course of 6
consecutive days (averaging 1 every 3 8 minutes), and of these 1,694
occurred in the course of 4 consecutive days (averaging 1 every 3-4
minutes). On February 21st there were 443 fits; on February 22nd
there were 437 ; on February 23rd there were 41 ; on February 24th
there were 3; on February 25th the girl was up, dressed and going
about.

Here is her daily record of fits for the month of February :

Fits during February , 1919.

Day of

Number

Day of

Number

the month.

of fits.

the month.

of fits.

I

• 17

15 .

• 195

2

11

16 .

. 160

3 •

. 6

17 •

• 236

4 •

. 8

18 .

• 323

5 •

• i 3

19 .

. 442

6 .

• i 3

. 20 .

• 372

7 •

• 50

. 21 .

• 443

8 .

. 187

. 22 .

■ 437

9 •

. 121

23 .

41

10

• 33

24 .

3

11

• i 7

25 .

4

12

• 14

26 .

6

13 •

. 68

27 .

. None

14 •

. 87

28 .

. 2

Born on August 20th, 1905, the patient was admitted to the Colony
in January, 1914. To the end of February, 1919, our record of her fits
is 12,363 (practically 200 a month). This does not include fits that
she may have had during visits to her home. She is lively, active,
pretty, a little coquettish, and, though a poor learner in school, fully
interested in her neighbours, her hair ribbons, and her pursuits. In
physical appearance, development, and manner she might pass for a
child of ten.

Clinically, the fits in this February series were mild major epileptic
attacks. The eyes and the head were twisted to the left; there was a

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tonic stage followed by a clonic. There was little cyanosis. There
was no tendency to bedsores. There is no record of the temperature
at any time reaching ioo° F. There was incontinence of urine.

On February 7th, the first day of the group, a 15-gr. dose of chloral
was given. No noticed benefit resulting, the dose was not repeated.
Except for that one dose no drug was given while the group lasted.
Till the fourteenth day of the group Benger’s food was given by the
mouth ; on the three following days feeding was rectal, as the patient
opposed feeding by the mouth. Judging by the eye, she did not lose
weight during the illness.

To those who were having the trouble of the case and writing down
the time of onset of each fit to the nearest minute, it sometimes seemed
that fits were suspended while the patient was being examined and
began again as soon as the examination was over; at other times it
seemed that the attacks ceased if the patient were left alone in the
room, the observer being out of sight but within hearing. In the first
days of convalescence the child, though as lively as ever, would not
talk, but made somewhat ostentatiously the sounds of a baby that has
still no vocabulary. Wherefore the fiat went forth on the Thursday
morning that unless meanwhile she took to talking properly there would
be no penny for her on the Saturday. That may or may not be the
icason why she recovered normal speech on the Friday.

What is the diagnosis ?

The answer seems to be : The fits were epileptic, the condition was
hysteria.

For I take it that when the subconscious mind has ousted the
conscious mind and has usurped sole command, the-condition is
hysteria. Let the fits clinically be what they will, if they are of
conscious origin the condition is malingering; if they are of sub¬
conscious origin the condition is hysteria; and if of unconscious origin
the condition is epilepsy.

For the most important of all purposes, that of treatment, the view
that the physician takes of the origin of a group of fits is of more than
philosophical interest. For it influences the treatment and consequently
the result. Among those who had charge of the case now under
consideration the opinion was general that a stimulating slap in the
interval between two fits (by startling the conscious mind back to duty)
would have cut short the series. The experiment was not made,
because in the presence of good nursing and the absence of drugs the
prognosis seemed to be quite good, and the introducing of a risk seemed
only doubtfully justifiable.

In certain patients at the Colony we have seemingly been able to
prevent the recurrence of serial trouble by giving the patient good cause
to wish series not to recur. For instance, one young woman who for

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REVIEWS.

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[July,

years had been having several isolated fits a month began to have groups
of four or five hundred. Clinically each fit in a series seemed similar
to the fairly severe isolated major fits that were usual in her at other
times. There was incontinence of urine and of faeces. Accumulation
of mucus in the air-passages with cyanosis and difficult breathing gave
the series a grave aspect. But on the patient being told that because
of these series it would be necessary to discharge her from the Colony,
she replied that she would have no more of them. She kept her
promise. Isolated epileptic attacks continued to occur, but there were
no more series.

Markedly in epilepsy post hoc is not always propter hoc\ we see
sudden improvement that we are unable to ascribe to changed treat¬
ment. But year by year the feeling grows stronger in me that the
frequency of fits that are called epileptic may sometimes be diminished
by treatment that is generally called anti-hysterical, and that it is not
necessary in every case of serial epilepsy to give dangerous drugs. In
other cases such drugs may give the patient his best chance of not
dying. What we for practical purposes want to know is, which series
are in themselves dangerous to life, and which are not. Is there any
sign that will enable us to arrive at a decision?

Part II.—Reviews.

Papers on Psycho analysis. By Ernest Jones, M.D., M.R.C.P.Lond.
Second edition, revised and enlarged. Pp. 715. London : Bailli&re,
Tindall & Cox.

Not so long ago, when the Darwinian theory was mentioned to many
a man of superficial learning he would dismiss it with a contemptuous
look and the statement “ Oh, that means that man is descended from
monkeys,” and so far as he was concerned that ended the matter. At
the present time when psycho-analysis is spoken of even in scientific
circles a similar scorn may be shown, ending in the phrase that psycho¬
analysis puts everything down to sex. For such people Freud's
psychology means the psychology of sex alone, and they are too high-
minded to have anything to do with it. They know nothing of Freud’s
views regarding determinism, the affective processes, the 'displacement
of affect, and the dynamic nature of mental processes in general.

The subject of conflict with its frequent termination in repression,
the nature of unconscious processes and their manifestation in disguised
forms are unknown territories to these people. Then there are dreams,
the psychology of wit, the psychology of every-day life, etc. This list
to be complete would need considerable extension, but enough has
perhaps been said to indicate that Freud’s psychology cannot be
limited to the catchword “ sex.”

It is not the purpose of this review, however, to hold a brief for

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psycho-analysis; it is rather the intention to indicate that it is unfair
to judge of anything without studying it, and secondly, to suggest that
ignorance is unseemly in anyone professing to be a specialist in diseases
of the mind. It is not so surprising after all to find that numbers of
the laity have more than a smattering of knowledge on these matters
considering the numerous publications for general readers, and these
same folk may ask for an opinion which cannot be given without
some knowledge of the subject under discussion.

Most of Freud’s writings are in German, and to the man unacquainted
with this tongue such literature is a closed book. Moreover, Freud to
the expert in German is, I am told, not easy to follow. It is therefore
fortunate that we have in Dr. Ernest Jones one who is able to write clear
and precise English. He is not merely a translator of the words, but an
expositorof the ideas of Freud. In addition there is the satisfactory feeling
that it is the orthodox Freud one is reading. In these days, when many
of the original band are leaving their master to set up conventicles of
their own, it is refreshing to find one who still holds the old faith. Dr.
Jones will have nothing to do with the schools of Jung, Adler, and the
other seceders. Dr. Jones also has contributed some original work on
Freudian lines, and papers embodying this are included in the present
volume.

It is impossible to review in detail a book of this kind. It is much
larger than the first edition, which was published in 1912. One chapter
of the original twenty has been omitted, and twenty-one new ones
have been added. It consists of a series of papers and lectures given
at different times. Naturally there is some repetition, but it is
surprising how small this is in amount, and even then it assists in
understanding the subject and never becomes tiresome. When another
edition is called for it is hoped that Dr. Jones will elaborate Freud’s
views on wit and its relation to the unconscious. This matter is dealt
with very briefly in the present volume. It is realised, however, that
it is impossible for the author to deal with everything and keep the
book down to a moderate size. Among many excellent papers it is not
easy to pick out one for special praise, but Chapter VII, dealing with
the theory of symbolism, is certainly a most interesting and valuable one.
Taking, then, the book as a whole, it can be heartily commended to the
readers of this Journal. Everyone interested in the psychology of
Freud must possess a copy. The value of the book is enhanced by the
glossary which is appended. R. H. Steen.

Criminology. By Maurice Parmelee, Ph.D., Professor of Sociology
in the University of Missouri. New York: Macmillan, 1918.
Pp. 522. Price 82.

Prof. Parmelee is known as the author of an esteemed work on The
Principles of Anthropology and Sociology in their Relations to Criminal
Procedure. It was published ten years ago, and since then, as the
author tells us, the subject has been transformed. He here presents
an entirely new work, a comprehensive but compact text-book of the
whole subject of criminology. There are some among us who deny

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that criminology has any right to exist. Everything brought forward
under that head, they explain, could be included under some other
head. It is quite true. At least a dozen different sciences contribute
to make up what is called “ criminology.” That is precisely the justifica¬
tion of criminology in bringing together all that bears on the nature of
crime and the treatment of the criminal. Certainly this has been a
favourite field for doctrinaires and dogmatists, each worshipping his
own particular fetich. Dr. Parmelee gives them but short shrift; for the
most part he ignores them. We are conscious throughout of a calm
and judicial mind, always able to see the various sides of a question,
always carefully weighing and balancing before reaching the finally
measured result.

What is crime ? Primitively, crime is a violation of custom, magic
and religion, as well as moral ideas, later coming in to reinforce custom.
At the present time a crime is, in Dr. Parmelee’s view, best defined as
“ an act forbidden and punished by the law, which is almost always
immoral according to the prevailing ethical standard, which is usually
harmful to society, which it is ordinarily feasible to repress by penal
measures, and whose repression is necessary or is supposed to be
necessary to the preservation of the existing social order.” There is
consequently, as is indeed generally recognised, no hard and fast line
between criminals and non-criminals. Legal and moral conventions,
which are always changing, determine what acts are criminal, though—
and this is sometimes overlooked—there are several types of persons
who are always peculiarly prone to violate these conventions, whatever
they may be. So that the criminal class at any time is determined in
part by what acts are criminal, and in probably larger part by traits more
or less universally characteristic of this class. But the fundamental
factors in the determination of criminal conduct, as of every other kind
of conduct, are the elementary traits of human nature. No one of
these traits alone causes such conduct, so that it is inaccurate to speak
of an instinctive criminal, but any instinct may under certain conditions
lead to crime. There are, therefore, no peculiar crime factors in
human nature. Every human being has in him the making of a
criminal. No person is born criminal in the sense that he is predes¬
tined to crime at birth, though it is convenient to speak of several types
of persons born with abnormal traits as congenitally criminal. Like
every other kind of conduct, criminal conduct is the outcome of these
internal factors of behaviour with the external factors of environment.
These principles thus laid down by Dr. Parmelee at the outset are
elementary and simple, but the failure to understand them has led to
many unnecessary disputes.

After the preliminary discussion of the nature and evolution of crime,
the main part of the book falls into four parts : First, the discussion of
the criminogenic factors in the environment—climatic, seasonal, demo¬
graphic, economic, and civilisational; then the organic basis in traits
and types, with criminal aments and psychopathic criminals, as well as
chapters on juvenile and feminine criminality; then criminal jurisprudence
with the judicial and police functions ; and a final part discussing in a
large and liberal spirit social readjustment and the prevention of crime.
A selected bibliography of ten pages brings to an end a work which for

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its purpose, as a text-book of criminology, probably deserves to super¬
sede the existing books, although on the narrower ground of the nature
and treatment of the criminal it cannot of course compete with the
masterly work on The Individual Delinquent by Healy, whose ex¬
perience and success in this field can at the present time scarcely be
equalled.

In his classification of criminals, Dr. Parmelee characteristically
avoids the excesses alike of those who carry simplicity to an impossible
extreme in the ordinary two fold grouping and those who indulge in
fine-spun elaborations which cannot be applied in practice. He
recognises five groups: (1) The criminal ament or feeble-minded
criminal; (2) the psychopathic criminal; (3) the professional criminal;
(4) the occasional criminal— (a) accidental, ( l>) by passion ; (5) the
evolutive criminal (political). He reaches this statement after a
detailed criticism of the earlier classifications. Lombroso’s classifica¬
tion, as we should expect, he discards, and points out that the “ born
criminal” is not a simple group but really appears under several head¬
ings, chiefly in his own first and second groups. While, however, Dr.
Parmelee sets forth in order Lombroso’s “egregious errors” with his
usual fair-mindedness, he has no mercy for those guilty of the ignorant
and prejudiced abuse of Lombroso which was at one time prevalent.
Thus he shows an unwonted vivacity in dealing in a special appendix
with the “ gross,” “inexcusable” and “ grotesque ” misrepresentations
of Dr. Goring, though, he points out, that self-contradictory writer in
his extreme emphasis on “criminal diathesis” was himself “more
Lombrosian than Lombroso.”

It is impossible to mention all the points of interest in Dr. Parmelee’s
work. We do not expect new facts in a text-book, and we do not here
find them. But every one of the thirty chapters is rich with thought
and suggestion, not the less so because some of them may seem to the
conservative English mind a little far ahead. In criminal procedure the
author proposes a number of simplifications : he approves the modern
approximation of the English procedure of accusation and the French
procedure of investigation, for while the latter, based on the protection
of society, is a higher and more advanced conception, in practice it
tends to violate individual rights, and needs to be corrected by features
belonging to the English procedure. With regard to medical jurispru¬
dence the author is averse to leaving any decision to lawyers and jurors
who know nothing of the questions involved. The decision of medical
questions must be left entirely to the medico-legal expert, whose posi¬
tion must be impartial like that of a judge. The foundation should be
an organised system of medical jurisprudence which could supply a
medico-legal court of appeal, since the system which permits ordinary
physicians with no special training to act as medico-legal experts has
been proved a failure. One result of this reform would be the abolition
of the coroner’s office and the gradual elimination of the jury from law-
courts. Dr. Parmelee also advocates a Public Defender to supplement
the Public Prosecutor, and free civil justice. He thinks the idea of
punishment can scarcely be altogether eliminated, but fully accepts the
modern principle of individualisation in dealing with criminals.

Havelock. Ellis.

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[July,

A Plea for the Insane. By L. A. Weatherly, M.D. Pp. 238.

London: Grant Richards, Ltd., 1918.

This volume consists of a vigorous plea for the reform of the existing
conditions in respect to the care and treatment of the insane. The
wide experience which Dr. Weatherly has had of the practical applica¬
tions of the Lunacy Law, which is now generally recognised as quite
inadequate to meet the needs of the subjects of mental disorder, has
thoroughly fitted him for the task which he has undertaken. The book
is designed in the main for the enlightenment of the general public and
the general practitioner, as the writer feels that the demand for drastic
reform by the public themselves will do much to accelerate the much-
needed changes. The first ten chapters are mainly devoted to criticism
of the Lunacy Act and those who are responsible for its administration,
and incidentally this section furnishes facts of considerable service to the
general practitioner, who is often at a loss to obtain information as to
the legal complexities associated with lunacy administration. Many
points are raised. Legislation, public officials, the various kinds of
institutions for the insane, testamentary capacity, criminal responsibility,
and the medical staff of public asylums are amongst the questions dis¬
cussed and subjected to considerable criticism.

The last chapters are constructive, and they contain the writer’s views
as to the directions in which reform should be carried out and the
methods of doing so. Many of his suggestions coincide closely with
those which are being advocated by various organisations interested in
the problem of mental disorder. He feels strongly as to the necessity
of adequate provision for the treatment of early mental cases, and he
advocates legislation which will permit of simple notification to the
Board of Control in incipient cases instead of certification. Such cases,
he urges, must be treated quite apart from the chronic insane either “ in
special wards of a general hospital, approved homes, private care, or
separate cottage-like buildings in the grounds of a public asylum, or
private villas in registered hospitals or licensed houses,” but he does
not refer to separate clinics, which, perhaps, furnish the most suitable
means for the treatment of early cases. The suggestion that no medical
man be appointed to any post in such institutions who has not had at
least two years’ experience in general practice is perhaps in need of
qualification, and “ or post-graduate hospital appointments ” might be
suitably added to the suggestion. Certainly some general experience
should precede entrance to the speciality. Dr. Weatherby has a good
deal to say in regard to criminal responsibility, and he urges very rightly
the obliteration of the MacNaghten dictum from the Criminal Law as
“ unscientific, untrue, and unjust.”

The style of the author is extremely vigorous, the phraseology
vehement, and his points are emphasised by reference to concrete
cases which serve to illustrate the anomalies and injustices which are
created by existing conditions. It is obvious that he feels very strongly
in regard to his subject, and it is perhaps the strength of his feelings
which produces in places a certain want of that scientific poise which
would be expected from the writer. Thus he refers somewhat scathingly
(page 62) to the pathological researches in asylums on the ground that
they have not resulted in an increase of the recovery-rate. Surely the

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scientific value of the pathological work which has been produced
cannot be estimated merely by the recovery-rate, which obviously
depends on a number of factors. It is certainly the case, as Dr.
Weatherly states, that there has been a striking neglect of “ individual
study of the living patient,” and it is a good thing to see this point
emphasised; it is to be hoped, furthermore, that in the future a much
more intensive study of patients and a search for the psychogenetic
factors of the psychoses will be possible, but the fact that one aspect of
insanity has been neglected does not diminish the value of work in
other directions which has received more adequate attention.

With the central purpose of this volume all psychiatrists will be in
sympathy, and it is hoped that it will have a wide circulation amongst
those for whom it is intended, since it cannot fail to exert an influence
upon those who read it, and it will thus help to bring about those
reforms which all who are interested in the treatment of mental disorder
so earnestly desire.

A sympathetic foreword to the book is provided by Dr. Theo. B.
Hyslop. H. Devine.

Part III—Epitome of Current Literature.

A Form of Pseudo-hermaphroditism iti the Insane [ Certain Pluriglandular
Anomalous Functions Associated with Psychopathic Sexual Interests\
iff our n. Nerv. and Ment. Pis., fuly , 1918.) O'Malley , Alary.

The exact nature of the disturbance of endocrine function behind
pseudo hermaphroditism—whether somatic, psychic, or mixed—has not
yet been ascertained. The evidence tends to show an inter-relation of
functioning in the pluriglandular system, the hormone of one gland
being related to those of all the others, with definite syndromes due to
physiological or pathological changes producing hyperfunction, hypo-
function, or dysfunction of these glands. The secondary sex characters
are known to depend upon the gonads, and abnormalities of the sex
attributes, whether in the generative or secondary sex domain, are
evidence of disturbance of these glands, and hence of the endocrine
system. In a broad sense the term “ pseudo hermaphroditism ” may be
applied to cases in which there are no evident somatic deviations in
the essential sex apparatus, but the abnormalities are limited to the
secondary sexual characters or to the individual’s psychic character,
such psychic deviations sometimes being evident only when by the
development of a psychosis “ the unconscious is given free expression
in the dissociation of the personality,” and the sexual demands, whether
heterosexual or homosexual, dominate conduct. It is as understood
in this wider sense that the author—who is Clinical Director of the
Washington Government Hospital of St. Elizabeth—seeks to study this
syndrome by the examination of eleven insajie women. This series of

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cases is selected from a large group of women showing decided variations
in anatomical growth and development, as well as in mental develop¬
ment, in the direction of external hermaphroditism and hermaphroditic
behaviour. There are extremely few anomalous conditions of the
primary generative organs. Usually the bodily development seems to
have been normal up to puberty, when male secondary sexual charac¬
teristics increased at the expense of female. Cases in which this
syndrome only appeared after the menopause are excluded.

The eleven cases are separately described in detail, the chief
symtomatology being alteration of the secondary sex-characters during
the developmental period in the hermaphroditic direction. It is
remarked that the patients conform to the classic type called Leonard-
esque, and especially illustrated by Vinci’s “ Monna Lisa,” with the same
facies and the same gracile hands. It can, however, by no means be
said that the photographs of cases, whether nude or clothed, here
reproduced, bear out this contention.

The most important symptoms in this syndrome are summed up
under five heads : (i) Faulty skeletal development, male habitus, narrow
pelvis, angularity, symmetrical but atypical features, the most striking
deviation being, however, in the shape of the hands and feet, which are
usually small, delicate, and well-formed, with tapering fingers—a type
associated with pituitary disease. (2) Other abnormalities in general
body contour, due to coarse skin, often vigorous musculature, and
especially to obesity—one of the most prominent and frequent symptoms,
sometimes beginning to appear even in infancy, and ascribed to under¬
functioning of the hypophysis, thyroid, and genital glands. (3)
Disturbance of the pilous system, with excessive development of strong,
coarse hair, where ordinarily there is only a light down, imitating in
distribution that on the male face and body, a similar hereditary
disposition being sometimes traceable, and several of the endocrinial
glands probably involved. (4) Genital disturbance, with widely
varying irregularities of menstruation, sometimes arrest, but few somatic
anomalies of primary sex-organs beyond an infantile uterus and a
few trifling external anomalies. (5) Disturbances of psycho-sexual
development, with periodic reversals to a predominating homosexuality,
sometimes, apparently, especially where there are manic-depressive
reactions, on a bisexual foundation, the sexual inclination changing with
change in the mood of the psychosis, but there is no definite mental
reaction type associated with the endocrinopathies.

While regarding the traits of this pseudo-hermaphroditic group as
constituting a polyglandular syndrome, the author makes no attempt to
interpret it, considering as still a subject for discussion whether it is
due to glandular insufficiencies or over-activities. There is here, she
concludes, a great unexplored field for further research.

Havelock Eli.is.

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NOTES AND NEWS.

2 I I

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 on Tuesday, May 20th, 1919, the chair being occupied by Lieut.-
Col. Keay, President.

The minutes of the previous meeting, having been printed in the Journal, were
taken as read and approved.

The General Secretary (Major R. Worth) read the minutes of a special
meeting of medical superintendents, which was held in the same building on
March 24th. These also were agreed to.

Proposed New Bye-laws.

The following new bye-laws were unanimously approved:

(1) The seal of the Association to be affixed only after a resolution by the
Council, and that it be affixed in the presence of two members of the Council
and the Honorary Secretary or the Honorary Treasurer.

(2) That a double lock be affixed to the Seal, and that the Honorary
Secretary should hold the key of one lock, and the Honorary Treasurer the
key of the second lock.

Report on Maudsley Lectureship.

The Secretary read the following report:

We, your Committee, have the honour to report to the Council as requested.

We would remind the Council of its decision “ That a lectureship should be
founded, the lecturer to receive a medal," and that our duty is merely to formulate
a detailed scheme on these lines.

We accordingly suggest as follows :

(1) The title to be “ The Maudsley Lectureship.”

(2) The lecturer to be termed the “ Maudsley Lecturer.”

(3) The " Maudsley Lecturer” to receive a suitable honorarium (the amount
of this will depend on whether the lectures are annual or biennial) and a gold
medal and ribbon of the value to be decided on later, to be presented to the
lecturer on the occasion of his giving his scientific lecture.

(4) The lecturer to be elected by the Council on the nomination of the
Nominations Committee at the meeting in May of the year preceding that of
the lecture.

In the event of refusal or death of proposed lecturer a committee composed
of the President, Ex-President and General Secretary shall have power to
appoint.

(5) The name of the Maudsley Lecturer to be announced at the Annual
Meeting at the same time as the President announces winners of prizes.

(6) The name of the Maudsley Lecturer to be printed in the first page
of the Journal of Mental Science of January of the year of the lecture
immediately after the list of the Council.

(7) The lecturer shall be a person who has made contributions of well-
recognised importance and value, bearing on the knowledge of mind and its
disorders, and their prevention and treatment, be he anatomist, physiologist,
psychologist, pathologist, neurologist or psychiatrist, of any nationality and
of either sex.

(8) The Lectures. —The lecturer shall be required to deliver two lectures.

(9) The first a scientific, and the second a popular one.

(10) The lectures must be delivered in English.

(11) The subject of the scientific lecture to be an original contribution with
regard to mental disease or any of the ancillary sciences. The widest
possible choice of subject to be permitted to the lecturer so long as the lecture
has some bearing on mind, normal or abnormal.

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(12) The subject of the “ popular ” lecture to be on any subject connected
with the hygiene of mind.

(13) As regards the question as to whether the lectures should be biennial,
the members who voted for the annual lecture made the valuable suggestion
that a “ scientific ” lecture should be given one year and the " popular ”
lecture the following year, and so on.

(14) As regards the time and place of the lectures it was decided that the
" popular ” lecture should be held at the Annual Meeting, followed the next
May by a “ scientific ” lecture.

(15) The President shall preside at the Lecture, with the General Secretary
on his right and the Treasurer on his left, as at the Quarterly Meetings.

(16) Your Committee anticipate that after all expenses are paid there will
remain a sum which will accumulate from year to year, and they suggest this
might be expended in two ways: (a) Assistance to assistant medical officers
for original research; ( 6 ) propaganda work. Your Committee attach great
importance to the latter, and suggest the printing and circulation of the
“ popular ” lecture if deemed expedient. They would also recommend that
other lectures might be given and suitable literature printed and circulated.
The expenses of this could be provided out of the accumulated balance.

(17) Your Committee feel that later experience might suggest some
alteration of the above regulations, and suggest that the matter should be again
considered by the Council. They would remind the Council that the will
of the benefactor contains no restrictions as to how the bequest should be
expended.

(Signed) Robert B. Campbell, M.A., F.R.C.P.E.,

L. R. Oswald, M.B., etc.,

C. C. Easterbrook, M.D., F.R.C.P.E
Richard R. Leeper, F.R.C.S.I.,

Jas. Greig Soutar, M B.,

R. H. Steen.

The Report was unanimously approved.

Election of New Members.

The following were proposed and unanimously elected members of the
Association:

Fraser, Kate, B.Sc., M.D., D.P.H., Deputy Commissioner, General Board of
Control, Scotland.

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

Latham, Capt. Oliver, Aust.A.M.C., M.B., C.M., Syd. Univ., Pathologist,
Lunacy Department, Sydney, N.S.W.

Adey, Lieut.-Col. J. K., Aust. A.M.C., M.B., C.M.Melb., Medical Officer, Lunacy
Department, Melbourne, Victoria.

Waddell, Arthur Robert, M.D., M.B., C.M.Glas. Univ., Deputy Commissioner,
Medical Services, Exeter Area.

Cuthbert, James Harvey, M.B., Ch.B.Edin., Senior Assistant Medical Officer,
West Ham Mental Hospital, Goodmayes, Essex.

Anthony, Mark, L.R.C.P.I., L.R.C.S.L, Assistant Medical Officer, Bucks County
Asylum, Stone, Aylesbury.

The President called upon Dr. McDowall to read his paper : “ The Genesis of
Delusions: Clinical Notes.”

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held by the
kind invitation of Dr. Alan McDougall at the David Lewis Colony, near Alderley
Edge, Cheshire, on Thursday, April 24th, 1919.

Dr. McDougall presided.

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1919. ]

The following eight members were present: Drs. A. J. Eades, R. W. Dale
Hewson, C. L. Hopkins, A. McDougall, J. Moir Mathieson, Major R.A.M.C.,
G. E. Mould, W. Vincent, Lieut.-Col. R.A.M.C.,and T. S. Adair, and two visitors,
Drs. E. Falkner Hill and A. Ramsbottom.

Apologies for inability to attend were received from the President, Lt.-Col.
Keay, the President-elect, Dr. Bedford Pierce, and a number of others.

The minutes of the last Meeting were read and confirmed.

Dr. T. Stewart Adair was re-elected Secretary to the Division.

Dr. J. Geddes and Dr. R. Kirwan were elected Representative Members of
Council for 1919-1920.

The kind invitation of Dr. Eades to hold the Autumn Meeting, 1919, at the
North Riding Asylum, York, and of Dr. Geddes to hold the Spring Meeting,

1920, at the Mental Hospital, Middlesborough, were cordially accepted.

Dr. McDougall then read a paper entitled “ A Group of Fits.” (See p. 202.)
Col. Vincent, Major Mathieson and others gave their experiences, especially
with regard to epilepsy caused by the war.

A paper, by Dr. Pierce, on some present-day problems connected with the
administration of asylums, was read by the Secretary. (See p. 198.)

A hearty vote of thanks was accorded to Dr. McDougall for his kind hospitality
and for so pleasant a meeting.

SOUTH-WESTERN DIVISION.

The Spring Meeting of the South-Western Division was held by the kind
permission of Lieut.-Col. A. F. Hurst at Seale Hayne Military Hospital, Newton
Abbot, on Friday, April 25th, 1919.

The following members were present : Drs. Bainbridge, Davis, Eager, Aveline,
Lavers, Mary Martin, Mules, Nelis, Prentice, Soutar, Starkey, Lieut.-Col. G. E.
Miles, Major Phillips, and the Hon. Divisional Secretary (Dr. Bartlett).

The visitors included Drs. Head, Waddell, Williamson, Rivers,- and many
Service guests at Seale Hayne.

Dr. Soutar was voted to the Chair.

Letters of regret were received from Lieut.-Cols. Goodall, Lord, and McKeay,
Major Worth, and Drs. McDonald, Rutherford, and Outterson Wood.

Dr. Bartlett was elected as Secretary.

Drs. Aveline and MacBryan were elected as Representative Members of Council.

Drs. Eager and Soutar were elected as Members of the Committee of Management.

The date of the Autumn Meeting was fixed for October 24th, 1919, of the Spring
Meeting for April 24th, 1920 ; the place of the former meeting was left in the hands
of the Secretary.

New Member: Annie Shortridge Mules, M.R.C.S., L.R.C.P., Assistant House-
Surgeon, Devon and Exeter Hospital, proposed by Drs. Eager, MacBryan, and
Bartlett, was elected a member of the Association.

A most interesting day was arranged by Lieut.-Col. Hurst. During the morning
hysterical cases under treatment and cases of war neurosis were demonstrated by
Lieut.-Col. Hurst, Major Venables, Capts. Gordon, Gill, Robin, and Wilkinson.
This was followed by a cinematograph portrayal of cases before, during, and after
treatment. After lunch and the Committee Meeting, Capt. Gordon ably debated
the causes of psychasthenia, and was followed by Lieut.-Col. Hurst, who gave us
much food for thought on the subject of the close alliance between hysteria and
epilepsy ; Drs. Head, Lavers, Eager, and Soutar took part in the ensuing discussion.
A most hearty vote of thanks was accorded to Lieut.-Col. Hurst and his officers
for their kind hospitality and unsparing efforts in the provision of a most
instructive and interesting programme, which was greatly appreciated by all
present.

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SOUTH-EASTERN DIVISION.

A Meeting of the South-Eastern Division of the Medico-Psychological Asso¬
ciation was held at u, Chandos Street, W. i, on Wednesday, May 7th, 1919.

Regrets at inability to be present had been received from Sir Robert Armstrong-
Jones, Sir H. Bryant Donkin, Drs. G. N. Bartlett, Fletcher Beach, W. Bevan-
Lewis, A. H. Boys, A. I. de Steiger, R. Eager, F. Elkins, G. C. Fitz-Gerald, John
Keay, John R. Lord, David Rice, R. Percy Smith, D. G. Thomson, and F. Douglas
Turner.

Present: Drs. Archdale, Bower, Chambers, Collins, Evans, Fothergill, Fuller,
Galpin, Haynes, Higson, Hughes, Norman, Prideaux, Stewart, Watson, and J.
Noel Sergeant (Hon. Div. Sec.).

Dr. David Bower took the Chair.

The minutes of the last meeting were read and confirmed.

Drs. Bower, Craig, Daniel and Steen were elected to be members of the Council,
and Dr. J. Noel Sergeant Hon. Divisional Secretary for the year 1919-1920.

Drs. Gilfillan, Norman and Steen were elected members of the Divisional Com¬
mittee of Management.

Dr. Mary Rushton Barkas, M.R.C.S., L.R.C.P., Temporary Assistant Medical
Officer, Bethlem Royal Hospital, 46, Connaught Street, W.2, was elected a
member of the Medico-Psychological Association.

It was decided to accept with thanks Dr. Watson's kind invitation to hold the
Autumn Divisional Meeting at Elm Lodge, Clay Hill Lane, Enfield, on Wednesday,
October 1st, 1919.

Dr. H. J. Norman opened a discussion on "Crime and Insanity.” Dr. Higson
followed with some very interesting remarks on modern procedure in connection
with the mental condition of criminals. Drs. Fuller, Sergeant and Stewart
also spoke.

Drs. Bower and Chambers expressed the thanks of the meeting to Drs. Norman
and Higson, and the meeting then closed, the members taking tea.

No dinner was held owing to the fact that insufficient members signified their
desire to dine.

SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Hall of the Royal Faculty of Physicians and Surgeons, Glasgow,
on Friday, March 21st, 1919.

Present: Lieut.-Col. Keay, Major Hotchkis, Capt. Patch, R.A.M.C., Drs.
Buchanan, Carre, Easterbrook, Kerr, T. C. Mackenzie, McRae, Macdonald,
Oswald, G. M. Robertson, Maxwell Ross, Shaw, and Surgeon-Commander R. B.
Campbell, R.N., Divisional Secretary.

Lieut.-Col. Keay, R.A.M.C., President of the Association, occupied the Chair.

The minutes of the last Divisional Meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary submitted a letter of acknowledgment received from Mrs. Reid,
thanking the members of the Division for the kind letter of sympathy sent to her.

Apologies for absence were intimated from Drs. Thomson, Carr, Eager, Lord,
Mills, Skeen, Alexander, Sutherland, Dods Brown, Orr and Crichlow.

The Chairman stated that Dr. Donald Ross, who had come to Glasgow to
attend the meeting, had been taken ill, and the Secretary was asked to write to
Dr. Ross expressing the sympathy of those present, and to send him their best
wishes for a speedy and complete recovery.

The President thanked the members for the kind letter which he had received
regarding his recent illness.

Dr. J. H. Skeen and Dr. T. C. Mackenzie were unanimously elected Representative
Members of Council for the ensuing year, and Dr. R. B. Campbell was elected
Divisional Secretary.

Dr. W. M. Buchanan was recommended to the Educational Committee of the
Council as an Examiner for the Certificate in Psychological Medicine.

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NOTES AND NEWS.

215

A general discussion took place on matters at present affecting asylum adminis¬
tration, and a scheme of reduced working hours for the nursing staff in asylums
was recommended.

The Secretary pointed out that a committee, drawn from recognised medical
bodies in Scotland, had been appointed for the purpose of considering the pro¬
posals under discussion for the establishment of a Ministry of Health, and that
he considered that the Scottish Division of the Association had strong claims to
be represented on such a committee. After some discussion it was unanimously
agreed that the Secretary should communicate with the Secretary of the com¬
mittee requesting that the Division should be represented, and Lieut.-Col. Keay
was nominated as representative.

It was also agreed that a small committee, composed of Lieut.-Col. Keay, Dr.
G. M. Robertson and Dr. Campbell should be appointed to act as a Watching
Committee re the Ministry of Health Bill.

A vote of thanks to the President for presiding concluded the business of the
meeting.

CORRESPONDENCE.

The following communication from Sir H. Bryan Donkin has been forwarded to
the Editors for publication :

It is greatly to be regretted that my article on the “ Factors of Criminal Actions "
was published in the Journal of Mental Science only a few days after the lamented
death of Dr. Charles Goring. This article consisted mainly in a reply to
Dr. Goring's criticism* of a paper by me which he published in the Journal for
April, 1918. My reply was written in the summer of 1918, and the proof was cor¬
rected by me many months before the article was printed off for the April number
of this year, some time previously to Dr. Goring’s death on May 5th.

But for this unavoidable concurrence of dates my article would have been pub¬
lished later, with an expression of my personal sorrow for the loss of Dr. Goring
and my regret that no further elucidation of the controversy between us could now
be made.

H. Bryan Donkin.

June 12 th, 1919.

PRISON REFORM.

The Policy of the Howard Association.

In a statement of policy, just issued, the Howard Association, which recently
celebrated its jubilee, says that the two main reasons for maintaining a penal system
are the protection of the community and the reformation of the offender; and
because society cannot obtain real protection unless the offender either be per¬
manently segregated or permanently reclaimed, it follows that the chief business of
our penal methods is to secure the reformation of offenders. To this end the
Association urges that prison governors and their subordinates shall be chosen as
possessing special aptitude for reclaiming men and women, and that a certain
amount of freedom to experiment shall be permitted. The Association instances
the striking results recently obtained in American prisons, notably at Sing Sing,
New York, and in British prisons advocates abolition of the “Silence Rule," which
is seldom observed, and breeds deceit in prisoners and warders alike; the shorten¬
ing to a very brief term of the period of separate confinement; more free inter¬
course from judicious persons from outside; extension of the functions now
exercised by the paid prison Chaplain to persons of all denominations, paid or un¬
paid, having the necessary gifts and calling; adoption of the Indeterminate
Sentence, ensuring that offenders shall be released when they are fit to be released,
and the adoption of the Parole System, that they may receive guidance during the
early days of liberty. An extension of the Probation System is advocated, together
with the appointment of more and better-trained and better-paid Probation Officers.
The Association shows that the easy method of making prison the alternative to
payment of a fine bears much more heavily on the poor than the rich, and urges

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NOTES AND NEWS.

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that j» " 1 ' tain well-defined cases it shall be compulsory on Justices to allow time
m which to pay fines. In cases of fraud, theft, and embezzlement, magistrates
should more often order compensation to be paid by the offender, by instalments
as in the case of civil debt. This course would supply the element of deterrence’
nmv often felt to be lacking in the system of probation. Copies of the Statement
of Policy of the Howard Association may be obtained on application to the Secre-
ary at 43, Devonshire Chambers, Bishopsg'ate, H.C. 2.

vyu* i u n i\ i .

Joseph Wiglesworth, M.D., F.R.C.P.,

Former M^cal Superintendent, County Asylum, Rainhill, Liverpool.

By Geo. H. Savage.

One by one our senior fellows and former leaders are dropping off and it is our
duty to note and record the work they have done. Time Jassfs so quickly tha
the mi estones of progress are not noticed by the hurrying workers of lo-dav h
I irst I will refer to the official position of Dr. Wiglesworth. 3

After a distinguished studentship at Liverpool and St. Thomas’s Hosnit,t i
was for a time House-Surgeon at the Royal Infirmary at Livernool He P ta A. he
appointed Assistant Medical Officer, under Dr Rovers at the Co-^ A
Rainhill, Lancashire. After some years he succeeded Dr. Rogers as head^f the
asylum, and was appointed Lecturer on Insanity at the Liverpool School of
edicine. He was I resident of the Association 1902-1903, and P Member of the
Neurological Section of the Royal Society of Medici^ 3 He conTributed fo
Tuke s Dictionary of Psychological Medicine and to our Journal. He also wrote
an article in Pram and contributed to the Liverpool Medical Journal He I
regtilar attendant at the meetings and spoke occasionally at them ' “

Next I must refer to his original work. This was both pathological and clinical
He studied very carefully the histology of general naralvsis of tl •

* descnbed very accurately the vascular !nd ofher changes present n th’aTdfsease
The relationship of ,t to syphilis had not been established, but Wiglesworth with some
diffidence traced a connection between the two. Probably he will rll t
as the first to point out that pachymeningitis is notanllt= s ^
all authorities now recognise h.s work on subdural htemorrhages He contributed
several articles on the subject which appeared in the Journal of MentT^
Another very important contribution by him was on Adolescent 7 wsZht a Ad the

relationship of delusions and hallucinations to the mental disorders ^ • »

co^olt 7t ° f HUgh i ingS J f aC ! tSOn Sh ° wi '^

control led to over-action of the ower rentrec • c ? \, cenlres °t

conditions depended on disorder in the highest centres " OtT the of. ma, ? ,ac ^ 1

depending on the sensory disorders. 3 part ‘ the delusi °ns

Wiglesworth contributed to the Journal various clinical records of interest He

As President °f the Association he took for the subject of his address "
and Evolution ”-he was, at the time, a firm believer or follower ef w . Heredlt y

confirmed the general belief that the mother r,a«ed on spring. He

female children more than to the males, and though the fatheAdid tosJmeV°
pass on a greater tendency to nervous disorders to sons than t n d mC ^ r ** ree

daughters run a great risk even from fathers. tH * dau gh‘ers, yet the

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He was not able to establish a special tendency to derelop similar symptoms—
that is, similar forms of disorder in parent and offspring.

He very distinctly believed in the transmission of certain acquired habits such as
alcoholism, but I think he has,hardly established his point, though I agree with
him in believing that a general poisoning by alcohol or syphilis must affect the
germ-plasm and thus the next generation.

Here, then, we have a brief outline of the work done for our branch of the
profession, but for a complete knowledge I must refer to Tuke’s Dictionary, to the
index of our Journal, and to the index of Brain.

Wiglesworth proved himself to be a good administrator as well as a scientific
worker.

He wrote on homicidal impulse apart from active symptoms of insanity, and by
fate he nearly provided an example in himself. He was attacked by a patient who
had prepared a sharp puncturing weapon. A wound in the neck was made
dividing the external carotid. With great calmness he recognised the injury and
compressed the vessels, and with the help of his colleagues controlled the
haemorrhage till a Liverpool surgeon came, who had to tie the common carotid.
Wiglesworth recovered from the severe shock, but it seemed to leave him an
older and altered man, and he retired on a pension.

Having discussed him medically it remains to describe the man and his other
aspects. He was a shy, retiring man, and apparently rather weak of physical power,
but in reality he had a great reserve of force, and he could undertake long and
arduous walks and excursions in pursuit of his natural history hobbies.

He was not given either to sport or to general social pleasures. Married to a
lady with similar tastes his home sufficed for him.

When at Rainhill he developed a very complete garden of British plants which
were arranged according to their natural orders, and he made ingenious plans to
suit each to its natural habitat. After retiring from active medical work he devoted
himself to bird study, and became an authority on the birds of Somersetshire. He
made an adventurous expedition to St. Kilda and wrote a book on its birds.

Thus life passed placidly till his only son was killed in the war. This was a
crushing blow.

His end was characteristic of the man, as I have heard he was in pursuit of a
kestrel’s nest on the cliffs and fell, and his dead body was found at their base.

So ended almost as he would have wished it the active life of a scientific recluse.

APPOINTMENTS.

Simpson, E. S., M.C., M.D.Edin., Medical Superintendent, East Riding
Asylum, Beverley, Yorks, vice Dr. Archdale, resigned.

NOTICE TO CONTRIBUTORS.

N.B .—The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to lix(u) of the
Articles of Association, " all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Papers read at Association Meetings should, therefore, not be published in other
Journals -without such sanction having been previously granted.

LXV.

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 271 ["‘nV"”*] OCTOBER, 1919. Vol. LXV.

Part I.—Original Articles.

Psychiatry a Hundred Years Ago : with Comments on the Problems
of To-day. The Presidential Address at the Annual Meeting of
the Medico-Psychological Association of Great Britain and Ireland,
held at York, July 22nd, 1919. By Bedford Pierce, M.D., F.R.C.P.
Lond., Medical Superintendent, The Retreat, York.

The theme of the address I am about to give—if anything so
discursive can be said to have a theme—is the medical treatment of
the insane during the period of transition and reform at the end of the
eighteenth and beginning of the nineteenth centuries.

In the latter part of the reign of George III many treatises on insanity
were published, most of them possessing a literary grace not common
in medical works to-day. They abound in reports of clinical cases and
details of the treatment, and the appearances on post-mortem examina¬
tion are frequently recorded. Probably the public interest taken in
the king's illness helped to stimulate this remarkable output. The
volumes are full of interest, and much that they contain seems wonder¬
fully modern : nevertheless, I have not found it easy to enter into the
spirit of the age. Old doctrines still survived, and the new doctrines
were as yet young and struggling for recognition.

During the early part of this period medical treatment was based
upon the hypothesis that acute insanity was due to inflammation of the
brain and its membranes. It was therefore considered essential, by
whatever method, to reduce the supply of blood to the head. This can
be illustrated by the treatment of George III himself in 1789. His
physicians had quarrelled in such an unseemly fashion that the House
of Lords appointed a committee to examine them. We learn,however,
from the report that they had at least been unanimous on one occasion,
namely, when they decided to blister the King’s legs to relieve his
acute excitement. The result is duly recorded : “ The pain undoubtedly

LXV, 16

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made him more unquiet, and increased the necessity for coercion, but
did not appear to increase or diminish the grand malady.” (i)

Similarly, the practice of blood-letting was considered of extreme
value in insanity. In reference to this, in 1789, Harper writes : “ I am
fully satisfied of the expediency of this preliminary step, being confident
that there never was nor ever will be a mania in which venesection,
less or more, would be improper at the beginning.” (2) Pinel himself
says : “ It is a well-established fact that paroxysms of madness thus
anticipated are in many cases prevented by copious bleeding.” (3) In
1811, Crowther, the surgeon to Bethlem, claimed to have bled 150
patients at one time without untoward result. (4) He also recommended
emetics, quoting a case of hypochondriacal melancholia relieved entirely
by their use. The patient took sixty-one vomits in the course of six
months, and for eighteen nights one every evening, and yet made a
perfect recovery! (5) This view of the pathology of insanity was supported
by the post mortem findings, which frequently described haemorrhagic
points in the substance of the brain.

We get some idea of the routine practised in Mr. Haslam’s evidence
to the House of Commons Committee in 1815. “The period of
physicking continues from the middle of May, regulated by the season,
to the latter end of September, two bleedings according to discretion,
half a dozen emetics if there should be no impediment to their exhibition,
and for the remainder of the time to Michaelmas a cathartic once a
week.” (6)

The treatment of insanity was founded on the antiphlogistic theory
which at that time was generally held, and we must not hastily pass
judgment upon those who conscientiously accepted it, and did the best
they could. We may be inclined to think certain practices barbarous,
but they were not intentionally cruel, nor were those who prescribed
them indifferent to the suffering they caused. In our own times,
theoretical considerations have suggested methods of treatment that
may be criticised adversely by our successors. For instance, seeing
that convalescent patients frequently possess an increased number of
white blood-cells, it was suggested that an artificial leucocytosis might
produce recovery. Turpentine or other agents have, therefore, been
injected in order to produce an abscess—a line of treatment founded
upon the gratuitous assumption that the leucocytosis in the two cases
was similar in nature. The underlying thought here is akin to that of
Dr. Joseph Mason Cox, who recommended inoculation with smallpox
or the itch, and the irritation of the skin by tartar emetic, blisters or
setons, and who says : “ Certain it is that if any considerable commotion,
any violent new action can be excited in maniacal complaints by whatever
means, the mental derangement is often considerably relieved or per¬
manently improved.” (7)

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BY BEDFORD PIERCE, M.D.

22 1

It would be difficult to find the teachings of the old school more
concisely expressed than in Dr. Cox’s little volume, Practical Observa¬
tions on Insanity, published in 1804. The modern reader is offended
from start to finish, and yet the book professes to state rules which will
lead to “ a more humane and successful method of cure.”

The importance of controlling the patient is first mentioned, and we
are told that it is of the essence of management to make impressions
on the senses, and that the grand object is to procure the confidence of
the patient, or excite fear ! Note the alternatives ! “Pious frauds ” are
recommended. (8) One instance may be recounted—that of a gentleman
who thought his housekeeper had tried to kill him by means of poison
in his shirt. It was arranged that she should be arrested in his presence,
and she was dragged away, making loud protestations of innocence.
A bogus analysis of the shirts confirmed his suspicions, and after a
solemn consultation antidotes were prescribed, and we are told that he
recovered in a few weeks.

That is bad enough; but the next method which Cox strongly
recommends is even more objectionable. It is the use of a circular
swing, invented, we are told, by Dr. Erasmus Darwin, by means of
which a patient firmly strapped in a chair or upon a bed could be made
to rotate round a central beam at any desired pace.

The treatment was designedly terrifying, but before passing judg¬
ment we should in fairness to Dr. Cox read some of his cases. I will
quote two:

“ Mr. —, set 40, of a florid complexion, very muscular, became
gradually depressed, then unusually gay and flighty: previous to these
symptoms he had been eccentric, ingenious, good-tempered, remarkable
for an accurate, retentive memory, and for feats of the palestra. . . .

“ For six weeks he had resisted all my attempts to introduce
medicines, possessed a voracious appetite, while days and nights were
passed in alternations of struggles from coercion and violent vociferation.
Judging from all the attendant circumstances no hazard could attach to
the employment of the swing, this was determined on, but a strong party
was necessary to place him in it. The first five minutes produced no
kind of change, and the novelty seemed to amuse, but on increasing the
motion the features altered, and the contenance grew pallid, and he
complained of sickness and prayed to be released: after a few rapid
gyrations more vomiting succeeded, his head fell on his shoulder, and
his whole system seemed deprived of vigour and strength: from the
swing he was carried to bed by a single attendant, where he immediately
fell asleep : slept nine hours without intermission, and awoke calm and
refreshed. . . . He soon became convalescent, and advanced to the

perfect enjoyment of health and reason.” (9)

Another case. Mr. —, tet. 22, naturally grave, reserved, his life a
model of probity and virtue, became depressed, seriously mutilated
himself, and passed into a state we should call melancholic stupor;
forcible feeding with spouting was tried under great resistance, and

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PSYCHIATRY A HUNDRED YEARS AGO,

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finally the rotating swing as a last resource. It caused alarm, then
nausea and vomiting ; he begged to be liberated, but would not promise
to take his food, so the swing was continued more rapidly. He then
promised acquiescence, was put to bed and slept some hours. Two or
three times the swing was repeated, till at length he became docile, and
at last body and mind were perfectly recovered. Dr. Cox concludes:
“ I am confident he owes his life and reason to the swing.” (io).

The swing was recommended by many physicians of experience.
Dr. Young, of optical fame, and a member of the Society of Friends, as
Sir James Crichton-Browne recently pointed out, advocated its use in
1809 (n); and in the report of the 1815 Committee of the House of
Commons it is stated that Mr. Finch at Laverstock near Salisbury,
“ finds the rotating chair, producing nausea, most useful, as the pain it
excites takes the patients off to it rather than the disease.” In justice
it must be added that the general condition of the patients in this
establishment was said to be very good. Every possible amusement
was provided: billiards and backgammon indoors, bowls, cricket,
coursing and riding out of doors, and Mr. Finch appeared to be “a
humane man and a man of sense.” (12) It is interesting to note that
in Morrison’s Lectures , published in 1828, an illustration of a swing
was given, that every private asylum might become properly equipped.
(13) It is difficult to understand how such a cruel method of treatment
became so popular, but in particular I should like to know how it
happened that the swing was found to be such a powerful hypnotic.
Something seems wrong somewhere !

The striking change in the treatment of the insane which began as
the eighteenth century was closing can, I think, be traced to three causes.

First there was the great humanitarian movement, which awakened
sympathy with all human suffering, even in the despised and degraded
—prisoners, slaves, and lunatics. Perhaps this movement reached its
high-water mark in our own country, but it was felt throughout
western Europe. Secondly, there was the social reform, initiated in
France, the demand for liberty, equality, fraternity, which penetrated'
even to the prison asylums of Paris. Thirdly, there was a gradual
enlightenment of medical opinion, which led to the discontinuance of
much that was grievous and painful in asylum practice.

It is not my intention to re-tell at any length the story of the reform
in the treatment of insanity. This was not the work of one man or of
one nation.

So far as I can ascertain, actual priority belongs to Italy. Between
the years 1774 and 1788 Vincenzo Chiaruji, assisted by Daquin of
Chamb^ry, introduced new methods at the Hospital Bonifacio in
Florence, where chains and fetters were abandoned, and patients were
encouraged to work. New regulations, embodying these reforms, were
approved by the Grand Duke Pietro Leopoldo.

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BY BEDFORD PIERCE, M.D.

223

But the premier place undoubtedly belongs to Philippe Pinel. He
not only transformed the conditions at the Bicetre and Saltpetrifere in
Paris, but he convinced the world by his writings that the old methods
were wrong and futile. Pinel’s treatise on Alienation Mentale , published
in 1801, takes the highest place in the literature of his time dealing
with insanity. It was translated into English by Dr. Davis of Sheffield
in 1806.

I should have liked to have referred to many incidents in the life of
Pinel, but time forbids. He was first led to study insanity by the
mental illness of a friend, for whom all methods of treatment failed, and
who finally escaped into the forest and died of inanition. Clasped in
his hands and untouched by wolves was found the one of Plato’s works
discussing the immortality of the soul!

Pinel was the hero of a wonderful chapter in the history of medicine,
with which I fancy many of our younger members may be unfamiliar.
This was the reform at the Bicetre, in 1793, during the darkest hours
of the French revolution. Pinel was suspected of harbouring aristocrats,
and had the utmost difficulty in obtaining permission to liberate his
patients from their chains. It was to Couthon, even in the reign of
terror a conspicuously repulsive character, that Pinel, during a personal
investigation, uttered the words which stand true for all time: “Citizen,
I have a conviction that the insane are only intractable because they are
deprived of air and liberty.” (14) The same day he began the removal
of chains from fifty patients, the first of them an English sea-captain,
whose history was unknown, but who had been in chains for upwards of
forty years.

I need not give many details of the establishment of the Retreat, for
the last meeting of the Medico-Psychological Association held at York
was at the time of its centenary, and much was then said of its early
days.

The project was first raised in March, 1792, the land was purchased
two years later, and the Retreat was opened in 1796, long before Pinel’s
work in Paris was known in York.

Two members of the Society of Friends were chiefly instrumental in
its establishment—William Tuke and Lindley Murray.

William Tuke was sixty years of age when he first proposed to build
the “ retired habitation ” subsequently named the Retreat. He was an
active, determined man, with liberal ideas on the subject of education,
and his portrait, reproduced by his great-great grandson, H. S. Tuke,
R.A., shows benevolent, yet strong features.

Lindley Murray, the well-known author of Murray’s Grammar, was an
American friend who had settled in York. He was an invalid, confined
entirely to bed, but deeply interested in all philanthropic works. In a
quiet way he contributed much to the foundation of the Retreat, but

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his energetic and strong-willed friend, William Tuke, actually carried
the project through, in spite of much opposition and misunderstanding.
Even William Tuke’s wife is reported to have said, “Thou hast had
many children of thy brain, William, but this last one will be an
idiot.”

What he accomplished would not have been so widely known had
not Samuel Tuke, his grandson, published in 1812 The Description of
the Retreat. This was a scholarly work and is well worth careful
perusal to-day. We possess at the Retreat a copy, formerly the property
of the late Sir Arthur Mitchell, the Scotch Commissioner, who wrote at
the time of the centenary: “The whole work of my life has been
coloured by Samuel Tuke’s Description of the Retreat. . . . The

title misleads. It is much more than a description. It is a presenta¬
tion of the principles which should guide us in treating and caring for
the insane.” (15)

The reader who acquaints himself with the writings of Philippe Pinel
and Samuel Tuke will realise that a complete change in outlook had
been inaugurated. It was not merely the introduction of humane
methods, the cessation of cruelty, and abandonment of the brutal
system of coercion, but the recognition and fearless application of a
new principle. This they called “ moral treatment,” by which they
claimed that more could be done for the insane than by drugs or
discipline. They asserted that the psychical environment surrounding
a patient was of no less importance than the physical conditions, and
that the course of insanity was influenced by mental and moral con¬
siderations. I must not follow up the subject, but the assertion was
profoundly significant.

It is interesting to read in Tuke’s description the account of their
attempts to cure insanity by the therapeutical methods of the day.

The following passage seems wonderfully modern : “ The physician
first appointed to attend the Retreat was a man equally distinguished
by medical knowledge and indefatigable perseverance. He possessed
too ... a highly benevolent and unprejudiced mind. . . .

He determined to give a full trial of the means which his own judgment
might suggest, or which the superior knowledge and experience of
others had already recommended. But the sanguine expectations,
which he successively formed, of benefit to be derived from various
pharmaceutic remedies, were in great measure as successively disap¬
pointed ; and although the proportion of cures in the early part of the
history of the institution was respectable, yet the medical means were
so imperfectly connected with the progress of recovery that he could
not avoid suspecting them to be rather concomitants than causes.
Further experiments and observations confirmed his suspicions, and led
him to the painful conclusion (painful alike to our pride and to our

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humanity) that medicine as yet possesses very inadequate means to
relieve the most grevious of human diseases.” I fear that the concluding
sentence is still true, although a hundred years have passed since it was
written.(16)

This passage refers to Dr. Thomas Fowler, known to every medical
man by the alkaline solution of arsenic which bears his name, and which,
by the way, was probably discovered by one Mr. Hughes, in analysing
a secret remedy known as Dutch drops (17). But Fowler introduced
it to the world, in a striking volume, published in 1786, which dealt
with the various uses of arsenic. He was a remarkable man, a keen
observer, devoted to experimental research. A citizen of York, he
practised there for many years as a chemist. At the age of forty-two he
graduated in medicine at Edinburgh, and settled for some years in
Stafford. But he returned to York, and in 1796, “without his solicita¬
tion and even without his knowledge,” was appointed physician to the
Retreat. He died in 1801, and it is stated he left in manuscript notes
of 6,000 cases. His published works breathe throughout the scientific
spirit, and he recites his cases concisely and without bias, failures and
successes alike. Any drug or therapeutic agent which he investigated
was administered singly, under conditions as similar as possible, and he
faithfully recorded the results for all to see and judge for themselves.
The Retreat was fortunate in its first physician.

Samuel Tuke explains that Dr. Fowler’s successors also tried
“various means, suggested either by their own knowledge and ingenuity
or recommended by later writers: but their success has not been such
as to rescue this branch of medicine from the charge, unjustly exhibited
by some against the art of medicine in general, of its being chiefly
conjectural.” (18)

In connection with this last sentence it may be interesting to note
that when it was written the Rev. Sydney Smith was living at Heslington,
less than a mile from the Retreat. His scathing remark that medicine
is the “ art of putting what we know little into bodies of which we know
less” may easily have been in Samuel Tuke’s thoughts.

Sydney Smith took a great interest in the Retreat, and when the
Description was published, he drew attention to it in the delightful
essay, u Mad Quakers,” which appeared in the Edinburgh Review.
This essay probably did more than anything else to acquaint the
general public with the Retreat’s existence and the principles for which
it stood.

I should not like to convey the impression that the Retreat was
the only institution in England conducted on humane and enlightened
principles. Mention has already been made of Mr. Finch’s House at
Laverstock, Salisbury, and, besides this, high praise was given to
Bristlington House, Bristol, in the 1815 Report to the House of

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Commons. This was opened in 1804 by Dr. Edward Long Fox, who
had had long experience in the treatment of insanity. The centenary
volume of Brislington House contains many interesting details of its
early days, but I have not seen any published accounts of Dr. Fox’s
medical practice. He was a man of high principle, and it is noteworthy
that, although he was a member of the Society of Friends, he appointed
a Church of England clergyman as chaplain, and was, I believe, the
first to provide regular religious services for the insane.

In estimating the results of treatment we are confronted with the
difficulty as to being sure that all the essential facts are known to us.
Rarely can we be certain what would have happened if this instead of
that had been done. This is also the problem of history.

Suppose, for instance, that Margaret Tudor, on her way to Scotland,
instead of riding in state into St. Mary’s Abbey, had fallen from her horse
as she passed through the gateway which still blocks the traffic outside
Bootham Bar, and had never married James IV of Scotland ! What
would have been the course of history with no Mary Queen of Scots, no
Lord Darnley to be murdered, with no James the First of England,
and no Stuart line of kings ? We can only say we do not know !

The same difficulty meets us in estimating the consequences of
our own acts. We find it impossible to measure the issues of a
chance meeting or a casual remark; we are bewildered with the com¬
plexity of life, and we are tempted to accept the philosophy of the
old Persian singer:

“ ’Tis all a chequer-board of nights and days
Where Destiny with men for Pieces plays,

Hither and thither moves, and mates and slays,

And one by one back in the closet lays.

"The moving Finger writes, and having writ
Moves on : nor all thy Piety nor wit
Shall lure it back to cancel half a line,

Nor all thy Tears wash out a word of it.”

In medicine the problem is similar. There are so many incalculable
elements that we can rarely foretell with precision the results of any line
of treatment. This fact is very apparent when we consider the question
of the use of sedative drugs.

A hundred years ago only three of these were in use—opium,
hemlock, and henbane; and opinion was greatly divided with regard
to their value. Haslam strongly condemned opium, saying that
“ many narcotic poisons have been recommended for the care of
madness, but my own experience of these remedies is very limited, nor
is it my intention to make any further trials.” (19) Pinel, referring to
the contradictory opinions on this subject, suggested that the experi-

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ments should be repeated with proper attention to the specific distinc¬
tions of insanity. (20)

At present I suppose that more than a hundred sedatives are
advocated for sleeplessness and mental excitement, and the problem of
their use is more complex than ever before, and as yet no clear and
well-established principles are available to guide us in their use.

It is, of course, recognised that chemical restraint is generally
harmful, that drug habits are easily acquired, and that sedatives dull
the faculties and mask symptoms. Moreover, all physicians in hospitals
for the insane know that many newly-admitted patients will not recover
until the hypnotics given before admission are withheld. Sedatives,
nevertheless, give temporary relief, and it would be cruel to forbid
them, unless it can be shown that they are hurtful.

Yet the extreme opinion of Haslam, already quoted, is shared by
many present-day physicians. Prominent amongst these is Dr.
Hitchcock, late Medical Superintendent of Bootham Park, York, who
published in 1900 in the JourJialof Mental Science a striking article sum¬
marising the results of treating 206 cases of acute mania without any
sedatives whatever.

I have Dr. Hitchcock’s permission to give some interesting details,
explaining how he found himself in opposition to the current practice
of the day. When he began to practise chloral was much lauded, and
at his first asylum appointment he found that this drug was given at the
discretion of the nurses. Without telling them, he substituted for it
camphor and chloroform water, which proved equally useful. Later,
at Bethlem, he found chloral, hyoscyamine, and cannabis indica
freely used. But there he obtained valuable help from Smeeth, the
head attendant, who had carefully watched the results, and was satisfied
that the patients were not benefited by drug sleep. Subsequently he
was appointed to another institution, in which the use of chloral was
rampant on both sides of the house, and 16-ounce Stock-bottles were
filled as often as needed, and dispensed by the night staff at their
discretion. Dr. Hitchcock first gradually reduced the dose, and then
substituted camphor, and later salt solution. When he had fully con¬
vinced the staff that the new “sleeping draught ” was fully as successful
as the old, both for recent and chronic patients, it was possible to
“ own up,” and explain that for some time past no sedatives whatever
had been used ! For the next twenty-five years he allowed no sleeping-
draughts of any kind, yet the recovery-rate at Bootham Park during
this period was a high one.

At the Retreat we do not use narcotic drugs in newly admitted cases,
and only rarely are they prescribed, when ordinary measures have been
persevered with for a long period and failed. It is only fair to say that
in some exceptional cases great benefit has seemed to follow. I cannot,

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therefore, claim to be a total abstainer, like my friend Dr. Hitchcock;
but I support his testimony, and believe that the stand he has taken
will make his name memorable in time to come.

Even, however, if it were demonstrated that drugs, in the main, were
useless and probably hurtful, it would not follow that they had no place
in psychological medicine. There are cases in which the intensity of
mental suffering calls for immediate relief, even if only temporary. It is
unlikely that all drugs are valueless: the problem is to find out their
precise functions and limitations.

I incline to think that members of our Association could investigate
this question to good purpose. We have many facilities for such a
research. Our patients live under very uniform conditions : in the
nursing staff we have trained observers, able to collect and record facts,
and the inquiries could be conducted on a sufficiently large scale to
eliminate many disturbing factors.

We have to admit at the outset that our present classification of
mental disorders is not sufficiently accurate to enable us, in the signifi¬
cant words of Pinel, “ to be sure that similar things are being
compared.” But practical therapeutics cannot wait until the setiology
of disease is fully known, and its pathology is complete. Physicians
should really be able to speak with no uncertain voice regarding the
use of narcotic drugs. Will not some of our younger members take up
this subject for systematic investigation?

The striking success obtained at Guy’s Hospital in studying the effect
of drugs in the treatment of acute rheumatism justifies the opinion that
a somewhat similar inquiry into the value of sedatives might be of great
service in psychiatry.

How this should be conducted it would be presumptuous of me to
say ; but I may perhaps suggest lines on which some inherent difficulties
might be avoided. We recognise that though the external conditions
of patients may be precisely similar in regard to surroundings, exercise,
and daily routine, internal conditions may be utterly diverse. Now, it is
useless to accumulate facts concerning too or even 1,000 individuals, if
in essentials they have little in common. At the outset, therefore, it
would seem advisable to limit the inquiry to groups of cases in which
psychical factors are of secondary importance—such as acute delirium,
the nocturnal excitement in senile insanity, the agitated melancholia of
the climacteric, and possibly maniacal excitement in well-marked recur¬
rent cases. Two groups of similar cases might then be compared, one
taking no drug, the other any drug that might be selected. I am aware
that the risks of drawing wrong conclusions would by no means be
eliminated, yet I am sure that results thus obtained would be of greater
value than the individual opinions of even the most observant people.

Another problem that confronted physicians at the commencement

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of the nineteenth century was the alcohol question, which from the
dawn of history has troubled mankind.

Let me give the following extract from a letter written in Egypt
nearly 3,500 years ago, now in the British Museum (21): “Whereas it
has been told me that thou hast forsaken books and devoted thyself to
pleasure : that thou goest from tavern to tavern smelling of beer at
the time of the evening. If beer gets into a man it overcomes his
mind. . . .

“ Thou knowest that wine is an abomination, that thou hast taken
an oath that thou wouldst not put liquor into thee. Hast thou for¬
gotten the resolution ? ”

A twentieth century parent might make a similar appeal, so little
have conditions changed.

Within the last hundred years, however, some advance has been
made. The habits of the people have improved, drunkenness is no
longer respectable, gentlemen are not now carried helpless to bed after
dinner, and teetotallers are not considered a menace to society. Never¬
theless, the problem is still unsolved, and all who are interested in the
welfare of the British people—I fear I must on this occasion say British
rather than English—deplore the drinking customs of our countrymen.
Physicians, employers, social workers are at one in this respect. The
wastage from intemperance is incalculable, and yet we see before us
increasing industrial competition with nations such as the States and
Japan which are relatively abstemious. I am no pessimist; yet I
cannot do otherwise than view the coming industrial conflict with
grave anxiety whilst we handicap ourselves so heavily. The social and
economic aspects of this problem are not, however, within the scope of
this address, and I turn to its medical aspect.

It is impossible to estimate the number of persons who may justly
be considered intemperate or addicted to drink. There are no trust¬
worthy data, but probably the number is vastly greater than we are apt
to assume. The great majority do not consult any physician and
relatively few come under the cognizance of the police. The statistics
of police-court convictions, moreover, are apt to vary with the vigilance
of the chief constable, or the sentiments of the members of the Watch
Committee.

In 1900 the average amount of alcohol consumed per head was
calculated to amount to 2'o8 gallons yearly. This included everybody
—men, women and children. But if children and adult abstainers are
excluded, and if we make allowance for the fact that women as a rule
drink much less than men, and remember that a large part of the
community is strictly abstemious, we are left with a minority whose
consumption of alcohol must clearly be excessive.

The word “inebriate” is unfortunate as it suggests actual drunkenness.

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whereas there may be dangerous alcoholic addiction without gross signs
of intemperance. As Sir William Collins has recently pointed out, the
term “ addiction ” is very appropriate, for the Addictus was a debtor who,
in Roman law, was handed over to his creditor, and the word implies
a limitation of freedom or some degree of slavery.

This morbid condition, of course, is essentially the concern of
psychiatry. It is virtually a disease, although, when the exciting cause
is removed, no symptoms may be discovered, and although no patho¬
logical findings assist in its recognition.

Experience tells us that the potential inebriate should be treated
early or there will be little hope of preventing confirmed addiction.
But, unfortunately, effective treatment can rarely be obtained, early or
late, and the position is not substantially altered since Haslam in 1808
dealt with this question in language which is appropriate to-day :

“ Thus a man is permitted slowly to poison and destroy himself; to
produce a state of irritation, which disqualifies him from any of the
useful purposes of life ; to squander his property among the most
worthless and abandoned ; to communicate a loathsome and disgraceful
disease to a virtuous wife; to leave an innocent and helpless family to
the meagre protection of the parish. If it be possible the law ought
to define the circumstances under which it becomes justifiable to
restrain a human being from effecting his own destruction, and involving
his family in misery and ruin. When a man suddenly bursts through
the barriers of established opinions; if he attempts to strangle himself
with a cord, to divide his larger blood-vessels with a knife, or swallow
a vial full of laudanum, no one entertains any doubt of his being a
proper subject for the superintendence of keepers; but he is allowed,
without control, by a gradual progress, to undermine the fabric of his
health, and destroy the prosperity of his family.” (22)

Unfortunately, to this day, no satisfactory means have been devised
to prevent or arrest alcoholic addiction. The Inebriate Acts are
practically useless, especially in the early stages of the disorder, and
to wait until some offence has been committed before adopting remedial
measures generally means disaster. The position, moreover, is one of
extreme delicacy. The patient often refuses to admit the necessity for
treatment; he or she may be in good health and possess an attractive
personality. Hardly anyone knows that indulgence is becoming habitual,
and probably those who do know are prejudiced observers.

If early treatment is to be obtained it must clearly be on a voluntary
basis and in strict privacy, for no one can afford to be branded as an
alcoholic.

Treatment, to be effective, means a long and patient investigation
into underlying causes, and this alone makes serious demands upon
the physician and his helpers. No one with experience in this depart-

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mentof medicine will under rate the amount of time and trouble needed
to help the patient along the difficult uphill road towards recovery. At
present such treatment is altogether outside the reach of the majority
of those who need it.

If the suggestion in an article by my old friend, Mr. Theodore Neild,
of Leominster, were adopted, and a consultation bureau were estab¬
lished in every large centre of population, much might be done to give
the necessary help. (23) The staff of the bureau would consist of a
secretary—preferably a trained lady social worker—with such clerical
assistance as might be necessary, and visiting physicians possessing
special experience in this subject. It would then become possible for
anyone to obtain confidential advice either for himself or for a relative
or friend, whilst the bureau would be able to secure the help of other
medical services and lay organisations as occasion might demand.

I am sanguine enough to believe that with assistance such as this
not a few patients would completely recover. The return to useful
work of many who otherwise would be a burden upon society would,
even from a financial point of view, justify the expense incurred.

It is, however, important to realise that this malady cannot be con¬
sidered apart from other forms of mental instability. This Association
in 1914, and again this year, urged the establishment of clinics, or hospitals
for nervous disorders, in order to provide early treatment of unconfirmed
mental trouble; the Board of Control have reported to the same
effect, and the Legislature is already taking up the subject. I would
submit that the proposed consultation bureaux be affiliated with or
become a special department of the new clinics. It is undesirable that
alcoholic and drug addiction should be dealt with altogether apart from
other neuroses. Moreover, out-patient treatment may often be insuffi¬
cient, and a residence in a special hospital will often be of the utmost
value as a preliminary measure.

So far it has been assumed that the patient has applied for treatment
voluntarily or has been persuaded to do so by his friends. Unfortunately
many will decline any treatment or refuse to be advised. Others will
derive no benefit upon voluntary lines, and some form of compulsory
treatment becomes necessary both for their own sakes and that of others.

It will be impossible here to deal with this aspect of the subject in
detail; I must only suggest that any new laws relating to inebriety
might provide three separate procedures or successive steps in dealing
with these patients :

First, a judicial warning, which might be given privately when the
justice has satisfied himself that the patient is in danger of alcoholic
or drug addiction. This probably would be accompanied by a recom¬
mendation to consult a neighbouring clinic, but it would in no way
interfere with personal freedom.

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Secondly, the appointment of a guardian, who would be legally
authorised to stop supplies, and forbid the sale of liquor to the patient,
to restrict his liberty within prescribed limits, and to prevent the im¬
poverishment of himself or his family.

Thirdly, internment in a farm colony or other approved home.

It is obvious that such steps could only be taken after independent
medical opinion has been obtained, and we cannot complain if the
state demands safeguards to prevent any hasty or unjust limitation of
freedom. Such safeguards we will welcome if only powers are given
to protect the inebriate from himself, and arrest his degradation.

Without fresh legislation, however, it is possible to do much more
for persons charged with drunkenness or with offences committed under
the influence of drink. Early in this year a report was presented to the
Birmingham justices, signed by Mr. Gerald Beesly, the deputy chairman,
from which I make a few extracts :

“The minds of many of the Birmingham justices have for a long
time been exercised as to the futility and inadequacy of the customary
methods of dealing with persons charged with crimes, particularly as
to the absence of any consideration of the mental condition of such
persons. It has been felt that in many cases some mental instability
is the fundamental cause of the commission of the crime, and that
1 treatment,’ as distinct from ‘punishment’ (either by fine or imprison¬
ment), is the proper and sane method to adopt. . . .”

“ A well-ordered State should clearly make provision for the efficient
treatment, and, if possible, cure of those who by their acts or mental
weakness are a menace to the community, and thus jeopardise their
right to freedom. Hitherto much provision has been made, at enormous
expense, for dealing with such persons in their later stages of disability.
It is suggested that machinery should be set up which can be put into
operation at the early stages.”

Among others the following immediately practical methods were
advocated :

(1) An expert medical practitioner should be appointed, with whom
the justices can confer and take counsel in any particular case. He
should attend at the courts from time to time to give evidence when
required, and he should interview and report upon cases on remand or
adjournment.

(2) The Probation of Offenders Act should be used more widely,
and conditions imposed that will ensure the periodic examination of
the offender on probation.

It is interesting to note that this report was at once acted upon, and
that a medical man with special experience was appointed to assist the
justices in dealing with cases of this kind.

Although there are at present no consultation clinics, or farm colonies,

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or even proper places of detention for the weak-minded offender, pending
a report as to his mental condition, it is gratifying to find that some
justices are awake to their responsibilities, and that the scandal of the
repeated imprisonment of mental defectives for offences directly due to
their deficiency has ceased, at any rate in Birmingham.

I had intended to compare the psychiatry of 120 years ago with
that of to-day, but I shrink from the attempt. It would be an easy
task to show that progress has been slow and disappointing. No
specific treatment of mental disease has been discovered save in the
case of that arising from thyroid insufficiency. It is doubtful whether
the recovery-rate has improved. Now, as then, patients break down
without any assignable cause ; now, as then, many recover without
our knowing the reason. Making due allowance for altered social
circumstances, it is probable that the condition of patients in the more
enlightened institutions was not greatly different from that of to-day.
In Tuke’s description the daily routine so carefully portrayed shows
that in the early days of the Retreat the patients received care and
attention worthy of our emulation.

The medical literature of that period, moreover, contains much that
anticipates modern teaching. In Haslam’s observations we find a vivid
description of dementia praecox. (24) It certainly is not divided into
eight elaborate and confusing subdivisions, but the clinical picture,
drawn in fewer and stronger lines, is all the more convincing. Haslam
also described general paralysis (25), and his discussion of the hereditary
problem, and of the relation of mental and physical factors in aetiology,
carries us nearly as far as we can travel to-day. The essential mystery
of mental disease baffles us now as it did then.

Still, it would be a mistake to measure the success of medical research
by considerations such as these. There is a great deal of unseen
work in a building before its walls appear above ground. It is quite
unnecessary for me to mention the vast amount of progress made in the
anatomy and physiology of the nervous system, in pathology and in
biochemistry, and in many departments of science which intimately
affect our subject, and which were unheard of a hundred or even twenty-
five years ago.

Any attempt to foretell the direction of further progress is quite
beyond my powers. It is probable that new clinical methods of
examination will be discovered. If, for instance, it became possible to
measure degrees of pain, or ascertain with precision the extent to which
palsy or some other disability depended upon structural defect, or if we
could calculate in advance the breaking-point of mental strain, a new
situation would be created.

The war has thrown some light upon one aspect of our subject. We
have learnt that symptoms formerly termed hysterical or functional are

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not peculiar to the frail or sensitive, but occur in strong men. We find
that they continue long after any recognised exciting cause has ceased
to operate, and that they frequently disappear suddenly, as if charmed
away. Unfortunately we cannot analyse the causes of this recovery,
which is ascribed to multifarious agencies: suggestion, hypnotism,
psycho-analysis, faith-healing, and sudden emotion, besides ordinary
hygienic measures. There is obviously no organic lesion, and though
the illness is usually characterised by some manifest physical disability,
it is clearly a disorder of the mind rather than of the body. There is
urgent need for careful research in order to establish a scientific
therapy, so that appropriate treatment can be selected with con¬
fidence. Only too frequently such treatment is not forthcoming, and
consequently our pension-board rooms are thronged with nervous
invalids.

In addition to this, the functional element in definite organic
maladies must not be overlooked. Patients with diseases such as
disseminated sclerosis and locomotor ataxy frequently present symptoms
that bear little relation to the extent of the organic lesion. Even in
these cases the disability may in large measure be functional.

Do not these observations throw light on some of the problems of
psychiatry, and may we not conclude that sometimes the symptoms of
insanity bear little relation to the assigned cause ? It seems reasonable,
moreover, to assume that such symptoms may continue for long periods
of time independently of the original disturbance.

Do not some of our sudden recoveries correspond to the recoveries
in the psycho-neuroses ? On the other hand, are not some of our
chronic cases akin to that of the confirmed neurotic, with this difference,
that in the one the disordered function affects intelligence and emotion,
and in the other some lower nervous mechanism such as vision or
muscular co-ordination ?

This thought, of course, does not carry us far; but it suggests that the
study of hysterical phenomena may help us greatly. Further, it reminds
us to lay due stress on the psychical as well as upon the physical
factors in aetiology. The attempt to separate mental and bodily factors
must inevitably lead to error, since they constantly react on each other.
It is well known that emotional disturbance produces changes in the
endocrine organs, and that degeneration of those organs leads to
emotional dulness and apathy.

Be this as it may, we have at any rate left behind the doctrine
expressed in the dictum, “All insanity is either toxic or traumatic.”
(26) Just as Tuke and Pinel considered moral treatment of paramount
importance in promoting recovery, so we recognise the profound
importance of mental strain in the causation and development of certain
forms of mental disorder.

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References.

(1) Report of the Committee appointed to examine the Physicians who
have attended His Majesty during his Illness, 1789, p. 135.

(2) Harper. —A Treatise on the Real Cause and Cure of Insanity,
1786, p. 48.

(3) Philippe Pinel. —A Treatise on Insanity, Dr. Davis’s translation,
1806, p. 252.

(4) Crowther.— Practical Remarks on Insanity, 1811, p. 102.

(5) Ibid, p. 112.

(6) Report of Committee on Mad houses, 1815, p. 130.

(7) J. Mason Cox.— Practical Observations on Insanity, 1804, p. 137.

(8) Ibid., p. 34.

(9) Ibid., p. 112.

(10) Ibid., p. 118.

(n) Thomas Young.—“ Oration,” Transactions Optical Society, 1915.

(12) Report of the Committee on Mad-houses, 1815, p. 299.

(13) Morrison’s Lectures, 1828, p. 163.

(14) Les grandes Alienistes Fran(ais, Semelaigne, 1894, p. 42.

(15) Hack Tuke. —Reform in the Treatment of the Insane, p. 74.

(16) Samuel Tuke.— Description of the Retreat, p. no.

(17) Medical Times and Gazette, 1864, p. 317, and Annals of Medi¬
cine, 1801.

(18) Ibid., p. 115.

(19) Haslam. —Observatiotis on Madness, 1808, p. 339.

(20) Pinel. — Supra, p. 259.

(21) “ Papyrus Sallier I : Eleventh Letter,” Tuke’s Dictionary, p. 1.

(22) Haslam.— Supra, p. 78.

(23) National Temperance Quarterly, No. 44, winter, 1918; No. 45,
Spring, 1919.

(24) Haslam.— Supra, p. 64.

(25) Haslam.— Supra, p. 260.

(26) Medical Annual, 1914, p. 366.

Goitre and the Psychoses. By Norman Routh Phillips, M.D.Brux.,
M.R.C S., L.R.C.P.Lond., St. Andrew’s Hospital, Northampton.
Awarded Second Prize in the Bronze Medal Competition.

That there is some relationship between goitre and the psychoses
is beyond all question. We have only to recall the mental syndromes
of Graves’ disease and endemic cretinism—goitre occurs in all but a
few exceptional cases of the former, and in about 50 per cent, of the
latter. Moreover it is by no means uncommon to find goitre in adult
myxcedema.

In this article I propose to show that the role played by goitre in the
psychoses is more extended than is indicated by the examples just
mentioned. I shall also endeavour to explain the nature of this
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[Oct.,

association of goitre and insanity, and, finally, I shall indicate the lines
upon which the treatment of these cases should be based.

Systematic examination of the thyroid demonstrates the fact that
enlargement of the gland is of fairly frequent occurrence in asylums,
especially in female cases.

It appears, however, that endemic goitre is more often associated
with the psychoses than is the sporadic form. Moreover, the enlarge¬
ment of the thyroid in the former case is much more evident, frequently
leading to great disfigurement.

I once had the advantage of visiting the wards of the Bel Air Asylum
near Geneva, and I was greatly impressed by the high percentage of
patients suffering from goitre—36 per cent, for both sexes. The
goitrous enlargement had in many of the cases attained to an
enormous size.

Various authors have drawn attention to the frequency with which
the goitrous become insane; others have remarked on the eccentricities
of character and enfeeblement of the intellectual faculties in districts
where goitre and cretinism is endemic. In particular I might mention
the work of Marzocchi and Antonini. As a result of much careful
observation the last-named writers came to the following conclusions :

(1) The goitrous, including congenital cases, are eight times more
susceptible to insanity than those not afflicted with thyroid enlargement
(i.e., as far as the Province of Bergamo is concerned). Moreover, if
one deducts all the congenital cases (cretins, etc.) the goitrous more
often become insane than other people.

(2) The curable psychoses do not furnish any difference in the
percentage of recoveries, whether the case be goitrous or not.

(3) People not afflicted with goitre, belonging to a district where
goitre is endemic, are no more subject to contract mental maladies
than those coming from a country where the affection is not
prevalent.

Up to a few years ago no satisfactory explanation was forthcoming to
account for this association of goitre with the psychoses. It was
generally believed that goitre did not affect the thyroid secretion.
Within recent years, however, as a result of much clinical, pathological,
and experimental investigation, the whole subject of goitre has been
revised, and a number of observers have produced evidence to show
that the goitrous lesion affects the secreting epithelium in such a way
as to cause signs of either hypo- or hyperthyroidism, or the two condi¬
tions may exist side by side in the same subject—thyroid instability.

These conclusions are of the utmost importance, as the mere fact of
goitre being associated with either thyroid insufficiency or excess places
this affection on a footing with the well-known diseases of the thyroid
mentioned at the commencement of this article, viz., Graves’ disease,

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cretinism, and myxcedema, whose relation to the psychoses is an
incontestable fact.

I is now possible to divide all the various forms of goitre into two
main groups, viz., Group I, those forms which produce hypothyroidism;
and Group II, those producing hyperthyroidism.

Group I. Hypothyroidism occurs :

(a) Sometimes as a later stage in parenchymatous goitre, the initial
activity of the gland being followed by a phase of secretory exhaus¬
tion.

(b) In chronic colloid goitre—as a result of the flattening and atrophy
of the epithelial cells from distension of the vesicles with excess of
colloid material.

(c) In adenomatous, fibrous, and cystic goitres, probably as a result of
mechanical interference with the proper functions of the gland.

(d) Sometimes as a late stage in Graves’ disease from fibrous
degeneration and atrophy of the epithelium.

Group II. Hyperthyroidism occurs :

(a) In the early stages of parenchymatous goitre as a result of the
hypertrophy of the gland which arises in response to a call for increased
thyroid secretion.

(b) In Graves’ disease where there is active hypertrophy and
proliferation of the epithelial cells, with the formation of new vesicles
lined with cubical cells and containing colloid.

(c) In a certain proportion of old colloid goitres the atrophied
epithelium taking on renewed growth, with the same active cell-
proliferation and formation of new vesicles mentioned in the last
variety.

Rogers holds the view that “ An increase in the size of the gland
seems the regular or natural first stage in all acquired thyroid diseases.”
This opinion is particularly interesting when one takes into consideration
the frequency with which pathological changes have been found in the
thyroid gland in the insane by many observers.

The frequent association of hypothyroidism with goitre referred to
above is worth noting, as the mistake is often made that enlargement of
the thyroid gland necessarily points to hyperfunction. Even some of
the most prominent observers continue to quote the weight of the gland,
implying that if it be above normal hyperthyroidism is indicated and
vice versa.

Auto-intoxication. —Let us consider in more minute detail how the
brain may be affected by the goitrous lesion.

The various endocrinic glands, in addition to their specific functions,
pour into the blood-plasma certain chemical substances called hormones,
which are endowed with the important function of regulating meta¬
bolism—one group of hormones exercising an augmentor, the other a

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retarding influence. Thus an equilibrium or balance is established, the
maintenance of which is essential to health.

We are justified in assuming that a lesion of an important organ,
such as the thyroid gland, resulting in diminution or excess of thyroid
secretion would produce disorganisation of the delicate hormonic balance
and so induce a state of auto-intoxication.

Now, as Lugaro emphasises, the brain is particularly susceptible to
the action of poisons, and reacts to those which are produced in the
organism itself not less intensely than it does to those derived from
outside.

Influence of the Nervous System on the Thyroid Secretion.

Increasing interest in this important subject has been manifested of
late in consequence of the close relationship which is known to exist
between the thyroid gland and the nervous system.

The nerve supply of the gland is derived from the sympathetic system
and the vagus. The sympathetic nerves have been proved not only to
influence the glandular secretion, but also to regulate and control the
delicate inter-relationships existing between the various endocrinic
glands.

The influence of the higher nerve centres on the thyroid secretion
is shown by the fact that emotional states— e.g., fear, anger, anxiety—
are capable of producing states of hyperthyroidism.

The following statistics are interesting as showing the frequent
association of endemic goitre with the psychoses :

Of 291 patients examined by Brissard at the Bel Air Asylum, Geneva,
106 were found to be goitrous (44 males and 62 females, or 36 per cent.
for both sexes). These figures are remarkable when compared with the
statistics furnished by the Recruiting Office for the Canton, the pro¬
portion of goitrous as indicated by the latter being only 5 per cent.
The 106 goitrous patients included 71 cases of dementia praecox, 18
cases congenitally weak-minded, 8 cases of senile dementia, and 4 of
manic-depressive insanity. The frequency of goitre in dementia prsecox
and in congenital idiocy is significant. Out of a total number of 149 cases
of dementia praecox 71 were goitrous, /.<?., 49 per cent., and out of a
total of 37 cases of congenital idiocy 18 were goitrous, i.e., 48 per cent.
Hardly less interesting are the statistics drawn up by Schranz at the
Hall Asylum in the Tyrol, and quoted by Brissard.

Of 277 patients under observation Schranz found 68 goitrous, i.e*,
24-5 per cent., as compared with 15 per cent, for the rest of the popula¬
tion. These 68 goitrous patients included 45 cases of dementia
priecox, 13 of mania, 7 of congenital idiocy, and 3 of epilepsy. The
large proportion of cases of dementia pnecox is again worthy of note.

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BY NORMAN ROUTH PHILLIPS, M.D.

Clinical Cases.

A word is necessary to explain why I have included cases presenting
exophthalmos (t.e., cases of Graves’ disease) in the following table.
Experience has shown me that all cases of goitre, both of the “simple”
and of the “ exophthalmic ” type, are liable to undergo changes, not only
in the size and shape of the thyroid gland, but also in the signs and
symptoms by which they are accompanied (whether these latter be of a
somatic or mental character).

Thus a case of apparently simple goitre may sooner or later develop
all or many of the signs indicative of Graves’ disease, e.g., exophthalmos,
trerpors, palpitation, etc., as well as the mental instability so charac¬
teristic of that disease; a case of Graves’ disease, too, is liable to
undergo changes, e.g., the exophthalmos, tremors, palpitation, etc., may
disappear—so that if one were not acquainted with the history of the
case one might be tempted to make a diagnosis of “ simple goitre.”

The following table summarises the observations made by me on
twenty-four insane patients who were affected with goitre. Two
hundred patients were examined at St. Andrew’s Hospital, Northampton,
so that the actual proportion of goitrous was 12 per cent.

’ No.
of

case.

Psychosis.

Lobes
affected.

Pulse

rate.

Systolic

blood-

pressure.

Exoph¬

thalmos.

I

Melancholia .....

M + R

96

148

s

2

Paranoia .....

R + L

72

ns

—

3

Dementia praecox ....

L

60

120

—

! 4

Senile melancholia

R

80

176

—

5

Mania ......

R + L

70-120

150

—

6

Manic-depressive ....

M

72

140

7

Melancholia .....

M

84

140

—

8

Manic-depressive ....

R

O

O

—

9

Mania ......

G

64

192

—

10

Manic-depressive ....

R + L

88

130

—

11

Paranoia.

R + M

0

O

—

12

Dementia praecox ....

L + R

80

142

—

13

Dementia praecox ....

M

88

130

—

14

Mania.

R + M

76

120

s

IS

Dementia praecox ....

G

84

160

—

l6

Manic-depressive ....

R

0

O

+

17

Involutional melancholia

R + L

O

0

+

18

Manic-depressive ....

R + L

120

190

+

19

Melancholia.

R + M

72

112

—

20

Manic-depressive ....

M + R

74

138

—

21

Mania.

M

90

160

—

22

Paranoia .....

G

88

140

—

23

Melancholia.

R + L

98

166

+

24

Melancholia.

L

92

142

+

Explanation of abbreviations .—M = Middle lobe. R = Right lobe. L = Left
lobe. G = General enlargement of the thyroid gland. S = Slight. + = Present
— = Not present, o = Not obtained.

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It will be seen that out of 24 cases of goitre under observation no less
than 17 suffered from manic-depressive insanity or from the melancholia
of involution, e., 70 per cent, of the whole number. Of the remaining
7, 4 were cases of dementia prascox, and 3 of paranoia.

Case 5.— JE t. 47, was admitted October, 1912.

Family history. —Father insane—chronic melancholia.

Physical examination. —Slight enlargement of the thyroid; exoph¬
thalmos ; palpitation; pulse-rate 100; some emaciation; poor general
health.

Mental. —She was restless, talkative, memory defective, attention
distractible, emotional, irritable, apprehensive. She was lacking in
concentration; complained of headache and noises in the head;
troubled with insomnia, frequently asking for drugs.

January, 1913, she was discharged.

September 22nd, she was again admitted, suffering from mania. She
had been over-indulging in drugs and alcohol. The physical and
mental symptoms were similar to those mentioned above.

October 19th, 1914 : Transferred elsewhere.

November 1st, 1915 : Readmitted into this Hospital suffering from
chronic mania.

Present state: Physical. —There is slight general enlargement of the
thyroid, frequent attacks of tachycardia, pulse varies between 70-120,
systolic blood-pressure 150, fine tremors of the hands, moisture of the
skin, slight exophthalmos.

Mental. —She is very emotional, with frequently changing moods ;
she is irritable and at times noisy and abusive; occasionally she is
violent to the nurses ; she is very verbose with flight of ideas ; attention
is distractible ; she writes endless illegible nonsense on scraps of paper
and leaves torn out of books ; she is very restless ; memory is impaired;
she is untidy and fantastic in dress ; she is apprehensive with delusions
of persecution.

This case may be considered a typical one of hyperthyroidism with
characteristic mental symptoms. It will be noticed that all the psychic
processes are affected, but it is the emotional sphere which is most pro¬
foundly disturbed, and which seems to dominate the whole personality.
It is interesting to note that the thyroid gland has been styled by
Leopold L<*vi, “ La Glande d’emotion.”

The frequent occurrence of mania, melancholia, and manic-depressive
insanity in Graves’ disease led Parhon and others to think that
exaggeration or perversion of the function of the thyroid gland plays an
important role in the production of these psychoses as a rule, and
pathological research has tended to confirm this view, but Parhon
admits that hypothyroidism sometimes favours the development of
melancholia.

The mental state of Case 21 resembles in many ways the above. In
addition, however, to the irritability, distractibility, restlessness, etc.,
she has auditory hallucinations and many changing delusions.

This patient has a large goitre about the size of more than half a

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BY NORMAN ROUTH PHILLIPS, M.D.

241

croquet-ball involving chiefly the middle lobe of the thyroid, the lateral
lobes being also slightly involved. This goitre occasionally increases in
size and is liable to cause some embarrassment to breathing, and some
cyanosis due to pressure. There are periods when the cardio-vascular
signs are accentuated—tachycardia, with a pulse-rate of 120 or more, and
fine tremors of the fingers ; there is no exophthalmos.

The family history is interesting, three sisters having goitre.

Case 14 is chiefly interesting on account of the family history. She
suffered from chronic mania with secondary dementia. There is a
large goitre involving the isthmus and right lobe of the thyroid which
has existed since childhood. (She is now 62.)

Family history. —One sister had goitre, and was also mentally
deficient and died of diabetes. Another sister had goitre.

Case 19.—Ait. 33. Admitted November 7th, 1917.

Family history. —One sister has a larger goitre. Maternal aunt
(Case 17) goitrous. Mother died in an asylum.

Patient has a goitre of the shape and size of half a hen’s egg, the
long axis almost vertical, involving right lobe and isthmus.

She is suffering from melancholic stupor. There is a history of coitus
interruptus.

Case i.— JE t. 43. Single. Admitted August nth, 1917.

Family history. —Father, paternal grandfather, one brother and one
sister goitrous. There is also a history of neuroses in family.

Previous history. —Since the commencement of menstruation (ret. 17)
she has made repeated attempts to earn a living by teaching, etc. •
These endeavours invariably sooner or later led to a physical and
nervous breakdown, with the following symptoms : “ Violent throbbings
in the neck and stomach,” retching, vomiting, and dizziness, all accen¬
tuated by exertion. She was at the same time troubled with insomnia,
was depressed and apprehensive. Six weeks previous to admission she
developed delusions of hypnotic influence. An attempt to take her life
by drowning resulted in certification.

State on admission: Physical. —Above average height; fairly
nourished ; fairly large goitre of the middle and right lobes. Heart,
systolic murmur at apex; palpitation at times ; slight exophthalmos.

Mental. —She was suffering from melancholia of the anxious type ;
emotional and agitated; delusion that she was hypnotised by an
atheist; that in consequence she was possessed of the devil, her soul
lost, and she was unworthy to live; auditory hallucinations ; insomnia
troublesome.

Later she became stuporose.

December 18th, 1917: Taken out by her father.

January 1st, 1918 : Returned to tins hospital in much the same
state, physically and mentally, as on previous admission.

Progress of case. —The goitre remained prominent; she complained
of throbbings in the neck and palpitation at times; easily tired. She
was anxious and apprehensive, and dreaded the thought that the
restlessness and insomnia might return ; fleeting delusions.

A change to our sea-side home in the summer had a beneficial
effect. She became more sociable and did some useful household
work.

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242 GOITRE AND THE PSYCHOSES, [Oct.,

December 3rd, 1918: She improved sufficiently to return home,
and she has maintained her improvement for six months.

Case 6 is a typical case of “ folie circulaire ” of many years standing.
Periods of depression are followed by periods of exaltation and rest¬
lessness, which in turn give place to intervals of comparative lucidity.

There is a goitre about the size of a walnut involving the thyroid
isthmus.

Heredity .—Two brothers insane.

Case 20.— ALt. 59. Admitted December 17th, 1917.

Family history. —Father, paternal aunt, and sister all had goitre.
Husband developed goitre shortly after his wife’s admission to this
hospital.

Previous history —She had had frequent attacks of depression,
alternating with periods of mania, when she quite lost control of
herself.

State on admission: Physical .—Goitre about the size of a small
tangerine orange chiefly affecting the isthmus, but right lobe also
involved. Pulse 98; heart irregular at times; systolic blood-pressure
138.

Mental .—Periods of excitement, when she was noisy, restless, impul¬
sive, and violent, alternating with periods of depression, apprehension,
and delusions of unworthiness and of culpability—she believed she
would have to suffer torment and be killed. Under the influence of
these ideas she had an uncontrollable impulse to scream loudly.

July nth, 1918: She was discharged recovered after a visit to
the sea.

It seems probable that the variety in the psychic syndromes which
occurs in the recurrent, alternating, and circular types of insanity may
be brought about by changes taking place in the enlarged thyroid gland,
resulting in the association in the same subject of hyper- and hypo¬
thyroidism.

It may be convenient at this stage to compare the psychic syndrome
of typical hyperthyroidism as seen in Graves’ disease with the mental
symptoms of typical hypothyroidism as seen in the myxcedema of
adults. The acceleration of the mental processes in the former is in
marked contrast with the retardation which obtains in the latter.

Perception is impaired in Graves’ disease, and hallucinations are
frequent.

Memory is impaired both in myxcedema and in Graves’ disease.

Attention is difficult to obtain in myxcedema, whereas it is easy to
obtain but difficult to fix in Graves’ disease.

Association of ideas is very slow in myxcedema, whilst it is rapid in
Graves’ disease owing to the distractibility of attention.

Emotions.— The myxcedematous is dull and indifferent. In Graves’
disease there is instability, irritability, and extreme irascibility.

Capacity for mental work is much impaired in myxcedema as a result
of apathy and indifference. In Graves’ disease the distractibility of

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1919-] BY NORMAN ROUTH PHILLIPS, M.D. 243

attention prevents concentration and perseverance—qualities which are
essential to the performance of mental work.

The reactions are rapid in Graves’ disease, whilst in myxoedema they
are sluggish.

Sleep. —In myxoedema there is somnolence. In Graves’ disease
there is insomnia.

Case 12.— ALt. 33. Dementia prsecox. Admitted January, 1904.

Previous history. —She had been weak-minded for years.

On admission she was dull and listless, unoccupied and untidy.

Progress. —On one occasion she expressed her intention to commit
suicide, but never attempted to do so. Occasionally she would mutter
to herself. At times she was restless. The mental processes have
gradually deteriorated.

Physical state. —There is a goitre affecting both lateral lobes of the
thyroid—more marked on the left side. She has many of the stigmata
of hypothyroidism— e.g., stature small with poor development of the
limbs, teeth deficient and defective, eyelashes scarce and blepharitis,
disappearance of the outer third of eyebrows, shivering fits, tempera¬
ture subnormal, cold extremities with cyanosis and chilblains, pulse
small, 76, oedema of feet, easily fatigued. There is marked icthyosis,
the skin over the whole of the body being dry, with copious shedding
of epidermic scales daily from the face and feet.

Mental state. —Expression vacant, she is listless and apathetic, and
will sit in one position for hours gazing vacantly on the floor; attention
is difficult to obtain and to fix; she has no regard for herself, her
personal appearance, or her future; she is unoccupied, occasionally
mutters to herself, association is sluggish—she never speaks on her own
initiative, showing some incoherence and defective memory; movements
catatonic in type.

This case is remarkable for the number of signs presented which
indicate thyroid insufficiency. Several observers have drawn attention
to the association of icthyosis with this condition. Hertoghe has
mentioned the occurrence of blepharitis.

The small stature and poor development of the limbs suggest that
the trouble began in early adolescence, and this view is supported by
the history of the case, which shows that the patient had been weak-
minded for many years previous to admission.

Confirmation of the subthyroidic origin of the syndrome is furnished
by the decided amelioration which results from the exhibition of thyroid
extract in her case. Thus within three weeks of starting the treatment
the icthyosis and the general physical health had considerably improved,
and there was also a remarkable change for the better in the mental
state—the expression became more intelligent; attention was readily
obtained and held ; association was improved. The patient thanked
me very much for ordering the tabloids, and said she woke in the
morning feeling much refreshed and clearer in the head since taking
them; she implored me to let her go on with the treatment. Besides

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GOITRE AND THE PSYCHOSES,

[Oct.,

displaying more initiative in conversation her memory was improved,
and she recalled without effort various events which had happened in
the past.

Case 13.—Dementia praecox, also shows some of the signs of
subthyroidism, e.g., small stature and poor development, the eyebrows
are sparse in the outer third (“eyebrow sign”)) eyes deep-set, small
and lacking in expression, anorexia is a marked symptom.

Case 15.—Dementia praecox, presents the eyebrow sign, coldness of
the extremities, and a tendency to chilblains.

Case 3.—Dementia praecox, shows the eyebrow sign, pulse 60 and
small.

It is thus seen that all the four cases of dementia praecox included in
the above table present, in a greater or less degree, stigmata of thyroid
insufficiency.

In order to explain the association of goitre with dementia praecox as
well as with congenital cases which was so striking in the statistics of
Brissard and Schranz, it is necessary to consider the facts.

The thyroid gland not only governs the building up of the cells of the
organism, including those of the central nervous system, but it also
regulates their development.

In consequence of this there is an increased demand for thyroid
secretion in infancy, early childhood, puberty, and adolescence. Owing,
however, to the goitrous lesion the thyroid gland is naturally hampered
in its endeavour to meet this demand. Should the weakened gland give
way under the strain and its secretion become exhausted, disorganisation
with auto-intoxication will result.

Now if this disorganisation occurs in infancy or early childhood it
may conceivably give rise to imbecility, or even idiocy. On the other
hand, if it be delayed to adolescence dementia praecox may result.

I have obtained a family history of goitre in three cases of dementia
praecox, only one of whom presents some fulness of the neck, the other
two show no thyroid enlargement at the present time:

The first is a male whose mother has a large goitre, and a maternal
cousin has exophthalmic goitre; in the second (male) the father and
paternal uncle both suffer from goitre with exophthalmos. The third is a
female whose paternal aunt has exophthalmic goitre.

In Case 2 (paranoia) the goitre is probably secondary to tuberculous
disease of the spine with psoas abscess. There are signs pointing to
hypothyroidism—scarcity of eyebrows, with chilliness and subnormal
temperature.

The remaining two cases of paranoia are so suspicious and deluded
that fuller examination is impracticable at present.

A study of the foregoing cases emphasises the great importance of
heredity as an aetiological factor in thyroid abnormalities.

There are certain points of difference in the results of my observa-

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tions as compared with those of Brissard and Schranz whicli need some
explanation.

I have pointed out that the majority (70 per cent.) of my cases were
manic-depressive or involutional melancholiacs, and a minority (i6‘6 per
cent.) were cases of dementia praecox.

On the other hand, Brissard and Schranz both found that the majority
of their cases belonged to dementia praecox and congenital idiocy
groups, the number of cases of manic-depressive insanity being com¬
paratively small.

In my opinion, this disparity can be accounted for by the fact that
sporadic goitre is more often accompanied by hyperthyroidism, and
that this latter condition plays an important role in the production of
manic-depressive insanity.

On the contrary, there is reason to believe that endemic goitre is
associated with hypo thyroidism, which condition appears to favour the
onset of congenital idiocy and dementia prrecox.

The absence of cases of congenital idiocy from the above table is
due to the fact that such cases are not received into St. Andrew’s
Hospital.

AEtiology of goitre .—Before discussing the question of treatment it is
essential to give a brief description of the aetiology of goitre.

Heredity is a most important factor, as will be seen by a reference to
the cases I have described above. In many of these I have found a
family history not only of goitre but of neuroses or psychoses.

Persons of an emotional or neurotic temperament are particularly
prone to develop goitre.

Women are much more liable to thisjaffection than men.

There are various circumstances and conditions winch impose an
extra strain on the thyroid gland, and may determine its enlargement.
Thus a goitre may develop as a result of emotional states, eg., fear,
anger, anxiety, etc., prolonged mental or physical stress, hygienic errors,
deficient or improper food, puberty, menstruation, pregnancy, or sexual
excess.

Enlargement of the thyroid gland in young girls has been particu¬
larly noticeable during the recent great European war—emotional and
physical stress and the poorer standard of food probably acting as
contributory factors.

Since the beginning of the war attention has been repeatedly drawn
to the occurrence of goitre accompanied by symptoms of hyper¬
thyroidism in men from 20 to 45 years of age. I have met cases of
this kind who have been diagnosed “ D.A.H.” ! The cause is said to
be chiefly emotional exhaustion, and in a lesser degree physical
exhaustion.

A number of diseases and toxaemias are capable of causing hyper-

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246 GOITRE AND THE PSYCHOSES, [Oct.

plasia of the thyroid gland, e.g., rheumatic fever, measles, scarlet fever,
pyorrhoea, tuberculosis, etc.

All these toxaemic conditions tend to weaken the secretory value of
the thyroid gland, and may result in thyroid insufficiency.

Endemic goitre is supposed to be produced by a chronic toxaemia.

Pathological examination in the majority of cases of endemic goitre
shows the thyroid gland to be in a state of colloid or fibrous degenera¬
tion which, we have seen, results in hypothyroidism.

Treatment.

In the aetiology of the psychoses associated with goitre it is
important to realise that there are often two factors, a physical and a
mental.

In the treatment of these psychoses the physical element should be
dealt with before any special mental therapy is undertaken.

Physical treatment .—The importance of an early recognition of the
somatic signs indicative of hypo- or hyperthyroidism cannot be too
strongly emphasised.

Hypothyroidism .—If the physical signs point to this condition
thyroid therapy should be at once commenced, and the greater the
number of stigmata present the better the chance of success from this
remedy. Quite small doses as a rule produce the best therapeutic
effect. The pulse and weight must be carefully watched, and if any
sign of hyperthyroidism appear the treatment should be suspended for
a while. In any case it is well to suspend the drug for a few days
about every tenth day and always during menstruation.

The treatment may have to be continued for years, and sometimes
for a lifetime.

It is essential in every case of goitre to look for any possible source
of toxic absorption ; thus attention should be directed to the condition
of the mouth, the state of the bowels; the diet should be regulated,
any tubercular focus should be efficiently dealt with.

Where insufficiency of the other endocrinic glands is suspected
suitable glandular extracts may be added to the treatment, but not
before a thorough trial has been made with thyroid therapy alone.

The results of this treatment are often gratifying, not only from a
physical point of view, but the mental symptoms may also be much
ameliorated and cures may result.

Hyperthyroidism .—Although an extraordinary number of drugs have
been tried in this condition, not one can lay claim to having a specific
action. It should be mentioned, however, that calcium lactate (gr. 10
three times a day) has been used with some success, both in Graves’
disease as well as in states of excitement.

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PRINCETON UNIVERSITY

I 9 I 9-J

BY NORMAN ROUTII PHILLIPS, M.D.

247

Organotherapy has been employed, but hitherto without success ;
it would seem that our knowledge of the complicated interactions
between the varions endocrinic glands is as yet but imperfectly
understood.

X-rays, surgical operations, and various other physical agents have
their advocates, but in many cases they are not only useless but
positively harmful.

Mental treatment .—Psychotherapy has recently been recommended
in cases of Graves’ disease, and there are three reasons which would
seem to justify its employment in all cases of hyperthyroidism, viz.:

(1) The undoubted importance of the mental element (whether this
be primary or secondary) in the aetiology of these cases.

(2) The predominance of nervous and mental symptoms in exoph¬
thalmic goitre.

(3) The failure of all other therapeutic measures (drugs and physical
agents) to deal effectively with these cases.

Moreover, psychotherapy might usefully be employed in those cases
of hypothyroidism in which thyroid treatment has proved inadequate in
the removal of the mental symptoms.

There are two methods of applying psychotherapy, viz. (a) suggestion,
and (b) the exploration of underlying mental conditions.

Psychotherapy has already been used with some success in certain
cases of dementia praecox, of paranoia, and- of manic-depressive
insanity.

In the other psychoses this method of treatment is still in the
embryonic stage, but, if one may judge by the progress made in the past,
there is every reason to look forward to still further extensions of its
applicability.

Summary.

(1) We have seen the frequency with which goitre is associated
with the psychoses—in a mental hospital receiving no cases of idiocy,
one patient in every eight having some thyroid enlargement.

(2) As to the mechanism of this association we have seen that (a),
goitre is, at some time in the patient’s history, accompanied by a
condition of hypo- or hyperthyroidism, and that (b) either of these
conditions is capable of inducing a state of auto-intoxication with
mental symptoms.

(3) My series of cases show that the nature of the psychosis is, in
some degree, determined by the form of the functional disturbance of
the thyroid gland, e. g., hyperthyroidism is usually associated with states
of excitement, agitation, etc. ( e.g ., manic-depressive insanity), whereas
hypothyroidism is more often associated with states of apathy and
indifference (e.g., dementia praecox).

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248 GOITRE AND THE PSYCHOSES. [Oct.,

(4) The treatment of the psychoses associated with goitre depends
to some extent on the nature of the functional disturbance of the
thyroid gland. If the signs point to hypothyroidism treatment by
thyroid extract should be instituted. If hyperthyroidism is present the
treatment should be directed to the removal of the mental element,
which is now admitted to be of great importance in the setiology of this
condition. The only satisfactory method of accomplishing this is by
the employment of psychotherapy.

My thanks are due to Dr. D. F. Rambaut, Medical Superintendent
of St. Andrew’s Hospital, for permission to publish the above cases, and
for valuable suggestions; also to Professor Weber, Meddcin Directeur
of the Bel Air Asylum, Geneva, for the kind interest he has taken in
my essay.

References.

(1) Brissard.—-Zrt frequence de goitre chez les alients, 1907.

(2) Farrant.— Brit. Med. Journ., February 28th, 1914; ibid., July
18th, 1914.

(3) Graves, T. C.— Jourti. Merit. Sci., April 19th, 1919.

(4) Hernaman-Johnson.— Practitioner , July 1917.

(5) Hertoghe.— Ibid., January, 1915.

(6) Hyslop.— Ibid., February, 1915.

(7) Johnson, W.— Brit. Med. Journ., March 12th, 1919.

(8) Leopold-Levi.— Practitioner, February, 1915.

(9) Lugaro, E.— Modern Problems in Psychiatry.

(10) McCarrison.— Practitioner, January, 1915.

(n) Marzocchi e Antonini.— Annali di Neurologica, fasc. 4-6, 1893,
p. 546.

(12) Medical Annual, 1918, pp. 144, 225.

(13) Parhon.— L' Encephale, 1913, Nos. 8-1 r.

(14) Rogers, J.— Ann. Surg., vol. ii, 1914, p. 281.

(15) Williams, Leonard.— Practitioner, January, 1915.

(16) Shaw, Batty.— Organotherapy , 1905.

(17) Wilson, L. B.—Journ. Amer. Med. Assoc., vol. i, 1914, p. in.

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PRINCETON UNIVERSITY

19 1 9 -] CEREBRO-SPINAL FLUID IN MENTAL DISEASE. 249

On the Cytology of the Cerebrospinal Fluid in Mental Disease.
By G. L. Brunton, M.D.Edin., Senior Assistant Medical Officer,
North Riding County Asylum, York ; late Neurologist to Third
Army.

Introduction.

The fluid obtained by the easy and now frequent procedure of
lumbar puncture affords, when subjected to simple tests, valuable aid
in the diagnosis of mental disease.

These simple tests served the purpose of the clinician whose main
object was to make a rapid diagnosis, yet it was felt that improvements
in method and technique were desirable so that advance could be made
in the field of cell differentiation.

Advance was rendered possible by the introduction by Alzheimer (1)
of a method whereby the cerebro-spinal fluid could be treated along the
lines employed in the histopathology of the central nervous system.

This method has been adopted on the Continent and in America,
but as far as I am aware there have been only two papers published in
this country—one by the American authors, Cotton and Ayer (2), and
one by Henderson and Muirhead (3). By means of it the various
types of cells are fixed and stained in a manner essentially similar to
those of the tissues. The types of cells present in the fluid and the
brain can be compared in a way that has never hitherto been possible.
In this method the cells are fixed by adding 96 per cent, alcohol to the
cerebrospinal fluid, which precipitates the proteid, and by centri-
fugalisation are drawn down with the proteid in the form of a coagulum
to the bottom of the tube.

Alzheimer’s technique has been followed in this research, and this
paper incorporates the results from an examination of the cerebro-spinal
fluid in 100 cases of mental disease.

In detail the method of Alzheimer as used is as follows :

(x) Lumbar puncture in the usual manner.

(2) Ninety-six per cent, alcohol is added drop by drop and well
mixed—10 c.c. alcohol to 5 c.c. cerebro-spinal fluid.

(3) Centrifuge the mixture for half an hour at a high speed in a glass
tube with a conical end. Tube well stoppered to avoid evaporation.

(4) The supernatant fluid is poured off, leaving a small coagulum in
the bottom of the tube.

(5) Add absolute alcohol—alcohol and ether—each separately for
one hour to dehydrate and harden coagulum.

(6) The coagulum is removed from the bottom of the tube by
tapping and allowed to drop into thin celloidin, where it remains for
twelve hours.

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2 50 CEREBRO-SPINAL FLUID IN MENTAL DISEASE, [Oct.,

(7) Coagulum placed in thick celloidin for twelve hours.

(8) Mounted on blocks, hardened in chloroform for half an hour,
and cut at 8 /1 on a Jung microtome.

(9) Section stained.

Procedure.

(1) Sections placed in absolute alcohol for a minute and spread out
on a cover-glass ; as many as eight sections can be accommodated on
one cover-glass.

(2) Ether vapour is poured over the cover-glass; by this means the
celloidin is removed and the section is fixed to the cover-glass.

(3) Section is hardened by placing in methylated spirit.

(4) Place section in water.

(5) Stain as follows : Pappenheim’s pyronin-methyl green (Griibler).
The sections are placed in this stain for five to seven minutes in an
incubator kept at 37 0 C. The sections are then washed in water,
differentiated in absolute alcohol, cleared in Bergamot oil and mounted
in balsam.

Other stains used were Unna’s polychrome blue, Nissl’s methylene
blue and toluidin blue.

The pyronin-methyl green gives excellent nuclear pictures, a slight
pink tint to the protoplasm in most cells, and is considered specific for
plasma-cells.

The fluid must be centrifugalised long enough to give a firm coagulum,
yet not too long, otherwise the cells are driven to the apex of the
coagulum. I found by experiment that to have the cells evenly dis¬
tributed throughout the coagulum centrifugalisation for half an hour at
2,000 revolutions per minute proved satisfactory.

The central portion of the coagulum was cut in vertical sections

Differentiation of Cells.

Hitherto the diagnosis of general paralysis by the examination of the
cells of the cerebro-spinal fluid has depended entirely on the enumeration
of those cells, and the determination of whether a lymphocytosis is
present or not. Recently, however, it has come to be recognised that
a study of the various types of cell is of equal importance.

It was generally recognised that the presence of plasma-cells was as
characteristic of general paralysis as a lymphocytosis, but this type of
cell is common in many chronic inflammations. That plasma-cells
occur in the cerebral cortex and pia mater in general paralysis is a well-
known fact, but until Alzheimer’s method had been introduced they
had never been found in the cerebro spinal fluid. Indeed, Nissl was
led to doubt the pial origin of any of the cerebro-spinal cells because

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PRINCETON UNIVERSITY

BY G. L. BRUNTON, M.D.

1919 .]

251

of the absence of these in the fluid in cases which showed abundance
of them in the pia and cerebral cortex.

The description of the cell-types closely follows that of Cotton and
Ayer, as the appearances in my sections have been in agreement with
their findings in fluid withdrawn during life.

In the normal cerebro-spinal fluid one has practically only one type
of cell to consider, namely, the lymphocyte.

It is doubtful whether the polymorphonuclear leucocyte can enter
the fluid during health, and its presence always indicates the existence
of some irritative process. As a rule this is acute, and the condition
in which the greatest polymorphonuclear leucocytosis occurs is acute
suppurative meningitis. This cell is, however, also found in the chronic
inflammatory conditions, of which the best example is general paralysis.

In general paralysis and tabes dorsalis several other varieties of cells
occur, and in these diseases the cells were sufficiently numerous for a
fair differential count to be made. A differential count was made in
cases in which at least 200 cells could be distinguished. In some
cases this necessitated a search through six to eight sections. The
percentage cell-counts will be found in Table I. In conditions in
which the cells were too scarce for differential purposes the existence
of each type of cell encountered has been denoted in Table II.

The following is a brief description of the various types of cells :

Lymphocytes.

Lymphocytes are found in all fluids, but apart from fluids of
parasyphilitic conditions they occur in very small numbers.

The nucleus is small and round, sometimes oval and slightly indented,
and contains as a rule a single, bright red nucleolus. The chromo-
philic granules lie round the periphery, giving a clock-face appearance,
and take on a deep, blue-green stain with Pappenheim’s stain.

The protoplasm is found as a thin line round the nucleus, stains a
faint pink, and it is usually a little wider on the indented side of the
nucleus.

Lymphocytes show altered and transitional forms. The nucleus is
similar, but there is an increase in the protoplasm. Occasionally the
nucleus takes on a deeper stain. Another type of lymphocyte, classed
as the large, is one in which the nucleus, with its granules, is much
increased in size, and has a thin ring of protoplasm around it.

In general paralysis the differential count shows that the lymphocytes
are the principal cells increased, varying from 39 to 78 per cent., the
transitional forms ranging from 2 to 19 per cent. Including all types of
lymphocytes together in one class the average in general paralysis is
71 per cent. The total cell-count in general paralysis averages from
458 to 100 fields.

LXV. 1 8

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252 CEREBRO-SPINAL FLUID IN MENTAL DISEASE, [Oct.,

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Polymorphonuclear Leucocytes.

Polymorphonuclear leucocytes were present in 15 out of the 17 cases
of general paralysis, and in only 6 of the remaining cases of insanity.

Case 12 is worthy of note, as the leucocyte count reached the high
figure of 29 per cent. Blood contamination could be fairly excluded in
the cases both by the clearness of the centrifuge deposit, and the absence
of red blood-corpuscles in the Widal film from the same fluid as the
Alzheimer. Further, the withdrawal of the fluid had no relation in
point of time with any seizure or expected seizure, or change in the
patient’s physical or mental state.

With the pyronin-methyl green stain the nuclei only are stained, no
protoplasm is visible, and the cells are distinctive.

Plasma-Cells.

These cells are comparable to that of a lymphocyte with its proto¬
plasm greatly increased in amount.

The nucleus is about the size of that of a lymphocyte, but the chromatin
granules are more distinct, take on a deeper blue-green stain, and there
is a bright red nucleolus. The protoplasm is two or three times the
size of the nucleus, takes on a deep red pyronin stain, and occasionally
has a lighter area round the nucleus. The nucleus is always placed
eccentrically in this deep-red protoplasm. Double nuclei are not
uncommon. The protoplasm is of oval outline, and in only a few cells
could the protoplasm be described as polygonal. This description
corresponds with the plasma-cells as originally described by Waldeyer
and Unna (4). In well-stained sections the plasma-cells are distinctive
and of easy differentiation.

Plasma-cells were found in 16 out of 17 cases of general
paralysis, the average being 2 per cent., in 2 cases of tabes dorsalis, the
average being 2 per cent., and in 1 case of a congenital syphilitic
idiot boy.

Endothelial Cells.

These cells were always present in my series of cases. They vary
considerably in size and shape, and are the largest cells found in the
fluid.

The nucleus is, as a rule, kidney-shaped, sometimes oval, and is
usually lying at the periphery of the cell.

The nucleus stains a faint blue-green with pyronin-methyl green
stain, contains few chromatin granules, and has from one to three bright
red nucleoli. The protoplasm stains a faint pink, and shows marked
variation in amount even in the same fluid.

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PRINCETON UNIVERSITY

1919]

BV G. L. BRUNTON, M.D.

253

There is a distinct form of endothelial cell, designated as “Gitter”
cell by Rehm (7), in which the protoplasm presents a fenestrated or
latticed appearance. These clear areas suggest that these cells are of a
phagocytic character. These latticed cells were found in 15 out of
22 cases of general paralysis, in 3 cases of epilepsy, in 2 cases of
melancholia, and in one case each of the following : tabes dorsalis,
imbecility and idiocy.

The average endothelial cell-count in general paralysis was 22 per
cent ., and showed little variation from the average, the highest counts
being 43 and 39 per cent, in 2 gereral paralytics who were in a dying
condition.

Phagocytes.

The most distinctive phagocytic cell encountered was an endothelial
cell which had engulfed a lymphocyte.

The endothelial nucleus was horse-shoe-shaped and devoid of
chromatin and stained a pale blue.

The lymphocyte nucleus was sharp and the chromatin elements
deeply stained a dark blue-green.

The endothelial nucleus occupied one segment at the border of the
cell and the lymphocyte nucleus occupied a central position.

The protoplasm of the cell was faintly stained pink except the area
round the lymphocyte, which was quite colourless.

This type of phagocyte was found in three of the seventeen cases of
general paralysis, but as a rule only nuclear remnants were present in
the protoplasm.

A second type of phagocytic endothelial cell was found in compara¬
tively large numbers (9 per cent.) in the fluid of case No. 5. At the
time of withdrawal the fluid was found tobe tinged yellowish-red, and
the colour remained even after centrifuging, thus proving that the
colour was due to blood originally present in the fluid, and not to con¬
tamination at the time of puncture. Further, no red blood-corpuscles
.were found in the Widal film.

The cells were endothelial in type, as they contained"eccentric oval
nuclei, and a large amount of protoplasm. In the protoplasm could be
seen fine yellowish granules occupying the greater part of the cell
protoplasm, and ihese were considered to be composed of altered blood-
pigment.

The clinical history of the case is of interest. The man was an
excited general paralytic, who had a slight seizure on February 26th,
1913, followed by a severe seizure on March 2nd, which left him with a
right-sided hemiplegia. Lumbar puncture was performed on March
nth. The patient died on March 17th, and the post-mortem examination
revealed an extensive meningeal haemorrhage over the left motor area.

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PRINCETON UNIVERSITY

254 CEREBRO-SPINAL FLUID IN MENTAL DISEASE, [Oct.,

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It can fairly be considered, therefore, that the endothelial cells of the
cerebro-spinal fluid were acting as phagocytes for the blood-pigment
derived from the haemorrhage.

Mitotic Cells.

Only two cells showing mitotic figures were encountered, and these
were found in sections of two different general paralytic fluids. Both
cells showed well-marked mitotic figures, and one appeared to be
undergoing subdivision.

Unclassified Cells.

This class has been necessary, as there are a few cells that could not
be included among the types above-mentioned.

The Fibroblast.

This cell is distinguished by its spindle-shaped nucleus, which contains
faintly stained chromatin filaments, and has apparently only a small
amount of protoplasm at the poles of the cell.

The Polyblast.

This cell has been described by Wickman (5) and by McIntosh and
Turnbull (6) as occurring in the infiltration of the meninges in polio¬
myelitis, and has not been described, so far as I am aware, as occurring
in the cerebro-spinal fluid.

The cell occupies on an average an area equal to that of three red
corpuscles, is round in shape, and the nucleus closely resembles that of
a polymorphonuclear leucocyte. The nucleus is stained darkly with
pyronin methyl-green, with a paler area in the centre which may show a
red nucleolus. The protoplasm takes on a fairly red tint with a pinker
stain round the nucleus—thus it is distinguished from the polymorpho¬
nuclear leucocyte. An occasional cell was found in general paralysis
(9 out of 17 cases), in two cases of tabes dorsalis, in one case of
dementia praecox, idiocy, and neurasthenia.

Discussion of Cytology.

The main features of interest have already been mentioned under the
cell types.

Plasma-cells, phagocytes, and lattice-cells call for a brief discussion.

Plasma cells were present with one exception in all the general para¬
lytic fluids. The exception was that of a slightly demented patient in
whom the disease was slowly progressing.

My findings in tabes dorsalis agree with those of Henderson and
Muirhead, who found plasma-cells present in two out of three cases of
this disease. I also found these cells present in the fluid of a con¬
genital syphilitic idiot, but in no other form of insanity.

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Original from

PRINCETON UNIVERSITY

Table I .—Shosuing the Analysis of the Cells in thirty cases.

1919.]

255

BV G. L. BRUNTON, M.D.

*2
• •

D

50 1

1 1

I^-

-?l

. JO JO vo JO JO VO ,

1 CO * « ** d ' CO 1

IIM

-III

- 1

Phago¬

cyte.

1 1

50 1

o\~ 1

1 1 1

1 1 1 1 1 1 1 1 1 1

Mil

II ^l

1 1

* 4 .

0 0

B. g

10 JO

ci d

1 5 ° 1 °

1 *■«

JO

~ ‘ vo

1 10 | vo to |

1 OS co *- vo 1 Cl 1 -

w Cl

IMI

II II

1 1

Plasma.

vo -

i?l

JO

~ CI ~

vo

Cl

JO JO JO JO JO 1

« ~ d co Vt- co ci ~ co 1

II II

■M 1 l

1 1

Endo¬

thelial.

»o

X

Cl

10

On

*- Cl

Ov Ov •-«
co -* ci

10 vo vo vo 10 vo vo

1/0 n in K a n n co K o « covo

- MHHCO^TtMClCOCO^

~ O ►- X
Cl ^-vo

JO

-NON
vo rf »*VO

Cx

d «

Large

lympho¬

cyte.

to 10

S"

JO

CnX

Cl

yo JO

« V* U

jo JO
d b ~

JO JO j

*t x O vo CN. Cl I Cl vo O

JO JO

vo CO ^x K 0 o\

?l

Transi¬

tional.

JO

co b

OS ^

, VO VO

1 b ci

vb j~ 1

JO JO JO _ |

Cl X Vi- Cvoo vo Os -<* d 1

1 y° ‘o

1 co ci vo vo b Os 0

Hi

*4

Small

lympho¬

cyte.

10
vo b
co VO

>C 5 ?

vo vo

O Os Cl
vo vo Cx

iO vo uovovovoto vo

COOO vo Tj- CO Cl b\ ~ CO b ■’T co Tf vo O d

CxVO N ts M CO vo CO CxVO VO CO Cx vo vo d

vo

CO Tt b Os Os

Cl co CO •- VOX

O •
X o *
22 — "O

w c-c

rj- o VO VO rt o ~
*-0*1* t^vo Tf- PI
Tf -*r « vo cs co ci

o ^ o O X
X Osvo CO ~

- __. 0 \V 5 V)H fl O

, _ _ tr-'OOO (?> 10 vo CO vo — CO Cl CO CO Ov

10 Os ttx -t ^ t\ ei n pi co - ^ ci ~ n

c^ ci ^tvo 0 _c>og p eg o^x p

n

V 2

u

^ *- "S' rb'

o « t'O rt
2 ZZ wf.o «

^ C/ 3 " 0

o

c

-t.

&

o

2

»o w •

V) ++ >< J 3

'53 •“ - C 8 5 “ M <®

•S' ..... _ ............. .*«3 _■- „ 5i W >.«’ c

2.£ i»i^ h ->-3^S

« O c D. “““ b* o g c J= •£

p, -rl f>U— M UC^ c D*:!i/)

«.S S o 3 « c S 5

1 | t

<u H 1 ju o

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in' bi 2 2 2 bi bi 2 2 2 u: h 2 2 2 2 2 2 2 2 2 2 2 2 2 bi 2 2 2 t

n n i- iovo c-~ » (to » s n + >0'0 r-.oo o\ o - ti n’t •ej'O t^oo <J\ o

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PRINCETON UNIVERSITY

256 CEREBROSPINAL FLUID IN MENTAL DISEASE, [Oct.

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Table II .—Indicating that Cells were present in the following Thirty-five
Conditions , but in such small number that Percentages were valueless.

| No.

Sex.

Diagnosis.

Fluid.

Cells
per 100

fields.

Lym¬

phocyte

Endo¬

thelial.

Plasma.

1

Poly-

morph.

3 *

F.

General paralysis

Clear

_

X

X

32

M.

>1 if

—

*

X

X

X

33

M.

11 11

II

—

*

X

X

—

34

F.

11 11

II

—

X

X

X

X

35

F.

1

11 11 11

—

X

X

X

—

36

M.

Mania, mono- „

_

X

X

—

37

F.

,, recurrent

—

X

X

—

38

M.

II II

„

10

*

X

—

—

39

M.

„ chronic

8l

X

X

—

—

40

F.

»» >1

64

X

X

—

—

4 «

F.

„ puerperal

13

X

_

—

—

42

M.

senile

Melancholia

X

X

—

—

43

F.

32

X

X

—

—

44

M.

»»

4

X

X

—

—

45

M.

II

30

X

X

—

—

46

F.

II

20

X

X

—

47

F.

II

X

X

—

48

M.

IP

l»

56

X

X

—

—

49

M.

II

3<5

X

X

—

—

50

M.

Epilepsy

120

X

X

—

5 i

F.

II

Slightly

bloody

105

X

X

X

52

F.

II

Clear

—

X

X

53

M.

li II

25

X

X

—

—

54

F.

II

Delusional insanity

II

28

x

X

—

—

55

M.

II

26

X

X

—

—

! 56

F.

11 n J 11

21

X

X

—

— •

57

F.

Dementia prrecox „

36

v

x

X

—

58

F.

II II II

74

X

X

—

59

F.

II II 1 II

—

X

X

—

—

60

F.

II II

Imbecility

.. 2

X

—

—

—

6l

F.

«4

X

X

—

62

M.

Dementia 1 ,,

6l

X

X

—

—

63

M.

1

II II

29

X

X

—

—

64

M.

II II

72

X

X

—

—

i 65

F.

II | II

1

10

X

Plasma-cells cannot, therefore, be considered pathognomonic of
general paralysis, but it may be taken that their presence in a case of
mental disease is strong evidence of a parasyphilitic lesion.

Phagocytic cells were only found in four cases, namely, three of
general paralysis, and one of paranoia (No 27). This latter case is a
querulant, impulsive patient, who so far has exhibited no signs of general
paralysis. The cerebro-spinal fluid showed no protein increase, but the
glycyl-tryptophane test was positive. A moderate lymphocytosis, the
indication of a ferment, and the presence of phagocytic cells in the fluid
of this case are at least suggestive of some irritative cause.

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Original from

PRINCETON UNIVERSITY

19 19-] by g. l. brunton, m.d. 257

Lattice cells: Cotton and Ayer describe, under the name of
“ Komchen,” a type of phagocyte cell filled with numerous fat-droplets
or fatty pigment, which they only found in ventricular fluids. Hender¬
son and Muirhead consider these cells to be an early stage of the lattice,
and I am inclined to agree with their suggestion.

All endothelial cells, which appear to have a granular or vacuolated
protoplasm are included under the one class—lattice.

As before mentioned, these cells were found in a number of con¬
ditions, and I cannot substantiate the view taken by Henderson and
Muirhead, who considered that the absence of lattice cells in their cases
of tabes dorsalis might be a point of value in the differential diagnosis
between general paralysis and tabes.

Conclusions.

Examination of the cerebro-spinal fluid is of great importance and a
valuable aid in the diagnosis of mental disease.

Alzheimer’s method is the best for the cytological examination of
the cerebro-spinal fluid : cells can be differentiated in a way never
hitherto possible, and a fair quantitative count can be made.

The cells of the greatest diagnostic importance are the plasma-cell,
the phagocytic and endothelial cell, and the lymphocyte in excess.

A high cell-count with an excess of lymphocytes together with the
presence of plasma-cells is strong evidence of parasyphilitic lesion.

Rest in bed after lumbar puncture is desirable to avert the after¬
effects.

References.

(1) Alzheimer.— Centrakblatt f. Nervenlieill. u. Psych ., June 15th,
1907.

(2) Cotton and Ayer.—“The Cytological Study of the Cerebro-spinal
fluid by Alzheimer’s Method, and its Diagnostic Value in Psychiatry,”
Rev. of Neur. and Psych., vol. vi, 1907.

(3) Henderson and Muirhead.—“ The Differentiation of Cells in the
Cerebro-spinal Fluid by Alzheimer’s Method,” Rev. of Neur. and
Psych., vol. xi, April, 1913.

(4) Walldeyer and Unna.—“ On the Plasma Cell.” See Councilman,
Journ. of Exper. Med., vol. i, 1897.

(5) VVickman.— Die Akute Poliomyelitis, Berlin, 1911, Springer.

(6) McIntosh and Turnbull.—“ Transmission to Monkeys of a Virus
obtained from English Cases of Poliomyelitis,” Lancet , February 22nd,
*9i3-

(7) Rehm.— Munch, med. IVoch., August 4th, 1908, p. 1636.

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Clinical Notes and Cases.

Notes on a Case Treated by Hypnotic Suggestion .( 1 ) By
G. Rutherford Jeffrey, M.D., F.R.C.P.E., F.R.S.E.

Mr. President and Gentlemen, —You will, I know, agree with me
that there is no doctor who has not frequently been at a loss to know
what treatment to adopt in a case which, although apparently simple
and straightforward, continued to show no signs of improvement, and
when we are dealing with mental cases this is, I think, especially notice¬
able. But, after all, we must admit that the means at our disposal for the
treatment of mental diseases are very inadequate—differing widely from
many medical and surgical conditions in which the only and proper
treatment is invariably followed by recovery. In most mental diseases I
am afraid we must acknowledge that there is still no specific treatment
guaranteed to cure any given case : recoveries frequently occur when
least we expect them, cases which we deem recoverable frequently
disappoint us.

I feel justified, therefore, in bringing the following case to your
notice as illustrating a method of treatment which, at least, should not
be lost sight of in dealing with cases which are presumably, shall I say,
hopelessly mental, and in connection with this case I am raising the
question of treatment by hypnosis and suggestion.

This form of treatment is at present giving rise to much discussion.
We all know, I think, how much suggestion, with or without hypnosis,
has been used during the recent war, when dealing with cases of shell¬
shock, neurasthenia, hysteria, and cases showing a variety of symptoms
common to each of these conditions. Hypnosis has been used in order
to produce sleep; I have seen it used, and have used it myself with
excellent results. Along with suggestion it has been used to cure
many conditions, and by making the patient, as it were, live through
his experience again, and thereby reinstating the emotion of fear,
mutism, amnesias, stammering, tremors and hysterical contractures
have been successfully cured.

Quite recently, in the British Medical Journal (’), there appeared a
short and interesting article on “Hypnosis, Suggestion, and Dissocia¬
tion,” by Dr. William Brown, and with that writer we will, I think,
agree when he says that the one satisfactory method of treating the
various forms of functional nervous disorders is that of mental analysis and
re-education, and he suggests the term “autognosis” or self-knowledge,
which embraces the two conceptions of analysis and re-education, and
is better than the term “psycho-analysis.” Dr. Brown goes on to point

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out that suggestion with hypnosis is undesirable for the reason that it
treats the symptoms and not the cause, and that the patient is passive
and abnormally suggestible.

I think it is difficult, however, to draw a sharp distinguishing line
between the cause and the symptoms. By mental analysis we may get at
the root of the illness, and perhaps find out the cause of the symptoms,
and then by re-education the symptoms may be, as it were, made to
disappear.

Whilst this is true, it is equally true that if persistent and distressing
symptoms can be made to disappear the normal cerebral mechanism
has a chance of re-establishing itself, and the person, cured from his
illness, may then return to what was his normal. What I mean to
suggest is that it is not always , in my opinion, necessary before a recovery
can be obtained to probe into the hidden depths of a person’s life and
try to find a “ flaw,” or attempt to correlate some circumstance in a
person’s past life-history with present symptoms. There are some who
are not contented until they find, or imagine they have found, some
circumstance in connection with a person’s sexual life, but with these
observers I cannot agree. I willingly admit that the sexual influence
as part of one’s life—for, after all, it is an instinct, mysterious, of great
importance, but often latent—is of considerable importance, but I fail
to see why what is a perfectly normal part of one’s, so to speak,
“ make up,” should be blamed, as it so often is, for producing all kinds
of mental states and symptoms.

When we have to deal with an apparently chronic mental case, or at
least with one which has for many months shown marked mental
symptoms, such a method as treatment by hypnosis with suggestion
would, at first sight, appear to offer no hopeful chance of recovery.
The following case, however, shows that even a long-standing case
can be successfully dealt with, and the result obtained even from this
one case certainly justifies the opinion that treatment by this method is
always worth consideration.

The case which I bring to your notice is that of a young lady, set. 20,
who came as a voluntary boarder to Bootham Park Hospital. Her
hereditary history is unimportant. Up to the commencement of her
illness she was in every way normal mentally, although she was of a
keen, sensitive, artistic, and highly-strung nature.

About eighteen months before the onset of her illnesss she was treated
for a severe attack of anaemia, and, although she made a good
recovery, she was left in a rather reduced state of health.

As in the case of most people, the war had made a marked impression
upon her, not only on account of her fiance’s unknown fate—for he was
a prisoner of war—but also on account of the terrible sufferings to
which our men were exposed, and, as her mother said, the appalling

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bloodshed seemed to “get on her nerves.” In addition to this she
seems to have thought a great deal about the war from a religious point
of view, and, like many other people, tried to find out from Biblical
comparisons and references if it in any way portrayed the approaching
end of the world.

These thoughts caused her to become dull and rather depressed—
perhaps quite a natural depression for a person who was so much
affected and so much impressed by all the truly terrible circumstances
which the war entailed. Suddenly all her symptoms became more
pronounced, and, from what I think was an almost natural depression,
she passed into a state of profound apathy, with some confusion, intense
miser)’, and at times marked emotionalism, a condition which remained
more or less unchanged up to the time of her admission to Bootham
Park on April 16th, 1919. Careful investigation of the history in
connection with the onset of this marked change for the worse in her
condition revealed the fact that it immediately followed on a dream,
which was as follows : She dreamt that the sun and moon came into
collision, and that, as a result, there was poured out over the whole
world a deluge of blood, in which she, along with others, was to be
submerged. She awakened in the morning in a state of fear, and felt
convinced that she was on the brink of some great catastrophe. She
became confused and dazed, depressed and emotional, and, after
remaining more or less in this state for a few months, she, of her own
accord, sought admission to Bootham Park.

On admission her expression and general demeanour denoted great
misery. She looked dazed and terrified, readily admitted that she felt
very ill, but on many points her conversation was quite rational. She
became very emotional and pleaded with me to make her better,
saying that she felt as if she was living in a mist and that she fell
detached from everything. Her misery found its outlet in copious
weeping, and I was at once struck by the complete absence of any
of the usual ideas which are so commonly associated with the true
melancholic state—I mean the self-accusations and the melancholic
delusions. I felt very strongly—and at that time I had not obtained
the true history—that there was something to account for her condition,
and, further, even then she appeared to me to be as if in a “ dream-
state.” Her physical condition showed nothing abnormal, but she was
much reduced in health and her cardiac action was somewhat feeble.
On the evening of the day of her admission I visited her, and endeavoured
to get into conversation with her and explain her symptoms. She did
not readily converse with me and did not appear to understand all that
I was trying to impress upon her. I decided, therefore, to use hypnosis
as an aid to suggestion, and in the usual way I put her into a condition
of very light sleep. At first, when I was impressing upon her to try

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CLINICAL NOTES AND CASES.

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Notes on Two Cases of Epilepsy in Twins, with Photographs,
By R. M. Toledo, M.D., Resident Physician Government Lunatic
Asylum, Malta.

Special features of interest in two cases of epilepsy in twin sisters
under care in this asylum induced me to publish these short notes,
although the cases do not exhibit anything particular from the clinical
side.

Salvina O— (left photo) and Lorenza O— (right photo) were born
eighteen years ago. Their father’s grandmother and uncle both died
in this asylum, the former from senile dementia, the latter from tumour
of the brain. No history of alcohol or syphilis in the family.

Both Salvina and Lorenza had their first attacks when eight years old,
within a few weeks of each other. The fits were never accompanied by
mental disturbance, and the children could be safely kept at home till
their first attack of delirium, which occurred about a year ago. They
both attended school with very little success.

Salvina was admitted to this asylum on August 30th, 1918, in a very
excited condition. She was completely disorientated, restless and
exhibiting aggressiveness. The relatives reported that it was the first
time that the girl could not be managed at home.

Lorenza followed her sister to the asylum after a couple of months
with the same symptomatology, and, as in the case of Salvina, it was the
first epileptic delirium exhibited by the patient. Both sisters had their
first menses at the age of thirteen, and these ceased on the supervening
of the delirium. The amenorrhoea still persists in both cases.

A point of interest is the fact that always, or nearly so, the appearance
of the delirium in Salvina is followed by that of Lorenza, necessitating
the warding of both sisters with the dangerous patients. The delirium
is always of short duration, and marked more by restlessness than by
aggressiveness.

Quite lately while Salvina was under a very severe attack of delirium
Lorenza was in the infirmary in a regular status epilepticus from which
she slowly recovered.

Both sisters are feeble-minded, and when free from delirium they are
useful helpers in their ward. While Lorenza is always morose and
gloomy, Salvina is cheerful, laughs, is coquettish in her manners, adorns
herself with bright-coloured ribbons, and she is particularly fond of
squeezing and kissing the assistant physician’s hand on his rounds.
This mood of hers helps us to distinguish at once Salvina from her
sister, as their features and their figures are almost identical, save
perhaps that Lorenza’s nose is very slightly flatter than that of her
sister. Both sisters weigh 8 st. and their height is 5 ft.

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Occasional Notes.

The Late Dr. Charles Arthur Mercier.

A fine personality and untiring intellect has gone to rest in the death
of Dr. Charles Arthur Mercier, who was gathered in on September 2nd,
I 9 I 9*

He occupied an unique position in medicine and philosophy. He had
a mentality of absorbing interest, and one about which, no doubt, there
will be many divers views, but all who knew him will agree that his
demise has created a vacancy in the intellectual world which can never
be filled. There can be no second Mercier, and his loss will be keenly
felt in more directions than one.

He was well known to us on the Editorial Staff of this Journal, to
which he contributed freely, and it is fitting that our pages should
contain an authoritative memoir of him. Sir Bryan Donkin has kindly
undertaken this for our next number.

We shall be glad also to publish any recollections of him which Dr.
Mercier’s many friends and acquaintances may think fit to send us.

In the meantime, we republish in “Notes and News” the Times
summary of his life and works.

Part II.—Reviews.

Sixty-seventh Annual Report of the Inspectors of Lunatics {Ireland) for
the year ending December 31 st, 1917.

The statistics of lunacy for the year 1917 show a very material
diminution in the number of insane under care in Ireland. This is the
third year in succession in which a reduction has been recorded, and
not only this, but a progressively advancing reduction, the decreases
for the three years 1915, 1916 and 1917 having been respectively 77,
337 and 874. Although caution in forming conclusions on merely
statistical grounds has been frequently urged in these columns, it
cannot be denied that the figures for the past several years have clearly
shown, first, a tendency to fall, as indicated by a reduction in the rate
of increase from what it was in previous years, and now for the past
three years there has been an absolute and progressive decrease in
numbers to the extent above stated, so that each successive year seems
to bring us a more certain assurance that insanity in Ireland has passed
its zenith and is on the downward grade. The proportion of insane
under care per 100,000 of estimated population for the years 1915,
1916 and 1917 has been 579, 571 and 551 respectively—a reduction
during the two years 1915-1917 of all but 5 per cent. The admissions
have also fallen from 3,538 to 3,444 in 1917,—a drop of 94—the number

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admitted into District Asylums having decreased by 133, while they
increased by 39 in the case of Private Asylums. First admissions into
District Asylums decreased by 143, while re-admissions increased by 10.
The proportion of total admissions per 100,000 estimated population
decreased from 75 to 72 and in the case of first admissions from 60
to 57. It is a matter for regret that tables which have hitherto appeared
giving statistics for a series of years as regards admissions, discharges,
and deaths are omitted from the Inspectors’ report—let us hope only
temporarily—and now that war conditions no longer exist that publica¬
tion of these tables will be resumed in future reports.

The Inspectors attribute the reduction in the number of insane
mainly to the unusually high death-rate—io'5 per cent, on the average
number resident, as compared with 81 in 1916, which was also the
rate for the whole quinquennium 1913-1917. This rise in the death-
rate is regarded as due principally to two causes—(1) long-continued
cold and inclement weather at the end of 1916 and during the spring
of 1917, accompanied by an outbreak of influenza; and (2) the adverse
effect of the war on food, chiefly bread, the unpalatability of which,
combined with the total or partial deprivation at times of tea, sugar,
milk, eggs, butter, etc., gave rise to digestive ailments, and thereby
reduced the vitality of already enfeebled patients. These conclusions
are based upon the opinions of the medical superintendents, and are,
no doubt, true to some extent, but patients in Irish asylums suffered
but little in comparison with those in the sister countries. The death-
rate has been increasing in recent years, and it is probable that this
is due in great measure to the fact that each year the proportion of
patients who have reached the average duration of life is increasing—
and will, no doubt, continue to increase—so that a higher death-rate
is to be regarded not so much as a matter of surprise as a not un¬
expected contingency. The ratio of deaths from phthisis continues to
decline, the proportion having fallen from a maximum (1895-1899) of
29 2 per cent, of the total mortality to 20*3, the ratio for 1917. The
relative mortality from general paralysis has also fallen, its maximum
having been 44. per cent, during the quinquennium 1910-1914, while
it was only 27 in 1917. The ratio of deaths from epilepsy, on the
other hand, appears to be on the increase. The average mortality due
to this disease for twenty-five years ending 1914 was 4'8 per cent, of the
total; in 1917 it was 6 per cent. As usual the death-rate in individual
asylums shows great differences, ranging from a minimum of 6'i in
Ennis asylum to a maximum of i5‘4 in Belfast. Only 156 post-mortem
examinations were made—a fraction over 7 per cent, of the number of
deaths.

The recovery-rate shows similar variations, the highest record being
56 3 in Clonmel and the lowest, 23’i, in Waterford. This is omitting
Sligo, with respect to which we are convinced there must be some
error in the figures, the percentage of recoveries on admissions being
given (Table VI) as 6'4 and that of recoveries on daily average as 88
—an obvious impossibility, as the former ratio should be from at least
three to seven times as large as the latter. The general recovery-rate
for all District Asylums was 377, or 4 per cent, lower than that of the
previous quinquennium.

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As to causation heredity was an element, either principal or accessory,
in i 6‘87 of the admissions, and alcohol was a factor in 9*41 per cent.,
but in only 6’38 per cent, was it a principal cause—a ratio which was
well under the pre-war rate. The restrictions on the use of stimulants
which were found necessary under war conditions seem undoubtedly
to have had a beneficial effect as regards at least one of the results of
over-indulgence. Mental stress operated as a cause in 20 per cent.
of the admissions, which was somewhat over the proportion in the
previous year. But in only i'i6 per cent, was the war assigned as a
cause, and a principal cause in only 0 64 per cent .—an amount so small
as to be practically negligible, although the ratio is somewhat higher
than in either of the two preceding years, when it was 0 32 and 048
respectively. The number of soldiers and sailors admitted in whose
cases the war was assigned as a factor in causation was 150, only 68
of whom had seen active service. So far, therefore, the war cannot be
said to have had more than a very trifling effect in causing insanity,
having regard to the comparatively few cases of military or naval men
who were sent to asylums. But it must not be forgotten that mental
cases occurring in members of both services were treated in other
institutions, where probably most of them were of temporary duration
and ultimately recovered. Of such cases we have no available statistics.

As regards expenditure, in the case of District Asylums this has
increased considerably. The total cost was in round numbers ,£780,736,
or well over three-quarters of a million. In 1900-1901 it was ^460,282,
or less than half a million, the actual increase during the inter¬
vening period having been 59 per cent., while the increase in the daily
average has been only 31 per cent. It is to be feared that this
expenditure has by no means reached its limit, as during the last two
years in practically every department of asylum service the cost of
everything, and notably as regards the wages of attendants, has gone
up by leaps and bounds, and there is, we fear, but little likelihood of
any reduction in cost for some considerable time to come, if, indeed,
it will ever come. The unrest which has been for a long time seething
amongst the staff's of asylums, as in the case of other branches of
labour, owing to dissatisfaction with the existing regulations in respect
of wages and hours of work, has during the past year culminated in
general strikes in not a few of these institutions, and committees have
had to make liberal concessions in both directions. It was quite right
that the pay of attendants should be largely increased under present
conditions, but, as a matter of fact, even in pre-war times adequate
remuneration was never given to asylum attendants, having regard to
their important and responsible duties. But there is nothing to justify
their making exorbitant demands such as have been made at the
instigation of outside “ organisers,” and which there is good reason to
believe have not received the approval of a large number of the more
moderate and sober-minded members of the staff's, who realise that
they occupy a position wholly different from, and superior to, that of
the ordinary trade-union factory hand, and feel that extreme measures,
while possibly securing to them advantages at the expense of a long-
suffering public, are lowering to their self-respect and the dignity of
their calling, and by simply appealing to purely selfish instincts can

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only have a deteriorating effect on their character. It is to be hoped
that with time saner counsels will prevail, and that a mutual feeling of
conciliation, leavened with an unselfish desire to give of their best for
the good of the community and the welfare of their patients, will be
the animating principle of their lives and work.

The Inspectors report favourably on the condition of private asylums
generally. That of patients in workhouses does not seem to be
altogether satisfactory, especially as regards facilities for bathing and
sanitary accommodation, which in many instances are far below the
standard which we have reason to expect in these enlightened days.
The query suggests itself: Is there proper and adequate supervision in
these institutions by the management, both lay and medical? And if
not, why not ?

Mental Diseases. By R. H. Cole, M.D., F.R.C.P. Second edition -
London : University of London Press, Ltd.

The publication of the second edition of A Text-book of Psychiatry
for Medical Students and Practitioners is an indication of the deserved
popularity of this work. This edition, which is well illustrated, has been
carefully revised and brought thoroughly up-to-date.

Four chapters are devoted to psychology and neurology, a knowledge
of which, as the author contends, is essential to the understanding and
treatment of psychiatry. These subjects are dealt with in such a manner
that the student should have little difficulty in understanding them.

Dr. Cole’s classification of mental diseases is a useful one, and is to
be commended.

Special reference is made to the psychoneuroses arising from the
war, to treatment by psycho-analysis and other methods, and to the
necessity for amendment of the existing legislation to meet the present
defects.

This book, in short, will be found most useful to those for whom it is
intended.

Studies in Forensic Psychiatry. By Bernard Glueck, M.D. London :

William Heinemann, fol. 266.

This volume is one of a series of monograph supplements to the
Journal of Criminal Law and Critninology. It is of interest to the
lawyer as well as to the psychiatrist, and it should do much to make
clear to the layman the modern view-point of the psycho-pathologist in
regard to one aspect of criminology. The whole subject of crime and
punishment is extremely complex and difficult, but the sentence which
the author quotes from Franz Joseph Gall as long ago as 1810 aptly
sums up the attitude of the criminologist of to-day : “The measure of
culpability and the measure of punishment cannot be determined by a
study of the illegal act, but only by a study of the individual committing
it.” Perhaps the truth of this is only now beginning to be realised, and,
as Dr. Glueck says, “The suppression of crime is not primarily a legal
question, but is rather a problem for the physician, sociologist, and
economist. . . . The slogan of the modern criminologist is “ intensive

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study of the individual delinquent from all angles and points of view ”
rather than mere insistence upon the precise application of a definite
kind of punishment to a definite crime as outlined by statute. Indeed
the whole idea of punishment is giving way to the idea of correction
and reformation. . . . For criminology is an integral part of psycho¬

pathology, crime is a type of abnormal conduct which expresses a failure
of proper adjustment at the psychological level."

The first chapters are devoted to the consideration of what are
commonly known as the “ prison psychoses.” These cases belong, of
course, to the wider group of what are known as the “ psychogenetic ”
or “situation psychoses,” so-called since they are immediately caused by
a painful situation in the environment. The study of these cases has
been curiousiy neglected in this country, though much attention has been
given to them in Germany, and in America the name of Dr. Glueck is
especially associated with careful studies of cases belonging to this
category. Perhaps if it had been more generally recognised that many
cases presenting a dementia praecox-like clinical picture are liable to
occur with severe environmental stress, and to rapidly clear up when the
stress is removed, less mistakes in diagnosis would have been made in
connection with the war psychoses. Many civil psychoses, which clear
up rapidly when removed trom their usual environment to a mental
hospital, probably belong to the group of the psychogenetic psychoses,
and the interest of the subject is by no means limited to those cases
which occur in prisoners awaiting trial or undergoing punishment. The
discussion of this subject in this volume, together with an excellent
description of a number of cases, will be found well worth the attention
of all those interested in the study of mental disorder, both from the
purely clinical standpoint as well as that of criminology.

A chapter is devoted to the study of “litigious paranoia,” and a full
and complete consideration is given to the question of the malingerer,
both these subjects being illustrated by descriptions of concrete cases.
These subjects contain material of much interest to the psychiatrist, and
the psychological problems which they involve are discussed from a
modern view-point which will be found helpful and illuminating. The
last chapter contains a psycho-analytic study of a case of kleptomania
which serves to suggest the value of an intensive individual approach in
attempting to understand morbid mental phenomena.

This book may be thoroughly recommended and will well repay
careful study, not only from the point of view of criminology, but from
its wider implications. It serves to illustrate that insanity is not only a
matter of classification, but it is a type of abnormal reaction to life, the
significance of which can only be understood by a study of the psycho¬
genetic factors which play a part in its production. H. Devine.

Rational Sex Ethics. By W. F. Robie, M.D. Boston : Badger. London:

Stanley Phillips, 45, Brondesbury Road. Pp. 356. Price 15J.
Sane Sex Life and Sane Sex Living. By H. W. Long, M.D. Same
publishers. Pp. 157. Price 2 55.

These two volumes are examples—more favourable examples, it
may be added, than might easily be chosen—of the most modern
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medical attitude in America towards those sex problems which now
seem to be attracting so much attention, medical and lay. They are
written from a fairly concordant standpoint, and the author of the first
has furnished an introduction for the second volume, but the scope of
the two works is entirely different, although both are sold only to
professional readers.

Dr. Robie, who is superintendent of a sanatorium for functional
nervous disorders, begins with a little autobiography, not, as he
remarks, for “ the purpose of emphasising my own modest ego,” but in
order that the reader may be enabled to appreciate that bias and
“personal equation” which, in approaching questions of sex, must
always be important. The practice, though unusual, seems commend¬
able, and in any case it is characteristic of the author’s American
directness and simplicity. The book is not a systematic treatise of
sexual morality. It is much better described in the subtitle as “A
physiological and psychological study of the sex-lives of normal men
and women, with suggestions for a rational sex hygiene with reference to
actual case-histories.” The chief value of the book lies in these
histories—many of them quoted or reproduced—of 95 more or
less normal persons (61 men and 34 women), while the author
also possesses the sexual histories of some 150 additional persons,
the majority females. Special attention seems to have been given
to masturbation. All but a very small percentage admitted practising
or having practised masturbation, or some form of conscious auto¬
erotism, the women nearly as often as the men, although they indulged
in it much less frequently—usually from two to five times a month, about
the period of menstruation. This was regarded by many of the women
as perfectly normal; they usually abandoned the practice at marriage
but seldom before. In accordance with the results found by other
recent investigators, Robie finds also that of 500 young people known
to him to have masturbated for longer or shorter periods (and many
excessively), “ none were ever known to have suffered in any way from
the results of this habit.” To this question the author refers again
and again throughout the book. He does not, he tells us, advocate
masturbation, and he is aware of its harmfulness in morbidly
predisposed subjects, but “ I am prepared,” he tells us, “ to maintain
that while, act for act, auto-erotism is as harmless as-ordinary promiscuous
intercourse—more harmless if account is taken of the venereal danger—
there is far greater relief of sexual tension, a more complete orgasm,
and infinitely less shame, disgust, and self-condemnation in this practice,
provided one knows the actual facts about it.”

Taken altogether, however, the author’s ethical attitude is unquestion¬
ably orthodox and conventional. He has much sensible advice to give
on the hygiene of marriage; he rightly insists, as it is now becoming
usual to do, on the importance of a knowledge of the art of love to
ensure conjugal felicity. He discusses intercourse during pregnancy
and approves of it. Although he regards the exercise of birth control
as necessary at some time or other for all, he approves of every healthy
married couple having from two to twelve children.

While the book is helpfully instructive and written in an engagingly
ingenuous manner, its method is not altogether scientifically satisfactory.

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The style is careless; the names, even of well-known fellow-countrymen
of the author himself, are frequently misspelt ; the arrangement of
chapters is unsystematic and casual. A considerable amount of space
is occupied in summarising the opinions of other authors whose books
are fairly well known and accessible. Freud is in this way responsible
for a considerable amount of space, but the author shows his usual
moderation and practical common-sense in his judgments of psycho¬
analytic doctrines. He himself has adopted something of the methods
of mental analysis, but he is convinced, from his own extensive obser¬
vations, that while there is much more sexuality in the child than the
older writers admitted, the early years of life are not so universally
sexual as Freud believes, and thumb-sucking or similar manifestations,
while almost general, cannot be regarded as always a sexual manifesta¬
tion. Nor, though the love of the child for the parent has at times an
undoubtedly sexual character, can the “ CEdipus complex ” be regarded
as universal, for he has witnessed the recovery of neurotics in whom it
was never revealed, and on Freudian principles such recovery would be
impossible. He also disagrees absolutely with Freud that the fruitful
investigation of sex matters in women by ordinary methods is impos¬
sible on account of their reticence and dishonesty, and finds on the
contrary that when a woman is convinced of its desirability it proves
more fruitful than in men. The author’s temperate conclusions on
these points will be approved by all but the more extreme of Freud’s
disciples.

Ur. Long’s book is misleadingly described by the publisher on the
wrapper as “a thoroughly scientific treatment of a subject which has
heretofore been treated in a merely empirical manner.” The author
himself in his first paragraph more truly describes it as “more a heart-
to-heart talk between those who have mutual confidences in each other
than a technical or strictly scientific treatise.” Although only sold to the
professional reader it is for the lay reader that it is intended, and it is
written throughout in simple language. Like many other doctors
nowadays, Dr. Long is frequently consulted by young husbands or
wives who are suffering from ignorance or misapprehension concerning
the conjugal relation, their difficulties often being complicated and
obscured by reticence and timidity. As he was unable to find any
manual which dealt simply, and in all the detail necessary for those
who are ignorant, with the necessary facts of the art of love and the
science of procreation, he wrote a manuscript covering the chief
ground, and has been in the habit of handing it over in these cases to
be read privately. Being impressed by the advantage of this method
for the patient, as well as the saving of time for the physician, he has
le-written and enlarged this manuscript. The result is the present
volume, “prepared for the sole and express purpose of helping
husbands and wives to live sane and wholesome sex-lives—to give them
the requisite knowledge for so doing ; knowledge of themselves and of
each other as sexual beings ; the correct ideas regarding such manner
of living ; to disabuse their minds of wrong sex-teaching, or no teaching at
all, of ignorance, or prudery, or carelessness, or lust.” Nothing is said
of perversions or anomalies, or even of venereal disease, but everything
bearing on the ordinary love-life in marriage is clearly set forth and

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fully discussed. The advice given is not at every point in accordance
with traditional maxims, but it is in accordance with modern scientific
knowledge, and usually shows practical sagacity as well. Dr. Long is
to be commended for the courage,skill,and sympathy which he has shown
in writing a hook, almost unique in character, which will certainly prove
of immense help to many readers.

Havelock Ellis.

Experiments in Psychical Research. By John Edgar Coover, Assis¬
tant Professor of Psychology, Leland Stanford Junior University.
Stanford University California, 1917. Pp. 641. Price 4 dollars.

This substantial and important series of studies requires some time
to master—all the more since it is furnished with no summary of con¬
clusions—and review notice has thus been unduly delayed. It is supplied
with a foreword by Chancellor David Starr Jordan, an introduction by
Prof. Frank Angell, and the author is a highly trained and experi¬
enced psychologist of judicial temperament. So impressive a piece of
work, proceeding from the “Division of Psychical Research ” of a noted
University, deserves serious consideration. Respectability, though by
no means universal belief, has been conferred upon the conclusions put
forward by the Society for Psychical Research by the distinguished
reputations of some of those who have endorsed those conclusions.
But, as Prof. Angell here remarks, “ it must be said with the utmost
frankness that the mantle of Sir Oliver Lodge’s great reputation as a
physicist cannot be stretched to cover his work in psychical research,
and it is doubtful if Sir William Crooke’s authority as a chemist has per¬
ceptibly swayed the minds of his colleagues in chemistry towards
spiritualistic belief.” It is special training in psychology which is
necessary for such investigations, a wide acquaintance with motor
automatisms and subliminal impressions, a training in the ideational
and affective processes underlying belief and conviction, in illusions of
perception, and in the value of evidence. The value of the present
series of investigations lies largely in the fact that it has been conducted
by trained psychologists.

The work falls into five parts (amply illustrated by diagrams, charts,
and plates), dealing successively with thought-transference, subliminal
impression, mental habit and inductive probability, sound-assimilation,
and miscellaneous contributions (pseudo-prophecy, local ghosts, auto¬
matic writing, etc.) by Prof. Lillian Martin. There are numerous
appendices, and a list of books dealing with the subject in the University
library which constitutes a formidable bibliography of over sixty
pages.

„ The problem of thought transference, a mental power by many
regarded as proved, is approached by a variety of methods. There is,
for instance, the guessing of lotto-block numbers, which in the
experiments conducted by Mrs. Henry Sidgwick furnished support for
thought-transference. The conditions of the experimentation at Stanford
University and the attitude and training of the reagent seemed to
promise a like favourable result, but this result was far from ensuing :
a thousand experiments indicated that the number of successful guesses

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is not beyond either experimental or theoretical probability. The
investigators agree with Prof. James that Richet’s belief that
thought-transference is a common capacity to be found in any long
series of guesses “is probably wrong.” It was incidentally established
that normal persons refer subjective experiences with a varying degree
of certainty to an objective source. This tendency, as is here pointed
out, indicates that the psychical processes of illusion and hallucination
are, in an incipient form, both common and normal. Investigations
with playing cards, carried out with both normal and “ sensitive ”
reagents, and elaborately described in nearly one hundred pages, led
to similar conclusions ; although some of the deviations, by consistency
and size, seemed to be beyond chance, they were yet matched by chance
deviations, and the psychics showed no advantage over normal reagents.
The “ feeling of being stared at ” was also investigated. It involves a
telepathic process—that is, the becoming aware in a super-normal way of
a specific voluntary action of another person. It is widely accepted ; at
Stanford University 77 per cent, among nearly 1,300 young men and
women from all corners of the earth affirmed that they had experienced
it. Experiment showed, however, no results that could not be perfectly
well explained by chance ; an objective validity is attributed to sub¬
jective impressions in the form of imagery, sensations, and impulses. This
seems a common trait in normal adults, but in its final manifestations it
becomes hallucinations and motor automatisms.

The most frequent explanation brought forward of the alleged
phenomena of thought transference is that of subliminal perception of
signs and signals involuntarily given. It is supposed that the reagent
unconsciously receives impressions of the signs involuntarily given by
the agent. This explanation is, for instance, invoked to explain the
marvellous accomplishments of the horse “ Clever Hans,” though, it
must be remarked, it can only explain correct answers that are known
to the agent, and the Mannheim dog, for example, could, it was alleged,
give correct answers (as of the number of violets in a bunch) that the
agent was unable to count.

Part II, which deals with investigations into this “subliminal
impression ”—by means of the tachistoscope and other methods—
is too varied and elaborate to be summarised, but the general
conclusion may be stated : there is some experimental evidence
of the existence of that “ fringe of perceptions, most often unconscious,
but all ready to enter into consciousness, and in fact entering in
certain exceptional cases or certain predisposed subjects ” with which
Bergson has insisted that “psychical research” should concern itself;
it is, moreover, more than probable that this sort of perception has
played a part in the evidence for telepathy gained from experiments and
the s/ance-room, and further investigation may determine the extent of
the influence of subliminal impression upon judgment in (a) normal
subjects when the stimuli are not removed so far from the lines of
normal perception, and when the stimuli are varied over the sense
modes, and ( b) in “sensitive” or “psychic” subjects.

In Part III inductive probability and the influence of mental habit
upon judgment are most instructively studied by statistical methods.
The influence of mental peculiarities in the general population is shown

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by the age-returns in the census, in the terms of criminal sentences
imposed by judges, in the registration of temperature, rainfall, star-
transits, and in various other ways, and the bearing of these inquiries on
the attempts to prove thought-transference is duly set forth. The infini¬
tesimal probability is also set forth, the fallibility of human testimony
and the operation of normal extra-chance causes.

In Part IV it is shown that sound-assimilation is very potently
influenced by suggestion. The perception of a word is not, as is
commonly supposed, a purely auditory affair. The auditory impression
may be slight and inadequate, but become assimilated by more powerful
psychic factors (images, motor dispositions, etc.), which assume primary
responsibility for the cognition of the word. This assimilating process
leads to illusions. All the other senses are similarly capable of reporting
facts that are not there.

There is to-day a wide-spread revival of interest in phenomena of
thesupra-normal (as we have usually understood “normal”) order. Hence
the value of a series of studies so expert, so many-sided, and so impartial
as we find in this volume. It furnishes a valuable armoury for those
who have committed themselves in opposition to such tendencies, and
it demands the most strenuous attention of those who accept them.

Havelock Ellis.

Spirit Experiences. By Charles A. Mercier, M.D. London: Watts
& Co.

“ A little nonsense now and then
Is relished by the wisest men.”

This booklet has been sent to us for review. To review it seriously
would be difficult, if not impossible. Professedly, if we may judge by
the rather sensational amplification of the title as “ The Conversion of
a Sceptic! Startling and Astonishing Experiences of a Seeker after
Truth—Unprecedented Marvels—Telepathy—Levitation—Communi¬
cations with the Dead—Telergy—A Completely Novel Experience—
Substitution,” the writer offers it to the public as a sort of recantation
of his published views on the subject of spiritualism. Whether it is, or
is not, must be left to the individual reader to decide for himself. In
reality it is a humorous skit on spiritualistic phenomena, its style and
motif akin to that of a previous paper on “ Dreams,” which was read by
Dr. Mercier at a meeting of the Association some years ago. The
astounding occurrences which have made a convert of Dr. Mercier—
and from what we know of that eminent psychologist, it is safe to
assert that any agency capable of converting him from any view he may
have adopted regarding any question whatever must be nothing less
than astounding—are detailed in a manner, if droll, at any rate circum¬
stantial, and can hardly fail to convince even the most hardened and
uncompromising opponent of spiritualism of the error of his ways,
and bring about his “conversion ” to the true faith. The interviews
with Hodgkins, who when in the flesh had been “a bit of a rip,” and
who spoke from a region where asbestos clothes were worn—“nothing
else would stand the heat ”—and where the daily fare was “ roast

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EPITOME OF CURRENT LITERATURE.

273

salamander, always cooked to death,” and with Mrs. Shegessdit—a
name full of significance—are diverting reading. And the real meaning
of such performances as the three-card trick (no longer a mere “ trick ”)
and thimble-rigging (nothing to do with sleight-of hand), as explained
on occult and spiritualistic principles, form a suitable climax in this
amusing—and amazing—brochure.

Part III.—Epitome of Current Literature.

War Neuroses and Military Training. (Afental Hygiene , October ,
1918). Rivers , IV. H R.

In this report to the Medical Research Committee Dr. Rivers con¬
cisely sets forth some of the results of his experience. War neuroses,
he finds, fall into three main groups: (1) Hysteria, though the term is
admitted to be unsatisfactory; there is some definite physical symptom
(paralysis, deafness, mutism, etc.), such as can be readily produced
by suggestion in hypnosis. (2) Anxiety neurosis, but usually termed
neurasthenia; there is physical fatigue and organic slackness with, on the
mental side, irritability or depression. (3) Definite psychic manifestations;
there are many varieties—including a manic-depressive tendency,
morbid impulses such as to murder or suicide, obsessions, phobias—
but the special feature is always a resemblance to the definite psychoses,
but yet without the severity or fixity which renders any legal restriction
on the patient necessary.

There seems nothing specially original in the grouping. Dr.
Rivers proceeds, however, to bring forward some interesting considera¬
tions with regard to the varying incidence of these groups of disorders
respectively on officers and on men. There is no reason to suppose that the
third group are specially liable to affect either offi cers or men. But of the
other two groups hysteria is almost exclusively confined to the men,
while anxiety neurosis, though not similarly limited to officers, affects
them much more frequently and much more profoundly. This difference,
Dr. Rivers seeks to show, is largely explainable by the varying con¬
ditions of training and duties in the two classes. “ The neuroses of
war depend upon a conflict between the instinct of self preservation and
certain social standards of thought and conduct, according to which fear
and its expression are regarded as reprehensible.” In cases of the first
group the conflict is solved by some disability which incapacitates the
patient from further participation in warfare. In the second group the
conflict is not solved, but rendered more acute by weakening of the social
factor through strain, etc. One cause of the difference is the superior
education of the officers, which renders them subconsciously dissatisfied
with the easy hysterical solution of the conflict. Another possible cause
is the greater repression of fear in the officers’ early education. The first
aim of military training is to enable the soldier to act in harmony with the
aggregate, and the agencies are habituation and suggestion. The next
great aim is to enable him to withstand the strain of warfare, and the

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EPITOME OF CURRENT LITERATURE.

[Oct.

chief agencies are repression and sublimation (of which esprit de corps
is an important development), together with side-tracking (of which
swearing, conviviality, and athletics are all manifestations). Of these
main agencies upon which the success of military training depends,
suggestion acts most potently on the private, sublimation and repression
on the officer. It is thus that military training tends to determine the
character of the neurosis from which each will suffer.

The present unsatisfactory character of the nomenclature is dealt
with. For “hysteria” Dr. Rivers rejects Babinski’s proposed term
“ pithiatism,” as well as Freud’s 1 ' conversion neurosis,” and considers that
“suggestion neurosis” would be the appropriate term. He defends the
use of Freud’s term “anxiety neurosis” for the “ neurasthenia” group,
but uses it in a wider sense than Freud. The appropriate treatment is to
lessen suggestibility by re-education, and in regard to anxiety neurosis
to concentrate on prevention. Most success, as Dr. Rivers has else¬
where stated, has been attained by a mental analysis resembling Freud’s
pyscho-analysis, but not attempting to go deeply into the unconscious.

Havelock Ellis.

The Rule of Focal Infections in the Psychoses. (The Journal of Nervous
and Mental Diseases , March , 1919.) Cotton , H. A.

In this paper the writer urges the important part played by chronic,
masked, or focal infections in the production of the psychoses. His
cases are submitted to a most thorough bacteriological examination on
modern lines, and special attention is paid to the teeth, which are
examined by the dentist and if necessary radiographed. Most of the focal
infections due to streptococci have their origin in the teeth, and in the
course of time these organisms reach remote organs and other structures.
In support of his views case histories are given and included under
three headings: (1) Severe cases of mania all of whom died, and the
autopsy revealed the cause of death as bacterial infection. (2) Hypo-
manic cases, which cleared up rapidly under treatment. (3) Profound
depressions, clearing up when the infection was recognised and treated.

As a result of these researches the following points are emphasised :

That the organisms concerned in focal infections in these cases
belong to the slow-growing, non-pus-producing type which are extremely
toxic, their origin is usually the teeth, and they may so spread as to
persist after the teeth are extracted.

That a thorough search for chronic infection is imperative, and that
bacteriological examination should be an essential part of the work in
every hospital for the insane.

That prophylaxis in mental disease should include the education of
physiciansand the public in regard to the fact of dental infections, and
dentists should realise the damage resulting from faulty dental work.

That many psychoses could be prevented, and chronic psychoses
cured, if these principles were followed in treatment.

H. Devine.

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PRINCETON UNIVERSITY

1919]

NOTES AND NEWS.

275

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITIAN AND IRELAND.

The Seventy-Eighth Annual Meeting was held at York on Tuesday and
Wednesday, July 22nd and 23rd, under the presidency, in the early part of the
proceedings, of Lieut.-Col. Keay, and later that of Dr. Bedford Pierce.

There •were present: Drs. T. Stewart Adair, Dora E. Allmann, David Blair
J. Shaw Bolton, C. Hubert Bond, David Bower, Geo. L. Brunton, Wm. M.
Buchanan, Robert B. Campbell, James Chambers, W. R. Dawson, Thos. Drapes,

C. C. Easterbrook, S. Edgerley, Francis H. Edwards, Henry M. Eustace, J. Tylor
Fox, Claud F. Fothergill, J. W. Geddes, J. R. Gilmour, Percy T. Hughes,
P. Rutherford Jeffrey, john Keay, Walter S. Kay, R. Macd. Ladell, S. Langton,
Oliver Latham, H. J. Mackenzie, W. F. Menzies, J. E. Middlemiss, George E.
Miles, Alfred Miller, Gilbert E. Mould, Alex. W. Neill, Wm. F. Nelis, Norman
Oliver, L. R. Oswald, B. Pierce, Daniel F. Rambaut, George M. Robertson,

D. Maxwell Ross, E. S Simpson, R. Percy Smith, J. G. Soutar, Charles T. Street,
R. C. Stewart, W. G. Thomson, A. H. Trevor, Marguerite Wilson, J. C. Wootton,
and R. Worth (General Secretary). Visitors: Dr. H. Colin, Marjorie Pierce.

MORNING SESSION.— Tuesday, July 22nd.

Held at the Retreat, Lieut.-Col. Keay in the chair.

Minutes.

The minutes of the last Annual Meeting, having appeared in the Journal, were
taken as read and approved.

The President put from the chair the following series of resolutions, all of
which were approved :

(a) That the officers of the Association for the year 1919-20 be :

President. — Dr. Bedford Pierce.

President-elect. —Dr. W. F. Menzies.

Ex-President. —Lieut.-Col. John Keay.

Treasurer. — Dr. James Chambers.

Editors of Journal. —Lieut.-Col. J. R. Lord and Dr. Thomas Drapes.

General Secretary. — Major R. Worth.

Registrar. —Dr. A. A. Miller.

(A) That the nominated Members of Council be :

A. Helen Boyle, G. E. Shuttleworth, David Orr, Lieut.-Col. D. G. Thomson,
R. D. Hotchkis, J. G. Smith.

(c) That F. H. Edwards and G. F. Barham be appointed Auditors.

(d) That the Parliamentary Committee be re-appointed and that Nathan
Raw, M.P., J. Shaw Bolton, A. A. Miller, J. N. Sergeant be added thereto.

(e) That the Educational Committee be re-appointed, and that T. P. Cowen be
added thereto.

(/) That the Library Committee be re-appointed.

(g) That the Research Committee be re-appointed.

The Report of the Council.

The Secretary read the report of the Council.

The number of members—ordinary, honorary, and corresponding—as shown in
the list of names published in the Journal of Mental Science for January, 1919,

was 626, as compared with 627 in 1918.

Number of new members elected in 1918 . . . .16
Number of members restored in 1918 ..... 1

Removed according to Bye-law 17 . . . . . o
Number of members resigned in 1918 ..... 5

Number of deaths in 1918.11

Transferred to Hon. Members ...... 2

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276 NOTES AND NEWS. [Oct.,

Endeavours have been made to revise the list of Honorary and Corresponding
Members. So far we have only been able to ascertain that Dr. H. Schule died in
December, 1916.

The following table shows the membership for the past decade : 626 + 32 + 18.
Total, 676.

Members.

1909.

I9IO.

191 I.

1912.

1913-

1914.

191S.

1916.

1917.

j

1918.

Ordinary

Honorary

Corresponding

673

32

'7

680

33

17

690

34

i 9

696

35

19

695

34

18

679

34

18

644

34

18

632

32

,8

627

33

18

1

626
32
18 '

Total

722

730

743

750

747

73 '

_

696

682

678

.

676

We have to record the retirement of Dr. R. H. Steen from the post of General
Secretary of the Association. Dr. Steen’s work as Secretary during the trying
years of the war was invaluable, and the very able manner in which he carried out
his duties is beyond praise.

Major R. Worth, Superintendent of the Springfield Mental Hospital, has been
appointed in his place.

The Special Committee appointed to draw up the English Legislation Report,
after a great deal of time and thought, placed their recommendation before the
General Meeting held in November, 1918. The report was unanimously approved
and adopted, and 1,500 copies circulated. Special Committees have been appointed
to deal with the following matters:

The Formation of Divisions Overseas.

The College of Nursing and Nurses’ Registration Bill.

The Ministry of Health.

The recommendation of the Special Committee appointed to draw up a report
on the Maudsley Bequest was approved and suggestions carried as to how and
where lectures were to be given.

Dr. Soutar was appointed to represent the Association on the recently constituted
Parliamentary Medical Committee.

It was decided that standing sub-committees should be limited in size.

Special meetings of the Association were held in March to go into the question
of Asylum Administration.

A new bye-law affecting the seal of the Association was passed at the May
meeting.

Sub-committees were formed to attend Guildhall Conference of Visiting
Committees to assist them in their deliberations.

We have to record with the deepest regret the death of Dr. Wiglesworth,
President of the Association in 1902.

The President announced that in connection with the Maudsley Lectureship the
Council had proposed to invite Sir James Crichton Browne to deliver this lecture
at the quarterly meeting to be held in London in May.

This was agreed to.

Treasurer’s Report.

The Treasurer submitted the Revenue Account and Balance-sheet for the
year 1918.

He stated that in accordance with the instructions given by the Council the
Maudsley Bequest had been invested in 5 per cent. War Loan, and acting on
the advice of the Association’s solicitor the Council had decided to make the
investment in the name of the Medico-Psychological Association. Similarly,
instead of appointing new trustees for the other funds of the Association, it had
been decided to make future investments in the name of the Association, and to
have existing investments transferred from the surviving trustee to the Association.

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PRINCETON UNIVERSITY

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278 NOTES AND NEWS. [Oct. r

This had necessitated the passing of a new bye-law with reference to the use of
the seal of the Association, which was done at the General Meeting in May last.

At the present rate of income-tax the net yearly revenue from the Maudsley
Bequest is ^73 18s. By adding to this the interest which accrued from placing
the bequest on deposit prior to its investment there will be a sum of .£90 to the
credit of this account at the end of the present year. Of the general funds of the
Association a further sum of ^250 was invested in 5 per cent. War Loan. Including
the Gaskell and Maudsley Funds the amount invested in 5 per cent. War Loan is
over £4,000.

The Revenue Account showed a serious increase in expenditure, due mainly to
the increased cost of the work done by the printers. There is at the same time a
large amount of unpaid subscriptions, with the result that the excess of income
over expenditure is a narrow one. This state of matters has been considered by
the Council, and a special Committee has been appointed to make a report on the
financial position of the Association.

The Treasurer proposed the adoption of this report. Agreed.

The Editors' Report.

Dr. T. Drapes presented the report of the Editors:

Editors’ reports during recent years have been mostly of an apologetic character.
The world-wide convulsion, which has by no means completely subsided, has
adversely affected certain kinds of journalistic literature, notably the scientific
class. The same disabilities which were alluded to in last year’s report continue
still. Research work in these countries is at a minimum, although a few of our
members have found it possible to make valuable contributions in this department
of medical science to the Journal from time to time, amongst whom Dr. Orr and
Lieut.-Col. Rows, in the sphere of purely experimental investigations, and Dr.
Ford Robertson, in clinical and pathological observations leading to the adoption
of effective therapeutic measures, are deserving of special mention, and merit our
warm acknowledgments. But there has been a paucity of material generally
which under normal conditions would have been disastrous to the Journal, although
not so under existing circumstances, owing to which its size has had to be largely
reduced, recent numbers, in fact, containing only about one-third the normal
number of pages which they did in pre-war times. Of these circumstances two
are outstanding as necessitating this great curtailment of size—the enormously
increased cost of publication and, as the Treasurer has informed us, a material
falling off in the funds at his disposal. In this respect we are, of course, not
alone, as other medical journals have had to largely reduce their dimensions
owing to similar conditions.

The Journal expenses for the year 1918 totalled £652. This is over £iooabove
the cost before the war. And as the dimensions of the Journal are only about one-
third of what they were in the former period, it follows that the cost of production is
over three times as much as it normally ought to be. However, necessity knows no
law, and over this condition of things the Editors have absolutely no control. It
is possible that a larger supply of paper may be now or may shortly be available,
and, we must only hope, at a diminished cost. The item of labour expense is, we
fear, not likely to get less, if it does not go on increasing. Whether it may be
necessary or politic to raise the subscription to the Association is, of course, a
question which must be decided by the members themselves.

We wish to renew our acknowledgments to the Assistant Editors for their
valuable help, to Dr. McRae in particular for his very accurate and painstaking
correction of proofs, and to Dr. Devine for his many interesting contributions to
the Epitome section of the Journal—an important part of its content, and one
which has suffered most from our restricted limits of space. And we are also
grateful to those writers who have favoured us with contributions at a time when
most members of our specialty were working at high pressure, and could command
but little leisure from practical duties of management and the discharge of admini¬
strative responsibilities. John R. Lord.

Thomas Drapes.

The President said they sympathised with the Editors of the Journal in the
period of difficulty through which they had been passing, and the Association
should congratulate itself that it had men as Editors who had the pluck to carry
on as they had done.

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NOTES AND NEWS.

279

The Auditors’ Report.

We beg to report that we have examined the Treasurer’s accounts and checked
the vouchers and receipts, and that the Balance-sheet represents a true and accurate
statement of the financial position of the Medico-Psychological Association.

Francis H. Edwards.

C. F. Barham.

Dr. Edwards, in presenting the report, said it was obvious to them as Auditors,
in going through the accounts, that the difference between income and expenditure
had reached a serious stage, coming down to practically a few pounds. Although
the financial position of the Association was a strong one, they must recognise
they had been w’orking with a Journal much reduced in size. It was obvious there
could not be any very material reduction in the cost of printing or paper, and
it was therefore necessary to draw very forcible attention to this state of affairs.
They had heard that a Committee was about to be appointed to consider the
whole financial situation, and he need not therefore comment further on it.

The report was agreed to.

Report of the Educational Committee.

The Secretary read the report of the Educational Committee.

The following is a brief account of the work which has been carried out by this
Committee:

As in former years four meetings have been held, and the attendances, con¬
sidering the abnormal conditions, have been quite up to the average of recent
years.

The Registrar reported that at the November and May Examinations 674
candidates presented themselves for the Preliminary Examination and 537 for the
Final, the total being 1211. On comparing the total entries for the Nursing
Certificate Examination, 1918-1919, a still further decrease is shown, those for
1917-1918 being 1,382.

At the November examination 105 candidates passed the Preliminary and 89 the
Final. The results of the May examination are not yet to hand.

Up to the present one candidate has entered for the Preliminary Examination
and the Mental Deficiency Nursing Certificate.

The professional Certificate and the Gaskell Prize Examinations were not held
in 1918. A divisional Prize of ten guineas has been awarded to Dr. Hubert J.
Norman for his paper entitled, “ A Plea for Optimism in Psychiatry.”

Owing to the ravages of influenza in the majority of institutions it was found
necessary to postpone the Nursing Examination from November to December.

. The Special Committee dealing with the question of the Nurses’ Registration
Bill have watched the interests of the Association.

During the year the name of one nurse was removed from the Register of
Nurses owing to the fact that she had been guilty of cruelty to a patient.

Amongst others, the following important resolutions have been recommended
to the Council:

“ That in view of the fact that the printed form announcing that a candidate
has passed the Preliminary Examination is still regarded by some nurses in
the light of a certificate, and that its possession enables them to pose as being
partly trained, the practice of issuing these notices should cease, and that the
fact of their having passed the examination should simply be notified to the
Superintendent of the Asylum, and that a register be kept by the Registrar.”

“ That V.A.D. nurses who have had three years’ nursing experience be
permitted to complete their mental training in two years on the understanding
that they pass both the Preliminary and the Final Examinations for the Nursing
Certificate of the Medico-Psychological Association, allowing an interval of
twelve months to elapse between the two examinations.”

Maurice Craig, Chairman.

J. G. Porter Phillips, Secretary.

Dr. Percy Smith inquired what had become of the certificate of the nurse who
had been removed from the Register.

Dr. Miller: It had not been actually issued.

The report was approved.

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Report of the Registrar.

I have to report the following particulars concerning the recent Nursing
Examinations :

Entries : 495 preliminary ; 402 Final. Passed : 338 Preliminary (68 per cent.)-,
270 Final (67 per cent.-, this includes 16, or nearly 8 per cent., who passed with
distinction.

Two Essays were received for Bronze Medal. These are now in the hands of
the Examiners.

Six candidates entered for the Certificate in Psychological Medicine, and all
passed the examination.

The Gaskell Prize has been awarded to Dr. James Walker ; second, Dr. Monrad
Krohn.

Dr. Eager wins the Bronze Medal, Dr. Norman Phillips being second.

I have an application from Stoneyettes for recognition. Dr. Oswald testifies as
to its suitability.

It will be necessary to make some arrangements to get a special plate for the
Certificate in Nursing of Defectives.

Alfred Miller,

Registrar.

The Parliamentary Committee.

The Secretary read the report, which was approved :

Your Committee has met four times during the year. The chief subject that
has engaged its attention has been the report of the English Lunacy Legislation
Sub-committee. This report has since been adopted by the Association, and has
been widely circulated, and your Committee has been informed by the Board of
Control that a Bill has recently been drafted and is now before the Secretary of
State providing for the treatment of incipient insanity. The newly-amended Rules
in Lunacy in consonance with the views of your Committee are already in force.
Sub-committees have been appointed in Scotland and Ireland to consider amend¬
ment of the Lunacy Acts in these countries. The Ministry of Health Bill has been
under discussion, and a special committee has been appointed. It has been urged
that the Association be represented on the Advisory Medical Committee to be
formed under the Bill, also that due representation be similarly granted on the
proposed Public Health Councils to be appointed in Ireland.

The Nurses’ Registration Bills have been considered with a view of safeguarding
the interests of mental nurses, and of obtaining adequate representation on the
governing Council. A special committee has been appointed for this measure
also. The Asylums Officers’ Superannuation Act of 1909 has been discussed in its
application of Sect. 4 (a), and an endeavour is being made to secure an amendment
in regard to gratuities for dependents of contributors who are under pensionable age.

Application has been made to the Home Secretary for amendment of the
Asylums and Certified Institutions (Officers’ Pensions) Act of 1918, to place
officers and servants of institutions for mental deficients in the first class for
pensions.

The desire for simplification of the forms for certificates of disability of soldiers
and sailors required from asylum superintendents has been impressed upon the
Minister of Pensions.

The scope of the Medical Parliamentary Committee has been approved, and a
member of the Association has been appointed on that Committee.

H. Wolseley Lewis, Chairman,

R. H. Cole, Secretary.

The Board of Control and the Ministry of Health.

Dr. J. G. Soutar said that certain matters had been dealt with by the Council
at their meeting that morning, and he desired to move the following resolution:

"That a deputation be appointed to place before the Minister of Health
the opinion of the Medico-Psychological Association that all matters con¬
cerning the care of the insane in England and Wales should as soon as
possible be brought within the authority of the Ministry of Health ; and that
the Board of Control, whose sympathetic experience and encouragement in
all matters concerning the welfare of the insane has been so valuable, be
maintained for the department.

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NOTES AND NEWS.

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He said it was felt that their branch of medical practice, which was so
important in its relationship to the health of the community, should not be left
outside the Ministry of Health. Unfortunately, in the past, it had been the lot of
their special work to be left lagging behind that of general medicine. Their work
had a most important bearing on the health of the general community, and they
desired it should be as early as possible recognised as a matter which should come
within the Ministry of Health, which was intended to co-ordinate all matters con¬
cerning the health of the community. There was another reason. They all
recognised that co-ordination ought to exist in what they might call the asylum
services generally. They felt it was preferable that the co-ordinating body should
be within a government department specially constituted to deal with the health of
the whole community, rather than left to some self-appointed and self-created body
which was inclined to consider asylum administration altogether from a lay point
of view, and to eliminate the medical element from what are really medical insti¬
tutions. They desired, instead of any such body claiming to be the co-ordinating
body, that they should come under the Ministry of Health, which would be
necessarily more sympathetic to the view that medical knowledge must pervade all
matters of asylum management. In regard to the part of the resolution which had
reference to the Board of Control, all of them who had had experience had seen
for a long time past that they had maintained a most sympathetic attitude towards
ideas of progress and advancement in dealing with matters concerning the insane.
Deputations from the Association had been sent to them again and again, and they
had met with most sympathetic encouragement in the evolutionary proposals made
for the treatment and the care of the insane; that was becoming more and more
a medical and less and less a legal matter (applause). The experience of the
members of the Board of Control was vast; no other body that they could conceive
of had such experience of the needs of the insane, or of the medical officers and
staffs who had to look after the patients. It would be a disaster if that experienced
and sympathetic body should be scrapped and some new body established when the
administration of lunacy passed into the hands of the Ministry of Health. They
tht-refore proposed to bring to the notice of the Ministry their appreciation of that
body, and their desire that it should continue to be an important element in the
Ministry of Health. (Applause.)

Dr. Miller seconded.

Dr. Edwards was in favour of the resolution but thought the two matters should
be dealt with separately.

Dr. Soutar thought the clause dealing tvith the Board of Control was most
important, and he saw nothing invidious in mentioning their desire to retain that
particular body in a department of the Ministry of Health. It was an important
point with a larger bearing than appeared on the surface. There was undoubtedly
a feeling in certain places that the Board of Control should be scrapped and some
new body instituted. “ We have had experience of the Board and know its value
and I think we ought to say so.” (Applause.)

Dr. Bower thought if they did not say so it might be inferred they did not want
to retain it.

Dr. Shaw Bolton said it was not fully realised how much it was desired by
some members of asylum committees to scrap the Board of Control. The chief
object in the formation of the National Federation was to form mental hospitals
which were free from the Board of Control. That would be most disastrous, and
he was consequently strongly in favour of Dr. Soutar's resolution.

Dr. Fothergill asked if the inclusion in the Ministry of Health would include
borderland conditions ?

Dr. Soutar said they would rather not make special reference to borderland
conditions; the whole question of what constituted mental disease would be
considered by the Ministry, and their Council thought it best to deal with general
principles only in the resolution.

The resolution was carried unanimously.

Dr. Soutar proposed that a copy of the resolution should be forwarded to Dr.
Addison, with a request that he would receive a deputation, and that it should be
left to the President, Treasurer and Secretary to appoint the members of the
deputation.

This was agreed to.

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NOTES AND NEWS.

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The Training of Mental Nurses.

Dr. Robertson said he had been asked by the Council to bring forward a
resolution dealing with the training of mental nurses, and the number of asylums in
which they required to serve before being eligible to go up for examination. At
present, according to the laws of the Association, this training might be taken in
not more than two separate asylums. The Council proposed that in future the
whole of the three years’ course of training should be taken in one asylum. It was
appropriate to bring it up at that meeting for two reasons. Twenty-six years
ago it was possible for candidates to take their training at as many asylums as
they cared to go to. Twenty-six years ago at the last meeting at York it was
proposed and carried that they should only be allowed to take this training at two
asylums. He thought they should now endeavour to insist on having the training
entirely in one institution, and thus come into line with the trained hospital nurses.
For mental nursing two different qualifications were required. In the first
place the candidate must be a skilled nurse who knew how to care for sick people
and to look after mentally deranged people. It was exceedingly important he or
she should have this technical knowledge. But, in the second place, it was
exceedingly important that those who looked after the mentally sick should also
be people of good character—persons upon whom they could rely. He ventured
to say the character of a mental nurse was often more important than the technical
training. He would much rather have a person as a mental nurse on whom he
could thoroughly depend that she would do all she could for the welfare of the
patient under her charge. Of what use was technical knowledge if they could not
rely on it being put into operation ? A person without character, although she
had technical knowledge of nursing, was most unreliable. The only way in which
they could satisfy themselves as to the character of nurses or as to attainments
was by keeping them under observation. A period of training which enabled them
to take it in two institutions did not enable them to test character so well as under
the scheme he proposed. It very often happened if a nurse had been in an institu¬
tion and got into trouble by making mistakes she left it and went on to another,
where she was able to hold on for some months and in due time she got her cer¬
tificate. On the other hand, if she could only get her certificate by remaining in
one institution three years, under the eyes of the matron or the superintendent, if
she did that and passed the test that was all they could ask. He moved—“ That
in future the three years’ course of training for nurses applying for a certificate of
proficiency shall be taken in one mental hospital in place of ‘ not more than two
mental hospitals.’ ’’

Dr. Oswald seconded. He asked that when the final results were published
there should be indicated the percentage who obtained their certificates in English
institutions and in Scottish and Irish. He had taken the trouble to analyse the
list of those who passed the November examination, and he thought that over
60 per cent, were from Scottish asylums. He took the resolution to mean that the
nurse must have been three years in the hospital from which she went up for
examination.

Dr. Robertson : She may be in any hospital she likes, but she must be three
years in the one from which she gets her certificate.

Dr. Edwards said it must be recognised in fairness to those already under
training that this would refer to the future and not to those now training.

Dr. Soutar: Certainly.

Dr. Menzies opposed the proposal, which he regarded as retrograde. He
hoped the next improvement would be to allow services in as many asylums as a
candidate desired. To suggest one asylum for training was to throw an unmerited
stigma on the superintendent of the former asylum by saying that the superinten¬
dent of the second asylum was a better judge and had more discriminating power.
He thought if the superintendent could not judge in six or nine months or a year
the character of a nurse, especially one supposed to be a senior nurse who had had
some training in another asylum, then he was not able to give any certificate of
character at all. He was one of those who agreed that general hospital trianing
was desirable in asylum nurses, but he thought the one-hospital rule was due to
jealousies between the various matrons. If hospitals were as far advanced as the
Medico-Psychological Association, and had only a national certificate, there would

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NOTES AND NEWS. 283

be no difficulty in a nurse going from one hospital to another. The idea of the
Conciliation Report was that the Medico-Psychological Certificate should ultimately
be scrapped, and that Management Boards of Asylums, together with the National
Asylum Workers’ Union, should gradually institute a nursing certificate in each
asylum and slowly squeeze out a national certificate, while compelling the medical
officers to teach what subjects the staff might select. That this would be a
retrograde step the staff did not at present recognise, but that made it all the more
incumbent upon the Medico-Psychological Association to oppose any such
tendency. Compelling a nurse to serve all her training in one asylum would
intensify this tendency, and therefore he opposed the motion.

Dr. Shaw Bolton said that ever since he had been a superintendent he had
systematically refused to take nurses from other institutions because they had so
much to unlearn. He had had a couple of dozen who had come from other
institutions who had certainly not been satisfactory nurses. Training was
necessarily so different, method was necessarily so different, that for nurses
to become really satisfactory it was much better to go through the full course
of training in one institution. A nurse so trained was of much more use in an
institution than if trained half and half. He did not know what alteration in the
law was likely to take place, but if it was in the direction they were desiring
the whole of the mental hospitals would approximate to the general hospitals.
If so, he hoped no asylum would keep a nurse who had not been trained. It was
perfectly true the Asylum Workers’ Union wanted to oust their certificate, but at
the same time it was true that not 20 per cent, of the mental asylum nurses were
trained and got the certificate. In the West Riding something like 10 per cent.
had got them; they should like 90 or even 100. If Dr. Menzies’ idea were
enforced they might be in a worse state. He would like to see training pressed
to the fore, and the question of examination kept more in the background.

Dr. Robertson denied that the proposal was a retrograde step. Dr. Menzies'
hope that nurses might be able to take their training in more than two hospitals
was a reversion to the state of affairs of twenty-six years ago. In reply to
Dr. Menzies’ other point, he denied that the proposal cast any slur or stigma
on the superintendent at all. Every superintendent was capable more or less of
judging character, but a certain amount of time was necessary for them to see
the candidate at work, and nurses might be able to hold out for eighteen months
and then give themselves away, but no certificate could be given until a certain
practical test had been made. He re-read the resolution and explained that it was
not retrospective.

The President put the motion and declared it carried by a majority.

Special Committee.

The Secretary read the report of the Special Committee.

Resolution tassed by the Special Sub-Committee ok the Medico-
Psychological Association, July 4T11, 1919.

" It was decided that the constitution of the Medico-Psychological Associa¬
tion was such that it could not help the Asylum Workers’ Association. The
members of the Sub-committee were very sympathetic and were willing to
help the Asylum Workers’ Association in the way of affiliation or absorption
by the Medico Psychological Association, but could not see their way to do
anything in the matter. The Sub-committee recommended the Council
to accept and administrate the Convalescent Fund of the Asylum Workers’
Association if this fund can be handed over to the Medico-Psychological
Association.”

There were present at the above meeting Lieut.-Col. Keay, Lieut.-Col. Thomson,
Major Worth, Dr. Shuttleworth, Dr. Powell, Secretary of the Asylum Workers’
Association.

The President said the Sub-committee were very sympathetic and most
anxious to help the Asylum Workers' Association, but to do so would involve
an alteration in the constitution of the Association. The Secretary of the Asylum
Workers’ Association had undertaken to ascertain what could be done towards
taking over the Convalescent Fund by the Medico-Psychological Association and
administering it for them.

LXV. 2 0

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284 NOTES AND NEWS. [Oct.,

Col. Thomson corroborated the President's remarks. They were very sorry
the Asylum Workers’ Association had come to an end, but certainly absorption
or affiliation between them was impossible.

The Secretary reported that Mr. Bethell, who did some work for the Association
at n, Chandos Street, and who received ^13 8 s. a year, had asked that it be re¬
considered. The Council suggest that the sum be increased to 25 guineas.

After discussion an amendment by Dr. Shaw Bolton, seconded by Col.
Thomson, that the sum be £26 , was carried.

The next business was fixing the dates of Annual, Quarterly, and Divisional
Meetings of the Association and Quarterly Meetings of the Council. The
following dates were suggested by the President: Tuesday, November 25th,
1919; Tuesday, February 24th, 1920; Tuesday, May 25th, 1920.

The Divisional Meetings are proposed as follows :

South-Eastern Division. —October 1st, 1919, at Elm Lodge, Clay Hill Lane,
Enfield.

Northern and Midland Division. —October, 1919, North Riding Asylum,
Clifton, York; April, 1920, Mental Hospital, Middlesbrough.

South-Western Division. —October 24th, 1919; April 24th, 1920.

Scottish Division. —November 21st, 1919; March 19th, 1920.

Irish Division. —November 6th, 1919, at Royal College of Physicians;
April 1st, 1920; July 1st, 1920.

This was agreed to.

The following were submitted for election as members of the Association:

Peregrine Stephen Brackenbury Langton, M.R.C.S.Eng., L.R.C.P.Lond.,
M.B., B.S.Lond., Assistant Medical Officer, York City Asylum, Fulford, York.
(Proposed by Drs. C. L. Hopkins, Bedford Pierce, and Stewart Adair.)

Henry Eggleston, M.B., B.S.Durh. Univ, Assistant Medical Officer, Brooke
House, Clapton, E. 5. (Proposed by Drs. Gerald H. Johnston, R. H. Cole, and
R. Worth.)

The President announced that Dr. Barkas had already been elected, and the
other two candidates were unanimously elected.

“ Notes on a Case Treated by Hypnotic Suggestion.”

Dr. Jeffrey read a paper bearing this title.

Dr. Robertson congratulated Dr. Jeffrey on his excellent summary of an
extremely interesting case. There was a time, a good many years ago, when he (Dr.
Robertson) made use of hypnotism to a very large extent in the treatment of
mental cases. He found that in all cases in which he attempted hypnosis those
suffering from melancholia were the most difficult to hypnotise. Those suffering
from acute mania were extremely suggestible, and so were very easily hynotised.
It was most difficult to get the attention of melancholic patients, and this being
necessary to induce hypnosis, nothing was done. In this case, as Dr. Jeffrey had
pointed out, the symptoms did not resemble those of ordinary melancholia. It
was probably a case of what was known as anxiety neurosis ; certainly the patient
had the anxious feeling, dulness, introspection, self-depreciation, self-accusatory
ideas, and defect of will-power they got in ordinary cases. But in this case he
thought there was—he said it with all deference—very probably a very strong
sexual element. The dream which was reported was one which, according to the
Freudians, might be analysed symbolically sexual. Seeing that the patient was
very anxious about her flan''*? at that time he thought there could be very little
doubt there was some sexual explanation. He did not think the dream was
the cause of the illness; probably underlying it was the anxiety, which was
merely brought to a head by the dream. It was a symptom of the patient’s
anxious condition. It was true the hypnotic condition dispelled the dream, but
he wished Dr. Jeffrey had entered a little more fully into detail as to what he told
the patient to explain the dream and to allay her anxiety. It was clear that what
partly happened was this : the subconscious was deeply stirred up by the dream,
and this produced an intense feeling of anxiety in the patient. One often found
that melancholic patients were worse in the morning, and as the day wore on they

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NOTES AND NEWS.

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grew better. One wondered what was the explanation, and so did Dr. Clouston,
but he found it was due to the fact that during sleep the subconscious was most
active, so one was worse in the morning and by evening the subconscious became
less active, and was repressed.

Dr. Ladell agreed that melancholic patients were practically impossible to
hypnotise. He sometimes wondered if it would be wise to drug patients sufficiently
to get them quieter, and then to superimpose hypnosis on the top of that. As
regards Dr. Robertson’s interpretation of the dream he thought his remarks
showed how far Freud was astray. It was of course quite possible to put a sexual
interpretation on the dream, but if Dr. Jeffrey had explained the sexual interpreta¬
tion to the patient would the cure have been any more effective ? The followers
of Freud went wrong here ; it was impossible to give a sexual interpretation to
every dream ; in fact, he seldom found that the sexual interpretation was the
correct one. He had occasionally found jealousy came in, but the actual crude
sexual interpretation seemed entirely unnecessary in every case.

Dr. Eustace congratulated Dr. Jeffrey on being able to induce hypnosis.
They realised personal magnetism was needed to induce it, but all had not the
power. He knew he could never induce it; he had tried and failed and would be
very glad of details as to how it was induced.

Dr. Jeffrey said it was a case of anxiety neurosis. He entirely disagreed with
the sexual explanation. Why should they try to correlate every circumstance of a
case like this with a sexual meaning? He took particular care to try to find out
if there was any sexual point which might have been raised in connection with this
young lady. There was none, and the dream that he related had no sex connection
at all. He induced hypnosis in the usual way. The first thing to do was to get
the patient to detach her mind, and put it in a condition of absolute blank. To
do that he sat quietly beside the patient and told her he was going to put her mind
into a condition of blank, explaining that if the mind got into a condition of rest
then they would have the condition of thinking normally again. He asked
patients to give him their attention and think of nothing at all, and then suddenly
he said the word “ sleep,” repeating it, and asking them to fix their eye on a
shaded torch. When they found that they were becoming calm they would
experience a feeling of detachment, and would then be able to listen quietly, and
appreciate what was being said to them.

Welcome to French Visitor.

Referring to the presence of M. !e Docteur Henri Colin, the President said:

At this our Annual Meeting, occurring very appropriately at the time of the
celebration of peace, we are honoured by the presence of a representative of the
Medico-Psychological Society of Paris, Dr. Henri Colin, its Honorary Secretary.
To our distinguished guest we extend a warm greeting and a hearty welcome, not
only on account of his eminence as an alienist and of the fact that he represents at
our Meeting the sister Society to which we are united by bonds of ever-growing
esteem and affection, but if possible even more so because he stands for closer
union and fellowship in all things with our brave and glorious ally the heroic and
immortal France. (Loud applause.)

Dr. Robertson endorsed the welcome, and added that he would like Dr. Colin
to carry away the feeling that the Association were looking forward to the celebra¬
tion in a few years of the centenary of the discovery of general paralysis of thi
insane by Dr. Boyle. He hoped that when their sister Association in Paris
celebrated that event Dr. Colin would assure them that this Association would
sympathetically consider any steps taken with that object—perhaps the greatest
neurological discovery that had ever taken place. (Applause.)

Dr. Colin’s Reply.

I most gratefully thank Col. Keay for his hearty welcome. It is for me a great
pleasure to find myself here in this world-famous Retreat of the City of York.

Everybody knows the Retreat, at least by name, and for us Frenchmen, par¬
ticularly, this name recalls the descriptions of our masters, Ferrus, Morel,
Parchappe. It evokes also the souvenir of this admirable family of Tuke, who,
without any other preparation than the goodness of their heart and their keen
sense of justice, devoted themselves to the relieving of the invalids of the brain.

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Our Pinel had begun in France in the year 1792; then in England William Tuke
opened this house in 1796, and was followed by Samuel Tuke and Hack Tuke, who
was the friend of many of my countrymen, and to whose dictionary I myself brought
my modest contribution.

After William Tuke came Conolly and the no-restraint method now universally
adopted, and the creation of these marvellous English asylums which have their
equal in no other country.

We can boldly say that the treatment of the insane, and the medical and
scientific study of mental diseases, was born and developed in France and in
England, and this is the reason why some years ago 1 was amazed to hear the
immoderate laudation given^to the Germans in this special part of [our medical
art. We were only a few In France to protest against the hasty generalisation of
German theorists relative to dementia praecox or manic-depressive insanity, and
this, not in a spirit of low jealousy, but simply from a critical point of view, and
because we knew that they were bringing us back from Germany under affected
names, morbid states that had been recognised and well described in other countries.

In this branch, as they used to do in many other scientific branches, the Germans
contented themselves to apply and to spread, without quoting the authors, the
discoveries of others.

Let us hope that here also the war will have been a lesson for us—a hard
lesson—and that before blindly admiring the theories of the other side of the
Rhine we will simply read over again our own authors.

1 bring here the respectful salute of my countrymen to the memory of the
Tukes, whose work is so well continued by their most distinguished successor,
the present superintendent of the Retreat, Dr. Bedford Pierce.

THE LUNCHEON.

Members were entertained to luncheon at The Retreat, Mr. Yeomans, of
Sheffield, Chairman of the Committee of Management, presiding.

The President (Col. Keay) thanked the Committee for their hospitality. In a
humorous speech he explained that the Association was practically an Irish
Association, and between Irishmen and Yorkshiremen there were many points of
similarity. There was their love for constituted authority; their love of law and
order; their antipathy to any violent methods of any kind, and their tolerance of
those who differed from them in discussion. (Laughter.) This being so, it was
natural that the Committee of the Retreat should welcome them there that
day, as they were, in point of fact, the Medico-Psychological Irish Association.
(Laughter.) They therefore expected to receive the kind of hospitality they had,
and they showed it by coming to the Retreat for their new President, a gentleman
who, if not an Irishman, could not help it. They had admired the Committee's
splendid hospital, with its historic associations and its world-wide reputation for
all that was good in the treatment of the insane. (Applause.)

The Chairman said the Committee appreciated the kind words which had been
said about their institution. It was a pleasure to entertain the Association. It
was not the first time they had visited York; he remembered the last occasion,
when their Medical Superintendent, Dr. Baker, was President for the year. He
remembered that his predecessor in the chairmanship of the Retreat took the
opportunity of urging improvements in the status and the raising of the standard
of education, and encouraging a higher type of woman to engage in the nursing
of the insane. He believed that idea had permeated the asylum world, and to-day,
though they still had a nursing question, it was of a very different character. It
was a special pleasure to the Committee to welcome them, because, in honouring
Dr. Bedford Pierce, they were in some sense honouring the Retreat. Perhaps he
might remind them that the Retreat was opened in 1796, and they must not,
therefore, expect to find it in some respects as a building altogether up-to-date.
But they had 'endeavoured to preserve the homely character and domesticity of
the institution, which had always been a feature of The Retreat. It was founded
by William Tuke, and was the first asylum in England which was established on
humane lines; at the same time M. Pinel, of Paris, independently carried out
similar reforms at the Bicdtre. (Applause.)

Members subsequently inspected portions of the building, and viewed with great
interest the archives ancFother historic’psychiatric treasures of the Committee.

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AFTERNOON SESSION.— July 22nd.

Thanks to Retiring Officers.

Dr. Percy Smith proposed a vote of thanks to the retiring President and the
officers of the Association. As regards Col. Keay, it was a pleasure to see the
chair again filled by a new president. Col. Thomson loyally stepped into
the breach and filled the chair for four years in succession, and now Col. Keay had
occupied it for a normal year, and they offered their hearty thanks to him. The
war had terminated, but Col. Keay was still in charge of a military hospital, and he
had no doubt his military duties had been as efficiently carried out as his duties as
President of the Association (Applause.) In leaving the chair they wished him
every success and happiness in the future. (Applause.) “ It is a pleasure,” continued
Dr. Smith, " that he is being succeeded by what I may call one of my old pupils.
I mean that it was in 1891 that Dr. Bedford Pierce came’as clinical assistant at
Bethlem Hospital when I was in charge there. As to the other officers of the
Association, I remember that when I was President I ventured to say that 1 Presi¬
dents come and Presidents go, but the officers go on forever,’ and that but for the
work of what may be called the permanent officers the work of the Association
could not go on every year.” Dr. Steen filled the gap as Secretary during the time
Col. Collins was on military duty, and it was only during the last 4 few weeks that
Major Worth had succeeded Dr. Steen. He thought special thanks were due to
Dr. Steen for the care he had taken of the affairs of the Association during the
time he was Secretary. He was glad to say their friend the Treasurer, Dr. Cham¬
bers, was not retiring. It would be vividly in the memory of them all how long
their Treasurer, Dr. Newington, held the post, and what an admirable example he
set in the way of keeping the accounts, and they were all confident that in Dr.
Chambers’ hands the Association accounts would go on in the same admirable
system.I »The Editors of the Journal during thejwar had had almost arduous
task, partly due to the lack of material, and partly owing to the expense of paper and
printing when they got the material, and the thanks of the Association were due
to them for maintaining the Journal at such a level during the war. They had
hinted that in consequence of the expense they might not get the Journal back to
the size it used to be, but he hoped they would be able to restore it. Then there
was their old friend the Registrar, who did an enormous amount of work. It was
difficult to estimate how much work he did in connection with the registration of
nurses. No one could grasp it who had not seen it; but no one could doubt their
thanks were due) to Dr. Miller. The* Auditors were still going on ; their posts
involved a good deal of work before the annual meeting came on. Dr. Smith
also expressed the thanks of the Association to the secretaries of the various
Divisions, who had each accomplished most useful work.

Dr. Eastf.rbrook seconded, remarking that, as the President had pointed out,
their Treasurer, acting Editor, and the General Secretary and Registrar were all
Irishmen—it was, in other words, an Irish Association (Laughter). He thought
they would agree that as Dr. Smith represented the Association south of the
Border, someone from the north of the Border should have the pleasure and
honour of seconding this vote to their Irish confreres, and they would agree they
had had a very peaceful year of Home Rule. (Laughter and applause.)

The resolution was unanimously agreed to.

The President returned thanks on behalf of ..his colleagues and himself for
the kind words which had been spoken. He had now had a year as President, and
he was more convinced than ever that it really did not matter what kind of a
President they had. He could only reproach himself with being most inefficient,
nothing else; it didn’t matter in the very least whether he did any work or not,the
work was carried on by their splendid permanent officers. It went like clockwork
whatever the President might do or whatever might be his endeavours to upset it.
He did not think it would be the desire of the officers that he should refer to them
individually, but he was convinced they could not have a better set of officers than
they had. The mantle of their old friend, Dr. Newington, as Treasurer, had fallen
on shoulders more able to bear the strain, and their treasury was safe. In the
Secretary they had one who was young and ambitious and with tremendous ideals,
with push and energy, and there were great things before them. He would like
to say one word about the Editors of the Journal. They had conducted it during

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the war with credit to themselves and the Association. They had surmounted
great difficulties and they would go on surmounting them because the acting
Editor was an Irishman. He would say nothing about the Registrar, because he
was another Irishman. “ We are a modest people, and, like Yorkshiremen, the less
said about it the better.” It now only remained for him to die as gracefully as he
could, but before doing so he had the satisfaction of handing over the affairs of the
Association to one better able to look after them than he had been—he referred to
Dr. Bedford Pierce. (Applause.) The Association was handing over the direction of
its affairs—as far as he would be allowed to direct them—to a strong, resolute man
who would perhaps hold his own among those officers of whom he had just been
speaking. He had great pleasure in ornamenting Dr. Pierce with the badge of
office in the certain knowledge that a year after this he would be as glad to retire
as he (Col. Keay) was.

Having been invested with the Presidential insignia

Dr. Pierce said he was very proud to wear the “ blue riband ” of the Associa¬
tion. He did not know that there was anything more pleasing in this world than
to win the goodwill and appreciation of one's friends and colleagues. He had
made no adventurous journeys in the realms of research ; he had not even written
a book, and he could not claim therefore any right to hold that position, except
perhaps this, that he had always been, since he knew the Association, an ardent
believer in it. He had always received the utmost kindness from the members; he
had always had the greatest pleasure in attending the meetings and in doing what
he could to help. It would therefore be a pleasure to pilot the Association this
next year. He did it with the more confidence because they had heard of the effi¬
ciency of their permanent officials ; but he also thought he could rely upon the
support of all the members. “ I hope they will check me when 1 may wander,
uphold me where I may fail, and give me sympathy at all times.” (Applause.)

Presentation of Prizes.

The President announced that the Gaskell Prize and Gold Medal had been
awarded to Dr. James Walker and the Bronze Medal to Dr. Eager. There had
been no Divisional prizes. He believed the papers sent in were of exceptional
excellence, and it was intended to give a second prize to two members of the
Association whose papers approached close to those of the successful prize-winners.

The President mentioned that they had received a large number of letters
expressing regret at inability to attend. Among them was a charming letter from
Sir George Savage, a letter from Dr. Yellowlees, from Dr. Bevan Lewis, and from
Dr. Ritti, of the corresponding association of Paris; also from Dr. Ren£
Senielaigne.

The late Dr. Joseph Wiglesworth.

Before beginning his address the President said his first duty was to refer to the
death of one of the late Presidents, Dr. Joseph Wiglesworth. He did so with
mingled feelings—a feeling of deep regret at the loss we had sustained, a feeling of
pride that they had had among their members such a distinguished and able man,
and of so high character. It was as long ago as 1883 that he won the prize for an
essay the motto of which was unusual, though it seemed characteristic of his
future work—“ He shall be as a God to me who shall rightly divide and define.” In
it he dealt with certain states of melancholia attonita or acute dementia showing
the inflammatory changes in motor cells. He was superintendent at Rainhill,
where he spent nearly all his professional life. He was President in 1902 and his
addresswas a distinguished and strikingly profound one on heredity. One fact of his
life was known to many here, and to some intimately, because they were actually
in the asylum when he was stabbed by a patient, the internal carotid artery being
severed, and yet he walked a hundred yards afterwards holding the artery himself
till he obtained assistance. He contributed numberless articles to our Journal, and
did much to maintain the best traditions of our Association. He was an ornament
to our profession, but he was by no means a one-sided man. Devoted to natural
history lie was especially interested in ornithology. After his resignation he lived in
retirement at Winscombe and saw but few visitors. He travelled widely in pursuit of
ornithology, and though persons around saw little of him he happened to hear from

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a schoolboy from an adjoining school that he was frequently at Dr. Wiglesworth’s
house. The reason was the boy was devoted to ornithology, and this formed a
common bond between them. His life was not without trouble. He had serious
and painful administrative difficulties at his asylum, and grave disappointment at
the end of his life by the loss of his only son in the war. They might consider him
fortunate in that he did not suffer a long illness and the slow decline of faculties
which is often such a sad feature of our common humanity. He was killed while
exploring cliffs in North Devon in search of birds. They mourned his loss,
and he was sure it would be the desire of all of them at that meeting to send a
message of deep sympathy to Mrs. Wiglesworth at this time of great sorrow and
loneliness.

Presidential Address.

The President then delivered his address on “Psychiatry a Hundred Years
Ago: with Comments on the Problems of To-day'' (see p. 219).

Dr. Thomson moved a vote of thanks to the President for his address. He
might be permitted to say they had had the kind of address they expected from
him. It had been thoroughly sound, nothing adventurous or speculative, but with
a sound outlook and consideration of the problems of psychiatry, both yesterday
and to-day. Specially interested, of course, in the Retreat, Dr. Pierce had
naturally looked back historically to the problems of years ago. He had brought out
the striking fact that they were asked 3,000 years ago and 200years ago very much
the same problems as we were asked to-day. We seemed to grope about for a
solution. Like Dr. Pierce, he was hopeful of an ultimate solution to many of
them, and not to sink into the slough of feeling that the problems of insanity were
unknown and unknowable. That was not the occasion to argue about the points
which the President had raised ; they had to thank him most sincerely for the
wise and sound thought that he had placed before them in that address.

Dr. Soutar, seconding, said that what struck him most in the address was that
the President had brought out in a very clear way how closely in touch their work
was with every interest of the human race. Not only had they to treat illness, but
they should recognise that the illnesses with which they had to deal were very much
due to social conditions, over which they must first exercise control if they were
going to stem the tide of mental disease. The President was not pessimistic, but he
did not give full credit to the very definite advance made in the period under
review. There was now established, largely under the influence of that Institution
(The Retreat) among others—firmly established—the idea that the old methods of
treatment were done with for ever. That was a definite step in advance at all
events. As Dr. Bedford Pierce hinted, the next step they had to take was to deal
with the earlier incipient cases. There was no reason for pessimism or questioning.
We were further on than we were in the early years, and the President had taken
a very material part in the progress that had been maintained, and the efforts of
that Institution (the Retreat) were being continued under the present medical
directorate. The paper was full of interest, and the way in which the President
emphasized the necessity for research was of the greatest possible value. They
were deeply indebted for the address, not only for its historical interest and for its
philosophical tone, but also for its practical direction. (Applause.)

The vote was very heartily accorded, and was suitably acknowledged by the
President.

GARDEN PARTY.

The Committee of “ The Retreat ” gave a garden party in the afternoon to the
members and their friends, a large number of guests being invited to meet them.

THE DINNER.

The Annual Dinner was held at the Royal Station Hotel, York, on Tuesday-
evening, July 22nd, 1919. The President, Dr. Bedford Pierce, was in the chair,
and among the guests were the Lord Mayor of York (Alderman Sir W. A. Forster
Todd), the Sheriff (Alderman C. W. Shipley), the Dean of York (the Very Rev.
Dr. W. Foxley Norris), Sir George Newman, K.C.B., Maj.-Gen. J. Thomson

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C.B., Deputy Director of Medical Services, Northern Command, Col. Roche,
R.A.F., Dr. C. H. Bond and Mr. A. H. Trevor, Lunacy Commissioners, M. le
Docteur Henri Colin, Paris, Prof. T. Wardrop Griffiths, Leeds School of Medicine,
Mr. G. W. Gostling, President, York Medical Society, Mr. Chas. Fernam, Chair¬
man of the Retreat Committee, Mr. J. J. Hunt, Chairman of the Governors,
Bootham Park Asylum, Mr. Arthur Rowntree, and others.

The Toasts.

"The Royal Medical Services."

Dr. Soutar proposed " The Royal Medical Services." He said that while they
might have chosen some one more fitted to propose this toast, it was hardly
possible to ask one who had helped to make the wonderful record of those
services, and therefore they had to fall back on one who had been an envious but
admiring spectator. An onlooker like himself was quite incapable of making a
speech worthy of the toast. But he had seen something of their ultimate
achievements, and they were looking forward to the time when they would get
a full record of the men and the measures whereby not only had the piteous cry
for help from suffering, pain, and disablement been met beyond all previous
experience, but whereby, in a way hitherto unthinkable, preventable disease had
been prevented, and thereby man-power had been maintained and victory won.
It was that which made possible the genius of our generals, the leadership of our
officers, and the valour of our men. Because men did not die as in previous
campaigns the shores of Great Britain were inviolate. That was due to the
medical services. That was a great achievement, which even they as onlookers
could perceive and admire. They were burning with desire, both as members of
the medical profession and as citizens of the Empire, to express their profound
and undying gratitude to those services—the men from the rural districts, the
cities, our own countrymen ; the men of the services from India, Canada, Australia,
New Zealand—from everywhere where the British flag flies. They did not forget
the United States, or anywhere where the sturdy strain of the British breed had
gone. These all, by unity of purpose, solidarity of action, interchange of experience
and knowledge, had not only effected this great achievement during the war, but had
placed the human race under a deep obligation by pointing the way through
which similar victories might be won over disease in civil life. (Applause.)

" By their works ye shall know them,” and in expressing their gratitude to those
who, having faced difficulties in our country's cause, had come back to them, they
sped a reverent thought to those who, having played their part, returned no more.
(Applause.)

Maj.-Gen. Thomson, C.B., responding, said the work of the R.A.M.C. in
certain theatres of the war had been carried out in circumstances of extreme diffi¬
culty, but they could congratulate themselves in having overcome the difficulties.
In France they held in check two diseases which had been the scourge of armies in
the field in previous campaigns—enteric and dysentery. Enteric had been so
curtailed by inoculation and improved sanitary arrangements that the admissions
had been less than 100,000. With regard to dysentery the incidence had been
greater, but even in that disease, by the strictest isolation and segregation of
carriers with sanitary precautions they had managed so that the disease had never
become epidemic, even during the latter part of the campaign when they were
occupying ground which had been fouled by the enemy, because, judging by the
prisoners of war, the disease must have been most prevalent. In addition they
had new forms of disease to contend with, such as trench nephritis, trench fever,
and trench foot, and last, but not least, so-called shell-shock. He thought it was a
great mistake such a name was ever applied to this disablement, because it had
given men all the glamour of being battle casualties, and furnished them with a
pretext of getting admission to hospital whenever they felt disposed. Had the
meeting been in Newcastle they would have been delighted to invite them to see
their cases in the Northumberland Hospital. Many were cases of young soldiers
who had improved considerably in hospital, though probably they would never be
fit to serve in the ranks again. The worst cases were those of old soldiers who
were drifting into the hospital. These men were highly excitable, intolerant of
any form of discipline, and it was difficult to know how to deal with them. They

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would be grateful for any advice in these cases. Maj.-Gen. Thomson
acknowledged the deep debt the Army Medical Service were under to the Board of
Control in placing at their disposal so many large asylums, fully equipped in every
detail, which had proved invaluable to them as general hospitals. Many of the
staffs, too, had joined the R.A.M.C., and had rendered yeoman service at home and
abroad. In concluding, he welcomed the introduction of the scheme whereby men
who were discharged from the army were treated in mental institutions instead of
being treated as paupers. This had been a great boon, and had been highly
appreciated by the relatives of these unfortunate men. (Applause.)

Col. Roche, R.A.F. also responded. He spoke of the great difficulty in
organising the naval medical service, which was hopelessly understaffed at the
beginning of the war, and said that although the position of naval surgeon and the
conditions of life with the men on a ship presented enormous difficulties to the
ordinary practitioners, yet they had been of immense help and assisted them to
win through in the most extraordinary way. They of the permanent service had
been most grateful for their help. As regards the flying service, the personnel at
the start was very small. They were constantly confronted with many complicated
conditions due to the extraordinary sacrifices and arduous tasks their fliers were
called upon to deal with. Naturally new diseases under new conditions sprang up
and they succeeded in dealing with them more or less—rather less than more—but
there was undoubtedly a great deal of work still to be done. But it has got to be
done in the future by a certain number of experts, because the work is too intricate
and too big to tackle by the ordinary service of the military officer, who has many
other things to think about besides research. They were looking forward to many
experts, especially in their department of medical science, lending their aid in
trying to classify the many diseases fliers were called upon to encounter. As to
the future, nobody had anything to go upon as to what they would be required to
do, but from what the general practitioner had done in the past they were confident
they would not be lacking in granting any aid they needed. (Applause.)

“The Medico-Psychological Association of Great Britain and

Ireland.”

Sir George Newman, K.C.B., in submitting this toast, said the Association
was established about the middle of last century. Its purpose had been two-fold:
first, the amelioration of the condition of the insane, and secondly, the advance¬
ment of medical knowledge with regard to the letiology of mental diseases. It
was clear there were two groups of persons who were entitled to propose their
health. One was the group of persons who were pundits on their particular
malady ; the other were the persons who could properly claim to be entirely
ignorant of their particular malady. He was fortunate in not being acquainted
with their particular malady, and he was fortunate in proposing the toast of the
health of their Association in that place—the city of York—where in 1792 a
great and courageous humanist, William Tuke, founded the York Retreat, and
with others stamped out for ever and finished for ever as an ideal practice, the
shackling of the insane. They were happy that evening in having a direct
descendant of William Tuke dining at that table. He was fortunate in having
to propose the toast and to couple with it the name of the distinguished man
who was their President. He was also fortunate in the circumstances of the
time in which their meeting was gathered at York. They were at the end of the war;
they were hoping they were at the beginning of a period of reconstruction. There
was no subject where reconstruction should bring better fruit to this country than
in the cause for which that Association stood. They were met at a time when
their own Association’s Committee had produced a report which he and many
others had read with great interest, edification and sympathy—a report which
marked a great step onward in the progress of their practice and administration
in regard to the treatment of those suffering from mental diseases; a report
which he hoped at an early date would form the basis of a Bill in Parliament—a
Bill which, he believed, would receive a large measure of support,'and which would
receive support, at all events, from the Minister whom he had the)honour to
represent that evening. There was another factor in the time in which they
were met. That was the wide movement which was going on in the medical

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profession in regard to the medical attitude to preventive medicine in relation to
almost every branch of their profession, its science and its art. As they knew,
it fell to his lot to be assessor of medical schools, and all over the country there
was a movement in medical education which, he hoped, would lend its support
to the cause for which that Association stood—for the reform of the treatment of
mental disease. Lastly, there was incidentally the beginning of a Ministry of
Health which, he hoped, would take its right share in this business. Might
he tell them how he viewed the position which he thought preventive medicine
should take in relation to mental disease ? He thought it was the business of the
Ministry of Health to endeavour to create and maintain the mental health and
capacity of the nation just as much as to maintain their physical health. (Applause.)
He drew no distinction whatever between their attitude towards the three diseases
which were the scourge of our time—tuberculosis, venereal disease and influenza ;
the attitude which an enlightened Ministry of Health ought to have to those
and their attitude to mental diseases. (Applause.) Secondly, they should
view mental disease from the preventive standpoint. He thought the Ministry
should say it was as much their business to prevent mental disease as to
prevent any other. Thirdly, he thought their method of preventing it should
be along lines which he should call physiological and psychological rather than
any other. He should like to see this applied to all forms of mental disease and
to all degrees, from the conditions of mental dulness and mental retardation to
advanced insanity; from nervous diseases which are mental to mental diseases
which are nervous. The whole group should come within the compass
of the State, in the sense of the State taking an enlightened view of their
preventability, and doing all they can to encourage newer, larger and more
emancipated ideas with regard to mental diseases as a whole. At the Board
of Education he had endeavoured to view the mental diseases of children more
or less from that standpoint. He recognised that we had—though perhaps not
very numerous, still, there were left in the population—persons of normal mentality.
(Laughter.) What that fraction of the people is he did not venture to suggest.
He was sure there was a large number—possibly 10, or 15, or even 20 percent, in
some districts—of children who were dull and retarded ; suffering from psycho-
neurosis ; a fourth group were aments, a fifth dements, and it seemed to him they
ought to grapple with all groups nationally, and from the point of view of preven¬
tion. That meant they had got to tackie the cause. He remembered very well
when he was bacteriologist at King's College for five or six years how impressed
he was by the fact that around almost every organism there was a group of similar
but atypical organisms. He noticed, too, in almost every epidemic they had not only
the notified cases, the true type, but a zone of atypical disease kindred to it lying
outside it. When he went to the Board of Education he had the same experience.
We had in the schools a zone of children round the true mental defectives who
were so dull and retarded that they could not be educated as normal children. It
was the same with the deaf. They had a group who, though not totally deaf, were
deaf enough not to get advantage from their education. It was the same with
the blind. They had to start schools, not for the totally blind but for the partially
blind, who lay immediately outside the zone of the totally blind. Was it not likely
to be the same in some measure with the mental diseases? They had got to
think not only of the true type certified for the asylum, but of the great mass of mental
incapacity lying all around outside the typical cases of mental disease, and it was
that great zone, as in other groups, that formed the problem of mental disease.
The problem of typhoid was the problem of its first-cousins ; it was the para¬
typhoids which gave them the trouble. It had not been the true, fixed, settled
type, but the type kindred to it, similar, but not the true form. Personally he was
satisfied that the State had got to consider not so much the acute fixed type, as to
view the whole problem of mental disease a!> initio, taking a possible standard of
soundness as an ideal to seek after, so that they might become not only persons
engaged in the treatment of advanced types, but that their labours might result
in an increase in the total mental capacity of the State. That surely was the true
view-point of the State with regard to mental disease. If that were so they had
got to set to work in a larger way to consider the problem. They had got to
think of causes—primary causes, predisposition and hereditary conditions, and
also exciting causes, alcohol, venereal, and mental stress. This had got to be

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considered positively rather than negatively by the State. All of them around
that table could see what that meant. It meant that preventive medicine
had got to begin with the difficult subject of eugenics. They had got to lay the
foundation of good breeding if they were going to turn off the tap of mental
disease. They had got to think in terms of childhood, not only in terms of acute
and fixed types of the insanity of the asylums ; they had got to preach the gospel
of good breeding as the basis of national health. (Applause.) Secondly, they
had got to work much more carefully on early diagnosis of incipient mental disease.
There was a great region of unknown territory not yet mapped out. Thirdly, they
must go a step further in regard to it and make some provision foritsearly and prompt
treatment, sympathetic, physiological and psychological—something which should
• be early preventive medicine. They had a chance in England to-day, which their
forefathers never had, of seeing with wider and larger vision the application of
this method to mental disease in its early treatment and diagnosis. He was quite
sure from what he saw in the medical schools it meant a new appreciation in every
one of them of what mental disease meant. There must be a mental clinic in
every medical school, so that no student should go out into medicine and medical
practice until he possessed—he would not say profound learning on mental disease
—but until he understood the profound importance of the relationship of psycho¬
logy to all disease, and not only to fixed or final forms of insanity. They took the
student now into an asylum and said he must be proficient in psychiatry in three
months, but what understanding did he get from seeing a number of advanced
cases ? They were out on a big business when they grappled with mental disease
from the preventive standpoint. He would not say it would mean the reconstruc¬
tion of the medical curriculum, but it would mean that an understanding of medical
psychology had got to form an integral part of the equipment of every medical
man in future. Fourthly, they would require some new institutions—some
outdoor clinics and indoor hospitals, for these early and at present perhaps un¬
recognised forms of mental disease. He did not want to see these places called
by any name which would keep away patients from the door. But he was looking
forward to the time when they would have—he hoped at no distant future—an
“ early-treatment clinic” for all conditions, for all grades of patients who wished to
be treated, available for all classes of the population ; open, sometimes for venereal
diseases, sometimes for tuberculosis, sometimes for children’s maladies, sometimes
for mental conditions, an early-treatment centre, in practice attached wherever
possible, anchored wherever possible, to any well-equipped hospital. If they
could get in every general hospital a larger and more liberal understanding of
mental disease as such in relation to other forms of disease they would have
started on the high road to reform. It was early treatment of disease; prompt,
effective, competent, and adequate treatment they required. He knew this was
not going to come to-morrow; but they had got to set their faces to the light
with regard to mental disease and then he had no doubt of the future. He believed
they had got to educate public opinion with regard to the grounds of mental
capacity. For instance, it did not require much foresight to see that there was a
psychology of the crowd, which was going to become very perilous in this country
unless it was properly and psychologically handled. Again, during the war he
had to go round the munition works as Chairman of the Health of the Munition
Workers’ Committee, and he learned the lesson that there was a psychology of
industry, and that you could get a higher output up to a certain period by studying
it than you could without it. He was sure there was a psychology of mental disease,
and if there was a psychology of the crowd, a psychology of the strike, of industry,
and of disease, surely the time had more than come that they should say that there
shall be increased attention given to some psychology in the medical curriculum.
"These are the reasons,” added Sir George, “why I have come from London
to accept the honourable task which your President has placed upon me of
proposing your health. I do so with the greatest possible pleasure in my own
name and in the name of the Minister of Health, who wished me to bring a message
of goodwill. I hope he will be able, as I am sure he is willing, to do the utmost
in his power in co-operation with the Board of Control to support your Bill which
you now have in hand. The fact that he has nominated to-day one of your
members to be a medical officer on his staff, representing for the first time in
English Government mental disease, is, 1 think, some guarantee that he means

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business. (Applause.) All the great conquests of the future in this country, of
all modern advanced countries, lie in the realm of the human mind. ‘ Soundness
of mind,’ said Dr. Clouston, ‘ is the master key of all human endeavour and
progress.’ I humbly subscribe to those words, for they are my creed in pre¬
ventive medicine in its relation to medical progress. (Applause.)

The President, in his reply, said they were glad to feel that the chief Medical
Officer of the Ministry of Health would support them. Two committees of this
Association had prepared reports which were unanimously adopted, and which
emphasised the need for the establishment of hospitals for nervous disorders in
which cases could be treated in their early undeveloped stages, and it was a great
satisfaction to know that the Ministry of Health was with them. His thoughts
during the previous speech had carried him back twenty-seven years to the first,
meeting of the Association he attended—to the annual dinner held in that room.
Through all those long years he had had from the Association the utmost help
and assistance. He would earnestly entreat all their young members to go to the
meetings; they would learn something every time they went; they would pick up
much from intercourse with their colleagues, and they would find their outlook
would be widened, and the benefit they would obtain would be vastly more than
they might think. At that time he was amazingly inexperienced : he had never
been an assistant; he expected he was the last superintendent that would ever be
appointed without having been an assistant medical officer. He was amazed to
think the Committee ever had the courage to appoint him ; in fact, there was an
official protest against his appointment, and it was justified, for he had had no
adequate experience. But there was one good point about it which was not
generally adopted. He was appointed twelve months before it was necessary to
take up the work. It gave him an opportunity to learn something. Through
Dr. Hack Tuke’s assistance he was appointed to Bethlem Hospital, and there,
under Dr. Percy Smith, he got a sound insight into psychological practice at its
best. He began his practical work in lunacy at a good school. After that he
went to Edinburgh, where he was under Dr. Clouston, and where he was touched
with the fire of that great man’s enthusiasm, his extraordinary devotion and
learning, and he saw a wonderful view of psychological medicine there. A
corrective was present all the while he was there, for Dr. Robertson and Dr.
Middlemass assisted to keep him in his place. (Laughter.) He learned from
these gentlemen very much more than ever they knew, and he was glad to have
an opportunity of thanking them. After that he went to Wakefield, where he saw
scientific medicine under Dr. Bevan Lewis. Then he began his work. Twenty-
seven happy years of life had gone, and, thinking over them, the first thing he
would like to mention was the cordial relations which he had always had with
those with whom he worked, more particularly the staff and the nurses, male and
female. They who lived in institutions of that kind knew far more than the
public the devoted services of the men and women who were engaged in nursing
their patients. They were not properly appreciated by the public, and the friends
of the patients did not know the services they rendered ; the committees did not
know; only the medical officers knew, and it had been an inspiration to see their
work. It was difficult—it was appallingly difficult sometimes—and it was painful.
He thought the words of the poet, speaking of humanity in general, certainly
applied to something they all knew about, where he said :

" Here where men sit and hear each other groan ;

Where palsy shakes a few sad, last grey hairs,

Where youth grows pale, spectre thin, and dies,

Where but to think is to be full of sorrow,

And leaden-eyed despairs.

Where beauty cannot keep her lustrous eyes,

Or new love pine at them beyond to-morrow.’’

So that we were tempted in the earlier words to wish we could—

“ Fade, far away, dissolve and quite forget
The weariness, the fever and the fret.”

It was sad, but there were compensations. There was the saving sense of humour.
Some of the patients, as they knew, were most delightful. Dr. Pierce recounted
several amusing stories, and concluded by saying he had found the Association

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of the utmost benefit to him in the course of his life. He was proud to hold the
position of President, and he cordially thanked Sir George Newman for the kind
words he had used of him, and was delighted to think the Ministry of Health
held such enlightened views. (Applause.)

"The City of York.”

Mr. A. H. Trevor, proposing “ The City of York,” said he was always pleased to
come to York and to visit the Retreat, which had carried on its work uninterruptedly
for a century, and Bootham Park, which was connected with his old and valued
friend, just retired from the Commission, Sir Frederick Needham. No legal
Commissioner could ever be treated with greater kindness and consideration than
the speaker had been by Sir Frederick Needham. There was no one who took a
more active interest in promoting the welfare of the insane. Mr. Trevor acknow¬
ledged the remarks of General Thomson with reference to the Board of Control
and the arrangements they had assisted in making with regard to the utilisation of
asylum accommodation to provide war hospitals. Whatever efforts the Board of
Control made would have been futile, he said, had it not been for the extreme
cordiality with which the scheme was taken up by every local authority, advised, as
he knew they were advised, by their medical superintendents. He had been very
pleased to hear the most interesting speech of Sir George Newman. They were
now at what he hoped would be the beginning of certain improvements under the
Lunacy Acts, and it was a matter for great hope when they knew the first medical
officer appointed to the new Ministry of Health had so thorough a grasp of the
problems with which he had to deal. It would be presumptuous for the speaker
as a mere lawyer to say more, but it was a matter in which he as a lawyer on the
Board of Control had taken great interest, and it was a satisfaction to know that
some of the problems which they were particularly keen to get dealt with should be
appreciated by the officers of the new Ministry. (Applause.)

The Lord Mayor of York (Sir W. A. Forster Todd) thanked Mr. Trevor for
his references to the amenities of York and its asylum work. The irreverent had
said that York was famed for its “ lunatics and lollipops.” (Laughter.) Certainly
much of the prosperity was due to the sweetness of its manufactures, and which
had delighted the palates of many children, and, he had no doubt, afforded scope
for the professional attention of many doctors. With regard to the lunatics, it
was true that they had in or near York the City Lunatic Asylum at Naburn (which
he hoped some of the members would be able to visit—temporarily), the North
Riding Asylum at Clifton, Bootham Park, the Pleasaunce, and last, but by no
means least, the Retreat, which it was unnecessary for him to tell them was a
landmark in the history of the treatment of the insane. For some years it had
been under the most able and dignified care of their President, whom they in York
are proud to count as a citizen. The York Corporation, like other corporations
in the country, was concerned mainly now with solving the housing question, and
dealing with the arrears of work in public health and other matters which the war
has brought about. This meant that the rates had taken a leap up, but they had all
become so accustomed to the expenditure of huge sums of money that the " dose,”
which would have been most unpleasantly received before the war, had been
swallowed with scarcely a wry face in the city. (Applause.)

The Dean of York (Dr. Foxlf.y Norris) also responded, and said that if that
great concourse of experts could see as far as they ought to be able to see
—(Laughter)—they would recognise in him something closely akin to themselves.
For this reason : there hung in the Hall of the Royal College of Physicians five
portraits of men who bore an honoured name, and who were all, he thought he was
right in saying, either Treasurers or Presidents of the Royal College in their time.
They were all mental physicians. They represented five generations of father to
son and—they would forgive him being personal in this matter—they were all, he
was proud to say, ancestors of his own—his uncle, his grandfather, his great
grandfather, and his great great grandfather, and therefore he was more “ tarnished ”
than Mr. Trevor suggested. When he told the company that the name of these
ancestors was Monro he thought many of the company would recognise he was
right when he made a very special effort to be present and take his humble part in
these proceedings. He was proud to respond for the City of York. When he

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asked himself why they should have chosen York for their meeting-place he found
a multitude of reasons. Among them there was the reason that actuated everyone
when they wanted to get away from all those things which ordinarily occupied
them, from all possibility of being reminded of ordinary duties, and therefore they
came to a county which was peculiarly sane, and a county which had been—at least
till the last fortnight or so—well known for its sanity. There was another reason
which appealed particularly to him why York should be attractive. He represented
one side and the Lord Mayor represented another side of very ancient jurisdictions.
He believed even at the present moment the Lord Mayor did not exercise any
jurisdiction over the speaker’s property, and that he could do what he liked and the
Lord Mayor could not touch him so long as he was in the Dean's Park and on his
own ground. (Laughter.) There was an ancient jurisdiction known as the Liberty
of St. Peter which dated back to Edward III. |Two years ago, when there was an
idea of the military occupation of certain houses within the Liberty, he told the
officer who came to inquire about it that it would be convenient to him if a certain
house might be commandeered. The officer replied his instructions were that that
was impossible, because it was in the Liberty of St. Peter. If, therefore, he was
immune from the War Office and “ Dora,” he was also immune from the Lord Mayor.
(Laughter.) The great building within that Liberty, which dominated the land¬
scape when they got outside York, dominated the affections and loyalty of all
people in York and Yorkshire. That great building stood in every sense for
religion. He ventured with all diffidence to welcome them to York, because he
represented the Minster, and the Minster represented religion. Personally he
believed that if the country was to be what they all hoped it would be after the
war, it would only be by those who represented their noble profession and those
who represented his in the widest sense working shoulder to shoulder and hand in
hand. He believed that the forces of science and the forces of religion probably
came closer together in connection with their work than in connection with any
other branch of science. He believed the day when they thought there was any
sort of antagonism between science and religion was passing away, and he trusted
that the day was coming when they who represented the religious side of things
would take larger and wider views than in the past, and that the medical men
would come nearer to the clergy than had been customary in days gone by. When
they were both working for the highest welfare of humanity they would work
together, and therefore they would succeed. (Applause.)

"Yorkshire Medicine.”

Mr. Arthur Rowntree, proposing " Yorkshire Medicine,” said it would be
easy to go through a long list of men who had been famous in York and the
county in connection with medicine. But he might just refer to two or three who
were of special interest to some of them. They need only go back to Martin
Lister, who must have been one of the first Fellows of the Royal Society in
Charles IPs reign. He seems to have turned his attention to other things, for he
was spoken of as the first who noted with interest the piece of Roman military
architecture that York possessed in the Multangular Tower. Then there were two
surgeons at the York County Hospital, Drake and Atkinson, both better known
on other grounds—Drake as the author of the famous Eberacum, and Atkinson as
one of the founders of the Yorkshire Philosophical Society. Then, of course, there
was Jonathan Hutchinson, who went out from the medical school in York to win
fame in London. When some of them were boys the name of North, too, was a
household word in York. Those in that room, as elsewhere, might be divided into
two classes—the healers and the sufferers. The healers sometimes condemned
the sufferers to sit in their armchairs and enjoy the fellowship of books in a way
that they would not be able to enjoy them they were allowed to go about their
daily occupation. Thus he recalled the famous Dr. Slop. His biographer gave
them a vivid description of the man which none could ever forget. He talked of
his four feet of perpendicular height, his breadth, and "the sesquipedality of his
belly, which might have done honour to a sergeant in the Horse Guards.” In
such reverence did they hold Dr. Slop in York that he believed they still retained
in the archives of the Medical Society his immortal forceps. (Laughter.) He
had recently been reading with great enjoyment the life of Lord Lister, whom he

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claimed as a Yorkshireman—(Laughter)—for in the sixteenth century there were
many Listers in Yorkshire, and a matter of two or three hundred years was insuffi¬
cient to eradicate the Yorkshire strain from his blood. He was especially pleased
to claim Lord Lister as a Yorkshireman because it seemed to him he stood so well
for their profession, as he taught his students to make their progress guided by
“ unfettered truth and love unfeigned.” (Applause.) He coupled the toast with
the names of Dr. Wardrop Griffith and Mr. G. W. Gostling, the latter the President
of the York Medical Society and a real healer, as he knew, and the former the
Principal of the Leeds School of Medicine. He did it, full of local York patriotism,
for he was one of those who still believed that his ancient city of York was made
by nature and by man to be a University city. In the eighth century it was vir¬
tually a University city, and scholars were senCout from it to almost every part of
Europe. When York was practically a University city in the eighth century,
Leeds was still primeval forest. But the Fates, or the Furies, had gone against
them, and to-day they dare not ask, 11 Can any good thing come out of Leeds?”
They remembered in this connection two names among others—Sir Clifford Allbutt
and Sir Berkeley Moynihan. They also remembefed Dr. Wardrop Griffith, and he
thought of him as representative of those hundreds of healers in this great county
who in times of depression gave them back their confidence in themselves, as
representative of the hundreds of men who spent their time in alleviating untold
human suffering, and of the great procession of those men who tread the road of
life in step with knowledge and wisdom because they held that great dictum of
Pasteur, that in the field of observation chance only favours the mind that is pre¬
pared. (Applause.)

Dr. Wardrop Griffith, in responding, said the subject of Yorkshire medicine
was a very large and extensive one. He might be excused if he thought of it from
three points of view: the Medical School at Leeds, the Medical School at Sheffield,
and—the backbone of the profession—the practitioners all through Yorkshire. If
he limited his subject to the Medical School at Leeds, it naturally divided itself, as
most things did, into three parts—past, present and future. In regard to the past,
distinguished names had been mentioned. In regard to the present, one dis¬
tinguished name had been mentioned—Sir Berkeley Moynihan—and for the
speaker to have had his name mentioned alongside those of Sir Clifford Allbutt
and Sir Berkeley Moynihan was indeed an honour. Sir Clifford Allbutt
was the man who in the past was associated with Leeds, and whose name they
honoured most of all, not only for his scientific ability, but for his kindness of
heart and charm of manner, which seemed to grow greater as he advanced in years.
The speaker mentioned that when he went to Leeds in 1883 he was Sir Clifford’s
last house-physician, for he retired from the Staff of the Infirmary in 1884. Dr.
Griffith outlined the later stages of Sir Clifford Allbutt’s career, and said that
when one considered how he had adorned the position of Professor of Physic at
Cambridge University since 1891, then truly they might say this was the age of old
men. But he was still young enough to preside at medical meetings, and to speak
with all his old charm of manner and with his beautiful English which they all
admired so much. As to the future, he had only to refer them to the most
stimulating words which had fallen from Sir George Newman. The future
of the medical profession as a teaching profession, was bound up to a great
extent with the spirit of everything which had fallen from him. They had been
considering of late certain alterations which might spring from what he regarded
as one of the most remarkable documents that had ever appeared—Sir George
Newman’s “ Report on Medical Education.” If they could bring in a great many
of his suggestions, while they retained the daily-bread side of teaching, then he
ventured to think the future of medical education in this country would approxi¬
mate more to the high ideal which Sir George had sketched out. (Applause.)

Mr. G. Wilfrid Gostling said he regarded it as a very great honour to be
coupled with the toast, and he accepted it as President of the York Medical
Society. With reference to what Mr. Rowntree had said about a University for
York, might he suggest that in the Palace of the Stuart Kings, the Museum, and
the site of the exhibition they had a site for a University which, perhaps, under the
Education Committee, might be realised in the future. York County Hospital,
unfortunately, lost its Teaching School owing to the number of beds not being
adequate. He very much regretted that the Governors and Trustees were not

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far-sighted enough to increase the numbers of beds so that they could continue the
School, for with Sir Jonathan Hutchinson and Mr. Jackson they had good reason to
continue the School.

“The Guests."

Dr. Oswald said he had to propose the health of those who had accepted their
hospitality, who had broken bread with them, and who were now their friends.
It would be impossible to deal with them individually, but he must mention Dr.
Henri Colin, of Paris. They honoured him not only for his own qualities—and
they were many—not only for the eminence which he had attained in the specialty
and in the general profession of medicine, but they honoured him as a son of
France—(Applause)—France, rapidly healing of her wounds, relieved of her
agony ; France—the old but ever-chivalrous and honourable enemy of this country,
and now her firm and enduring friend. Perhaps he should have said the old enemy
of England, because, Scot as he was, he remembered she was never the enemy
of Scotland ; indeed, they cherished her memory as their ally against “ perfidious
Albion.” (Laughter.) Referring to the presence of the Dean, he said they
highly appreciated the connection between the Church and Medicine. They in the
specialty valued its ministrations and knew how much it helped them in their
work in dealing with one of the most grievous afflictions which God could put
upon suffering people. As regards Sir George Newman, he hoped he would
succeed in carrying into actual practice the ideas which he had so eloquently
expressed.

He wished to say how much they appreciated the support given them in
their difficult work by the general practitioners, how much they valued their
sympathy and help. In regard to the lay guests, he would like specially to refer to
the presence of Mr. Tuke, one of the lineal descendants of William Tuke, who
founded the Retreat, the Mecca of the mental physician. It was said that “ science
knows no frontier," and they hoped that the presence of Dr. Colin would lead to
a continuance of the friendship and intimacy between their Association and the
corresponding societies in France.

Dr. Henri Colin, in responding, thanked the members of the Association for
the honour done to the Soci^t6 Medico-Psychologique of Paris by the invitation
to their meeting. They would excuse him if he read his speech, because it was so
long since he had the opportunity of speaking English that he was not over¬
confident. Would they allow him to express the sentiments of deep gratitude
that the French felt towards them? They would never forget that England was
the first to stand by them ; they would never forget that without the British fleet
the war would have been lost, just as would have been the case if during more
than two years the French soldiers had not opposed a stubborn resistance to
German barbarism. This would have been a universal calamity, for this war was
not a war of one nation against another nation ; it was a superhuman fight in
order to save what they felt were the most noble things on earth—justice and the
freedom and rights of mankind. (Applause.) Two great democracies—England
and France—rose to defend these imprescriptible rights, and these two democracies
were well made to understand and to assist each other. Both of them had always
fought in order to insure to men a greater amount of liberty and welfare; both of
them, for this one object, had made a revolution. Was it not a marvellous
thing that, even when France and England fought against each other, they had
not for that ceased to keep a mutual esteem and admiration one for the other?
British philosophers, scientific men, were the friends of French encyclopaedists of
the eighteenth century who prepared the great Revolution. Even when they
were adversaries the French spoke of them with admiration. “ Ces tiers Anglais ’’
—" these proud English ”—said Mirabeau. The key of this mutual esteem was
to be found, he believed, in the deep sense of justice and in the keen appreciation
of individual liberty which is to be found in their two nations. An example will
enable him to make this thought quite clear. He did not believe that an affair
like the Dreyfus case could have awakened the formidable and tremendous move¬
ment which they remembered except in a democracy like theirs, or in a democracy
like that of England. This indignation, which made a whole nation rise because
an unmerited wrong had been caused to one sole man, would not have been
understood in Germany, where everything was submitted to a so-called State

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interest, as if injustice and evil could be of any use to the State. One of the
facts that struck him most during the war was that in France the incomparable
victories of a Napoleon had not prevented the thinking and liberal classes to
protest against his imperialism and despotism. This never took place in Germany,
where everybody lightly accepted the war and the worst atrocities if some profit
could be had in that way. One was amazed to think that a country which has
given birth to such a great number of illustrious thinkers and philosophers could
have been brought down to have such childish and at the same time such
monstrous conceptions. Now that their soldiers had come in innumerable forces
on the soil of France, he hoped they would understand the soul and they would
love his country ; they had been able to know it closely and not merely to get a
false idea of it by what they saw of a cosmopolitan part of Paris, which is not the
real Paris. Just as it seemed to him impossible for one to come to England to
know the English, their habits, their homes, and not to love and admire England,
it seemed to him impossible to come to France and know France without loving
and admiring France. He could not refrain from expressing sentiments which he
felt so deeply, and he thought he could not find a better place to do so than at that
meeting of psychologists, accustomed to deal with the various manifestations of
mind and the greatly diversified feelings of human nature. That was the reason
why meetings like that were of such great utility. He hoped that in their turn
they would come and take part in their Congress, especially if their next Congress
was held, as they hoped, in their dear city of Strasbourg, now at last liberated.
(Loud applause.)

During the evening a programme of piano and violin selections was given by
Mr. W. Baines and Miss Madge Tuff, Mr. Frank Straw contributing songs.

MORNING SESSION.— Wednesday, July 23RD.

Held at the Bishops’ Room, St. William’s College, York, Dr. Bedford Pierce,
President, in the chair.

Papers.

Dr. G. L. Brunton read a paper entitled " Notes on the Cytology of the
Cerebro-spinal Fluid.”

The President said the paper represented an immense amount of good work.
It was the record of original research undertaken by Dr. Brunton, and was, he
believed, an abstract of a fuller paper which he prepared for his M.D. thesis at
Edinburgh, where it obtained very marked distinction. A technical paper of that
character was a rather difficult thing to discuss. Many of them were almost
exclusively concerned with clinical medicine and their knowledge of pathology was
not great, but they had the pleasure of the presence with them of Capt. Latham, a
pathologist from New South Wales, and he hoped he would take part in the
discussion.

Dr Robertson said he thought Dr. Brunton's observations were extremely
important from the clinical point of view ; it was one of those instances where they
obtained very great help from laboratory work. Its chief reference was the
diagnosis of general paralysis and differential diagnosis of other conditions some¬
what related to it. General paralysis was the most terrible disease with which man
was afflicted, and its diagnosis practically meant sentencing a man to death, and
therefore should not be done unless every precaution had been taken. The
discovery of several laboratory tests for general paralysis enabled them to
diagnose this disease with greater certitude—in fact, he thought no disease could
be diagnosed so certainly. At the same time there were some doubtful cases, and
it was from these cases they derived help. With regard to diagnosis by these
cells he believed there was absolutely no specific test for general paralysis in
respect of the presence of these cells, or the proportion in which they were to be
found. They found them apparently in many different conditions ; they found
them in all syphilitic conditions, and he did not think there was any definite con¬
clusion to come to in regard to them. He believed the lattice-cell was merely a
degenerated cell; it looked as if the cell were become fatty, and he thought no very
special significance could be attached to it. Dr. Muirhead and Dr. Henderson
found all these cells even in the fluid of pleural effusion and tubercular meningitis.
Though it was a great advantage to have this examination of the cells, and in the
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majority of cases the help obtained was very great and confirmed one's diagnosis
of general paralysis, still, in the extremely doubtful cases he did not know that
one could come to any definite conclusion either by the presence or the percentage
of the cells. With their increased knowledge of general paralysis they realised
that syphilitic conditions—chronic syphilitic lesions—gradually passed into con¬
ditions of incurability, and the phenomena they presented resembled general
paralysis very closely.

Capt. Latham expressed his deep sense of gratitude to the reader of the paper.
He said it had been the custom in New South Wales to examine every case by
Wassermann reaction, and if there was no result the cerebro-spinal fluid was sent
down to be examined. The method employed was the same as that used
ordinarily in counting white blood-corpuscles, and they found this worked very
well, and in the majority of cases the results were as the lecturer stated. In some
cases it was valuable in examining cases of insanity due to lead poisoning, which
was rather frequent in Brisbane among children, who were much given to scraping
the powder paint from the verandahs. If not treated early by lumbar puncture it
meant total blindness. He was once asked to see a child in hospital, suffering
from encephalitis of unknown origin. He examined it and found very few cells
but an excess of globulin. A lot of very important work was done in their
laboratory in connection with the treatment of general paralysis by injecting
salvarsan, and he thought it was true to say that a large number of these cases
regularly went out of the hospital and then came back again, and the question
remained how far were they cases of general paralysis ? It was impossible at
times to tell cases of general paralysis from the peculiar conditions of the spinal
fluid. They had done several hundred experiments, and they found they very
seldom got an increase of cells without an increase of globulin. In regard to the
cell-count, in a certain number of cases it was found that the cell-count decreased
as a person went under treatment with intra-venous salvarsan and the subsequent
injection. Capt. Latham mentioned, as showing the care taken with these cases,
that they encouraged inquiry among the friends of the patients, and got to know
many wives and children on whom they found the definite stigmata. A great
many families of patients treated in mental hospitals were affected and did not
know it, and they then had the opportunity of getting treatment through the
energy of the medical officer in charge of the case.

Dr. Edwards said the thing that would come home to most of them with a
note of wonder was what Dr. Robertson had remarked about the question of
lymphocytes in the cerebro-spinal fluid not being pathognomonic of general
paralysis. In recent years most of them had made this test in association with the
Wassermann reaction, and had made a positive diagnosis on the result. He
remembered a -man transferred to his care who had no clinical trace of the
disease; he was apparently normal, so much so that the family thought
a mistake had been made. An eminent pathologist had examined the cerebro¬
spinal fluid a year earlier and had found lymphocytes. He asked him to renew
the test, but he was assured in reply that there was not the slightest use in doing so
as the former examination had entirely settled the prognosis. The subsequent history
proved that he was right. Most of them as clinical physicians had never given
thought as to the type of cells ; but, in future, he would get the varieties of cells
examined, and bear in mind Dr. Brunton’s results. In conclusion he did not think
that it had been generally realised what Dr. Robertson had told them of the
difference between the various parasyphilitic conditions.

The President said that one remark of Dr. Latham’s showed them they could
learn something from Australia. Neighbouring asylums in England were not
able to join together for pathological investigation. The auditors would not
permit it. With the very full system of co-ordination between the institutions in
New South Wales their pathological work could be done easily and efficiently.
Here every institution had to do what it could by itself; the smaller ones were not
able to join with others in co-operative work of this kind.

Dr. Brunton thanked the members for the favourable reception they had given
to his paper.

Analysis of Cases of Mental Defect.

Dr. J. E. Middlemiss read a paper entitled “ An Analysis of Two Hundred
Cases of Mental Defect.”

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The President said they would prefer to read the paper quietly before dis¬
cussing it, but he would like to say he thought Leeds was to be congratulated on
possessing a medical officer who took such pains with the cases of mental defect
with which he had to deal.

Col. Dawson associated himself with the President’s remarks and said they
would learn much from the paper when they had been able to study it quietly.

Dr. Edwards said the references to the stigmata of degeneracy were full of
interest, and he wondered if Dr. Middlemiss had noticed any large proportion of
the condition of polydactylism, web-finger or other abnormalities. In his own
personal observation he had often noticed the conformation of the hand was of a
simian type in people who developed dementia prsecox.

Dr. Middlemiss said he did not recall many cases of actual polydactylism. He
had met cases where there was disparity in two or three fingers, but the toes were
approximately the same length. He did know that he had noticed hands abso¬
lutely comparable to the dementia prcecox type of hand ; he had met them long
and flat. He was convinced anomalies of the hand were properly described as
stigmatic.

War Fatigue as a Cause of General Paralysis.

Dr. Henri Colin contributed a paper on “The Influence of War Fatigue on
General Paralysis.” He summarised his paper as follows :

(1) The question of the reform of general paralysis in the Army in France has
gone through two phases. It is only since July, 1917, that the great majority of
psychologists have recognised that in the aetiology of Bayle's disease the influence
of the war was much greater than had been supposed to be the case.

(2) The observations which had been gathered in the military section of the
Villejuif Asylum, which is placed under my direction, have confirmed us in that
conviction. Especially the rile of all kinds of fatigue, toxi-infection, emotion,
etc., has seemed to us to play a most real part in the exceptional rapidity of the
evolution of general paralysis in the fighting units.

S The most recent services of general pathology explain the rile. General
ysis is due to a hypersensibility of the nervous tissue. It is also, clinically
speaking, a malady due to exhaustion. This notion of exhaustion enables us to
do the synthesis of the observed cases.

The President, congratulating Dr. Colin, said he had raised many serious
problems which were of great importance in this country. The question of the
extreme rapidity of acceleration of general paralysis arising from war strain was
one of which he personally had not had much experience, but there were service
members present who would be able to say whether the observations in Paris
corresponded to those in England. He felt that the whole question of the
retiology of general paralysis was at present in a most unsatisfactory position.
The London school had always held the doctrine, “ No syphilis, no general
paralysis,” and it had gradually gained ground until it was almost an accepted
dogma. He had always had doubts of its truth. In a large percentage of cases
spirochaetes can be found in the cortex of the brain, but the evidence is not satis¬
factorily demonstrated. He had asked pathologists about them and they told
him there was an immense number. They were found in everybody's mouths
in conditions of health, and the differentiation was by no means satisfactorily
established, nor their life-history particularly well worked out. He was not aware
that the micro-organism which was found in the brains of sufferers from general
paralysis was sufficiently identified as the spirochrete of syphilis. If syphilis was
the basis of general paralysis, why was it they never found the tertiary symptoms
in general paralysis? It was most unusual to find well-known syphilitic stigmata
in persons who died of general paralysis. He had been much struck by the facts
which Dr. Colin brought out as to the causation of general paralysis—emotion,
accident, and so on. We had a great deal yet to learn of the part which the
micro-organism played in its genesis.

Col. Dawson congratulated M. Colin on a-i extremely interesting paper which
raised many points. Owing to his position as Mental Specialist to the Irish
Command and the special medical board which dealt with Ireland, Col. Dawson
said he had seen a certain number of cases caused by war conditions. These
cases had not presented any very marked peculiarities. Of course he had no

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observed them from day to day, but his impression was that they were not of a
specially rapid type. General paralysis in Ireland was almost a rarity ; most of
the country places in Ireland were absolutely free from venereal disease, so com¬
paratively few of the Irish soldiers had been syphilised in the first instance what¬
ever may have happened when they were abroad. As regards the aetiology of
general paralysis, personally he believed syphilis was the essential factor, but so
small a number of them developed general paralysis that there must be other
influences giving rise to it. Fatigue must have played a leading part, combined
with emotion and toxins. He would like to know if alcoholism played a
leading part in Dr. Colin’s cases, because he had thought that in civil life
alcoholism had played a leading part on nervous systems weakened by syphilitic
virus. Many of Dr. Colin’s colleagues laid great emphasis upon the influence of
alcohol. If one admitted, as he thought they must admit, that comparatively few
syphilised people got general paralysis, then it followed that there must be a
number who w'ould not get it if it were not for the stress and strain and toxins
brought to bear upon them. That being so it was obviously unjust to penalise
men who developed it, by reducing their pensions. Personally, he thought a man
who, so far as they could tell, was sound when he went out, and who, as a result of
service, had developed general paralysis, was due for a full pension. With regard
to the question of the absence of tertiary signs, which was the rule in general
paralysis if not invariably so, he did not think there was much in that, because they
found the same thing in other conditions which were toxic—for instance, in alcoholic
diseases of the nervous system. They did not get cirrhosis of the liver in asylums
although in many cases the insanity was due to alcoholic indulgence.

Dr. Robertson added his thanks to Dr. Colin for his masterly summary of the
aetiology of general paralysis. He believed the procedure in this country in regard
to the pensions of those suffering from general paralysis was very largely founded
on the work done by Dr. Colin. His observations on special cases of general
paralysis confirmed those presented by Dr. Colin. They had been impressed at
Morningside by the rapid course of general paralysis during the war. Dr. Colin
had raised the whole question of the astiology. His own inclination was rather
against the hypothesis that there were accessory factors, but his belief had been
somewhat shaken by what Dr. Colin had said and the evidence he had produced.
He thought they might agree that the statement, “ No syphilis, no general paralysis,”
was absolutely true. He did not think any statement had been made which
refuted it. The point was, Why should so few who suffered from syphilis develop
general paralysis and so many escape? In the first place, general paralysis was a
disease which started very late ; he only knew' three cases in which it started
within three years of the infection. The best explanation of this was that general
paralysis must be looked upon as a hypersensitive reaction. If this were so they
must look upon it as a condition in which there was re-invasion of the brain by
spirochsetes some years after infection—generally five years.

The President : Where is the micro-organism all the while ?

Dr. Robertson said the brain was invaded in the secondary stage, and then
there was a latent period during which people were supposed to be cured. In this
stage, where there were no apparent symptoms, they knew by the Wassermann
reaction it was merely a latent condition, and then for some reason—it might be
alcoholism—the spirochaete became active and invaded the brain a second time. It
was quite true, as everyone realised, that they seldom got cases of general paralysis
which had had tertiary lesions, but there had been numbers reported and he had
seen certain cases. Seeing that general paralysis did not develop, on an average,
till at least five years after syphilis, and a very large number of those who suffered
from it recovered—Boas made observations in 2,000 cases of syphilitics and found
in two-thirds of the cases negative reaction, therefore they still had one-third
suffering from latent syphilis—they might say they had 9 to 15 per cent, of the
cases of latent syphilis developing general paralysis. That was a very large per¬
centage, but if they compared it with the number of lesions in other diseases—take
diphtheria and diphtheritic paralysis—it did not amount to more than 12 per cent.
of the cases in which it developed. No one dragged in accessory factors as to
why one suffered from diphtheritic paralysis. Why should there be any extra
factor in the syphilis cases? He did not think it at all necessary there should be
an accessory factor called for. There was one point connected with the tetiology

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of general paralysis worth reference : lie thought the amount which developed in
women and children was not relatively the same proportion as developed in men.
The amount of general paralysis among women is comparatively small, and they
knew a very large number of children suffered from inherited syphilis, especially
amongst imbeciles, but the amount of general paralysis that occurred in young
children was very small. It was only in 1877 that Dr. Clouston described his first
case of juvenile general paralysis. It was an extraordinary thing there should be
a lesser number developing general paralysis in children, and it was possible they
were not subjected to the accessory factors—as Dr. Colin and others stated—of
accident and alcoholism. That might be the explanation. It had been a great
pleasure to have Dr. Colin to present them with such a masterly paper, and as an
associate member of the French Society it gave him additional pleasure to thank
him for his address.

Dr. Ross said that in the later years of the war he was posted to a northern war
hospital for general paralytics. He was present at the time of their reception, and
having charge of the refractory wards he got nearly all the general paralytics.
There was a very large number of young men, twenty-six years of age or there¬
abouts, many of whom had a history of recent syphilis—quite a number since the
war began—and therefore there could be no doubt about the acceleration of the
disease. A large number were very excited and had to go into the refractory
wards, so there was little doubt about the aggravation of it. Also a very large
number died or were in a moribund state in a very short time, and that was why
they had not been seen in civil hospitals. These men were kept in military
hospitals rather than sent to civil asylums, and many went down in health
rapidly. Another point—and this would interest Dr. Brunton—when the cerebro¬
spinal fluid was examined in many cases a large number of them had an enormous
number of cells. He wondered what had been the general experience of repatriated
prisoners. Quite a large number had turned out to have general paralysis—in
fact some of their medical men wondered whether the Germans had been playing
tricks. These men had been exposed to all sorts of privation and hardship—more
than the average soldiers—and the great majority had a history of brutality, and
these might constitute factors in the development. One thing had rather
dismayed him—the large number of cases not recognised although they showed a
great many of the symptoms. He quoted the history of one case; the doctors had
noticed at different times all the symptoms, yet general paralysis never once
appeared on the man's sheet until he (Dr. Ross) actually wrote it in himself. It
was the worst case he had had. He thought it was rather appalling how very
many general paralytics went about the world unrecognised by medical men.

Capt. Latham said that in Australia the serums of patients in temporary
syphilitic hospitals were examined. The medical officers seemed sceptical of the
result and asked him to do it again ; apparently for some reason or other the incuba¬
tion period seemed too short and most of the soldiers too young. In most cases
the symptoms were very mild, and being very mild the medical officers doubted
the diagnosis. In a certain number of cases where the cerebro-spinal fluid was
examined there was no doubt—particularly in view of the quantity of globulin—
that they had to deal with very serious lesions. In contradiction to Col. Dawson’s
experience, general paralysis was a very serious disease in Sydney and one of
the most important causes of death in New South Wales. Their medical officers
were well acquainted with it, and one was surprised with the suddenness of the
symptoms needing certification. The onset was frequently too sudden for sclerosis,
and it gave one the impression that they were suffering from toxaemia. As to the
causation of general paralysis by syphilis, he said they had tried injecting animals
with small quantities of spirochaetes, and in a certain number of cases they had
induced a condition resembling general paralysis.

Dr. Colin, replying on the discussion, said they all agreed that alcohol besides
syphilis must be a factor of general paralysis, but in war time they had not noticed
the preponderating influence of alcohol. He was glad to see from an article in
the last number of the Journal of Mental Science that Dr. Chambers had come to
the same conclusion. A certain number of absolutely teetotal physicians were apt
to come to false conclusions on this matter. Fever symptoms were so often like
alcohol symptoms that care must be exercised not to confuse one with the other.
He did not think the influence of alcohol in general paralysis was very great. He

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was of Dr. Robertson’s opinion that syphilis was the primary factor. He always
felt that if it were the only cause of general paralysis, then men had not a right
to a pension ; but, though it was the primary cause, there were many others. He
mentioned that he had had a case where only a few months intervened between
re-infection and the onset of general paralysis. In reference to the case of
returned prisoners, he had noticed that there were many instances of general
paralysis, and it was horrible to think they had not been noticed while prisoners in
Germany. The same lack of recognition of cases as bad happened in England had
also occurred in France, where general paralytics had been swept into the Army.
He quoted the particulars of two typical cases, and said he agreed that in every
country the knowledge of the retiology of mental diseases was still in a backward
condition.

MENTAL DEFICIENCY.

A representative meeting, convened by the Essex Voluntary Association for
the Care of the Mentally Defective, which will lead to results of far-reaching
importance, was held at River Plate House, Finsbury Circus, London, E.C. 2, on
May 29th, when a large body of justices decided that a practical mental expert
be appointed to advise Essex courts of summary jurisdiction on the mental
condition of doubtful cases charged with crime. Above one hundred justices
from Essex, Colchester, East Ham and Southend were present. The following is
a summary of the speeches and the arguments brought forward:

The Chairman of the Essex County Council (Mr. W. S. Chisenhale Marsh),
in opening the meeting, said that during the last fifteen or twenty years the
practice of giving bail to persons had made it difficult to keep the mentally
defective under observation. He had received a letter from the Magistrate at
Westminster Police Court suggesting that remand homes were wanted for medical
observation.

Mr. Trevor, a Commissioner of the Board of Control, said: It will be
remembered that the Report of the Royal Commission on the Feeble-minded stated
that there were large numbers of defectives whose wayward and irresponsible lives
caused an infinity of trouble and misery to their friends and themselves, entailing
a great deal of wasteful expenditure on the community.

As the result of the Report of the Royal Commission the Mental Deficiency
Act, 1913, was passed, which provided for the custodial care of defectives under
very careful safeguards. Before much could be done in working the Act the war
came, and, not unnaturally, any effective working of the Act had to be postponed.
Now that, as is hoped, peace has returned, the Board of Control are urged by the
Government to do all that is possible to encourage local authorities to work the
Act. At the same time a Bill has been presented to Parliament to remove
the limitation of the Government grant of £150,000 which had been inserted in
Section 47 of the Act, and which had been allocated amongst the various local
authorities in England and Wales on the basis of population. The result now is
that local authorities will no longer be restricted by the limited amount of the
grant allocated to them, but will receive half of all approved expenditure. It
must not be thought that such a step indicates any reckless extravagance, for, on the
contrary, it is hoped that an expenditure of money now will effect real economy in
the future.

The general scheme of the Act is this : In the first place certain definitions are
given of defectives, which include idiots, imbeciles, feeble-minded persons, and moral
imbeciles. The circumstances are then set out which enable defectives coming
within these categories to be dealt with under the Act. When any such defective
is dealt with by order under the Act the local authority has the duty imposed on
it of making provision for the case, and the Government contributes one-half
towards the cost of its maintenance. The Act proceeds to impose certain duties
upon local authorities, and also certain duties upon justices or judicial authorities
when called on to make orders under the Act.

Duties of local authorities: Ascertainment. —Sect. 30 (a) of the Act provides
that it is the duty of a local authority to ascertain what persons within their area

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are defectives subject to be dealt with under the Act. This duty up to the
present has only been partially carried out, and is complicated by the fact that a
local authority has no duties in the first instance as regards defective children who
are being dealt with by local education authorities, or defectives who are
being dealt with by Poor Law authorities. The Royal Commission reported
that there were some 150,000 defectives at large in the country, some 60,000 of
whom were in urgent need of supervision. At the present time less than 10,000
defectives are being dealt with under the Act, and of these between three and four
thousand were being dealt with under the Idiots Act before the Mental Deficiency
Act came into operation. It is evident that a great deal still requires to be done
in the direction of ascertainment.

Accommodation .—The local authority has also to provide suitable accom¬
modation for persons dealt with under order. Speaking generally, in England
and Wales but little new accommodation has been provided. Essex is more
fortunately situated than most other counties, inasmuch as it is able to send its
most pressing cases to the excellent Royal Eastern Counties’ Institution at
Colchester. It has also a call on the institutions of the Metropolitan Asylums'
Board, which have been approved under Sect. 37 of the Act. The Board of
Control think that the county will have to take steps to get more of the Poor
Law institutions within the area approved under this section.

Duties of Justices .—In making orders for the detention of defectives under
the Act very responsible duties are imposed on the justices, whether sitting in
court or acting as judicial authorities under the Act. Many of the requirements
of the Act are very complicated, but, in view of the serious consequences of the
making of an order to the person affected, a certain amount of strictness is
undoubtedly required. It has to be remembered that some of the cases in which
justices will properly be asked to make orders are not easily recognisable
on the view. Feeble-minded persons and moral imbeciles present some of the
most difficult psychological problems, and in these matters it would be advisable
for a justice not to depend on his own impression of the case but to be absolutely
guided by the two medical certificates.

The ultimate success of the Act must depend on the completeness with which
juvenile cases are deal with. At the present time it is impossible to find institu¬
tions in which to detain all the adults who require protection. With the children,
however, if they are duly reported by the local education authority before leaving
school and are then dealt with by the Mental Deficiency authorities, good results
should be shown in a comparatively short space of time. Complete co-operation
is essential between local authorities, local education authorities, and poor-law
authorities, and it appears to the Board of Control that in the case of a large
county like Essex it would be very advisable to appoint a whole-time expert medical
officer, whose duty it would be to advise and report on all cases occurring within
the area of the county. The Board of Control are entirely in favour of the resolution
which is about to be put to the meeting.

Sir H. Bryan Donkin, Director of Convict Prisons : I am glad of the opportunity
of making a few remarks on this subject. The prison authorities, and especially
the medical department, contributed largely by their repeated representations
to the appointment in 1904 of the Royal Commission on the Care and
Control of the Feeble-minded (of which I was a member), and this led up in time
to Parliamentary action. More than twenty years ago, when I was appointed a
Commissioner of Prisons, I was soon convinced of the necessity of a change in the
law under which all more or less irresponsible offenders, except such as could be
certified under the Lunacy Acts, had to be tried as ordinary criminals, and treated
as such with respect to their discharge on licence or on expiry of sentence. The
only really differential treatment they have even now consists in the fact that they
have been for many years regarded and separately classified while in prison as
weak-minded, and placed by the Commissioners under special medical regulations
as to supervision, employment, and treatment generally.

The Royal Commission reported in 1908. It was not until 1912 that a Bill
embodying a considerable part of its recommendations was introduced into
Parliament. Opposed by vigorous parti-coloured criticism, it was withdrawn by
the Home Secretary, and in 1913 another Bill, widely differing from the first in
many important respects, became the present Mental Deficiency Act. This Act

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has caused much disappointment among the supporters of the first Bill, and much
tribulation among those who have to administer it, both medical and lay.

The remarks I am about to make in support of the resolution concerning the
appointment of a specially qualified medical officer to assist the courts in dealing
with suspected cases of “mental deficiency” are merely general, and are intended
as a preliminary to the more practical information and comments which will be
given to this meeting by Dr. Treadwell out of his long and up-to-date experience
both as former prison medical officer and as a Commissioner. It is no easy
matter, even for an expert, in some cases to decide justly whether any person of
any age is mentally defective to such a degree as to be regarded and treated as
more or less irresponsible, or, in other words, unfitted for such punishment as would
be rightly awarded to the average sane individual. It follows that no action should
be taken in the direction of deciding the question of any offender’s mental con¬
dition without having recourse to an accredited medical opinion. But it is equally
important that the courts or councils who may appoint such medical advisers
should recognise fully that in a considerable number of cases it is impossible even
for the most experienced practitioner to form a trustworthy opinion in one interview.
This is a point of first importance, which Dr. Treadwell will illustrate.

I agree with those who urge that suspected “ mental defectives ” should not be
sent to prisons for the purpose of obtaining medical opinions on their mental
state. I have very good reason to be convinced that in the larger number of
instances the opinions of the medical officers of prisons are of the highest value at
the present time ; but in a service which in some of the smaller prisons is supplied
by local practitioners it is not to be expected that every one of them would take
the responsibility of deciding on a case of patent difficulty. Moreover, it seems
to be not fair that the suspected “ defective ” should be sent into a prison at all for
the purpose of obtaining a medical opinion.

The existing difficulty as to the certification of mentally defective offenders is
mostly due to the drafting of the Bill of 1913—now the Mental Deficiency Act.
At the head of this Act are certain so-called “ definitions ” of the various grades of
defect, and it is enacted that only those persons whose cases can be stated to
come under these “ definitions ” are to be certified as mentally defective. These
descriptions or interpretations of the words idiot, imbecile, feeble-minded and
moral imbecile are generally taken to imply that in every certificate there must be
evidence given that the alleged mental defect did exist from birth or from an early
age. At any rate, such is the meaning seemingly placed upon this clause by the
Board of Control; and such also is the way in which many, if not most, of the
medical men called upon to certify, do actually read it.

It follows that this clause of the Act, interpreted as it is, and probably
correctly interpreted as far as literal accuracy goes, demands a far more rigid,
and, indeed, a far more impracticable definition of congenital mental deficiency
than is required in the case of certification in lunacy by either the Board of Control
or any court of law. As a matter of fact there is no definition at all of " lunacy "
(i.e., the state of lunacy) in the Lunacy Acts. It is true that in the glossary of the
Lunacy Act, 1890, it is said that “ lunatic ” means an idiot or a person of unsound
mind. This merely divides “ lunatics ” into two classes ; but there is no attempt
to say what is meant by either of the terms “ idiot " or “ unsound mind.” I suppose,
however, that most doctors in certifying take idiot to mean mentally defective
from birth, and unsound mind to mean a disordered or defective mental state of
a person whose mind has once been sound.

It was not the intention of the Royal Commission on the Feeble-minded, or, as
I believe, of the framers of the Bill of 1912, to make the above-named so-called
definitions statutory as they stand now in the Mental Deficiency Act, October,
1913, or to require that contemporary evidence must be obtained in all cases that
the person to be certified was actually known to be defective in early childhood.
This requirement is seen on reflection to be absurd. In a large majority of the
cases with which the Mental Deficiency Act was meant to deal the diagnosis of
the early origin of the defect, even without any contemporary evidence of it, is"as
sound and trustworthy as that of a large number of diagnoses made not only in
lunacy, but also in many other departments of medical practice which of necessity
are based to a considerable extent on analogy and inference.

I am forced to the opinion that this provision at least in the existing Act should

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be altered, for it seems very unlikely that its present interpretation will become
enlightened by the process of time alone. At present the claim in question is not
only one example of the proverbial differences between medicine and the law, but
it is also a stumbling-block for practitioners in each of these faculties.

Mr. O. F. N. Treadwell (Prison Commissioner): I am very glad of the
opportunity afforded me by the kind invitation of the Essex Voluntary Associa¬
tion to attend this meeting, and say a few words on the working of the Mental
Deficiency Act, 1913, from the prison point of view.

We have had a good deal of experience during this past five years, particularly
as regards the difficulties involved in certification, owing to the limitations imposed
by the Act and of the delay, which appears to be unavoidable at present, in finding
institutions to accept the cases.

As regards the difficulties of certification, these are probably more fully realised
by those who have to deal with cases in prison than elsewhere, because it is the
commission of some crime that accentuates the need for action. Practically all
the cases we deal with are over the age of sixteen—many are adults; obviously
they have always been mentally defective, but they have, before the commission
of the offence with which they are charged or for which they have been convicted,
escaped recognition, or at any rate certification. They are therefore evidently not
obvious cases. It is, of course, the commission of some obvious offence which
accentuates the need for institutional treatment, care and control.

Sect. 1 of the Act defines the classes of persons who shall be deemed defectives
within the meaning of the Act. I need not refer to classes (a) or (6)—idiots and
imbeciles. They seldom come to prison or present difficulty.

Class (c)—feeble-minded persons—differ very much in degree and kind, and
many present much difficulty. There must be intellectual defect; but in cases
where the defect is not of marked degree it is not always easy to say whether it
is the result of developmental defect, or due to want of, or neglect of educational
opportunity. Age has an important bearing. The older the person when coming
under first observation, the more difficult it is to prove that the condition existed
from birth, or from an early age. Very commonly they come for the first time
under the observation of the medical officer of the prison. The early history of the
case is generally essential; this necessitates research and delay. Most medical
officers are extremely loath to certify without a full early history.

When we come to class (d )—moral imbeciles—our troubles really begin. This
class is perhaps the most frequent and certainly the most troublesome met with in
our prisons. Naturally this is so, because the definition connotes disorder of
conduct, and it is for some disorder of conduct that they are brought before the
courts and into prison. Where a moral imbecile is also a feeble-minded person
the task of certification is of course easier. Again, certain offences of themselves
indicate probable mental defect, but many of these moral imbeciles come in for
offences such as are common to ordinary criminals. They frequently exhibit
little or no intellectual defect, have attained a very fair education, and in prison,
unless they are violent, destructive, or intractable, prone to self-injury, suicide or
feigned attempts at suicide, may have no opportunity to demonstrate the particular
quality of misconduct to which they are addicted. Perhaps the most prominent
feature in this type is “ lack of control,” but it is not easy to say whether this is
inherent in the individual. Age, again, is an important factor. Obviously they
have always been mentally defective, but no action has been taken to deal with
them until they commit crime, or repeatedly commit crime, and the urgency for
action then becomes apparent.

The following case is a good illustration, perhaps, of the difficulty experienced.
A young woman, set. 20, charged with false pretences, tried at quarter sessions,
found to be mentally deficient, ordered to be detained for twelve months in an
institution, which, however, refused to receive her; returned and was liberated.
Admission to another home was secured and she remained there some time, but
was found to be unmanageable and released. Again brought up for larceny and
sentenced to twelve months’ hard labour. Certified under sect. 9 (I), (rf), as a
moral imbecile. Said to be cunning, plausible, vain, deceitful, very untruthful,
and sullen if corrected. Has been troublesome since the age of seven years, when
she ran away from home. Incorrigible, prone to suicidal attempts, but it is
doubtful if they are genuine. Six convictions had been recorded against her since

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the age of thirteen and a-half. Removed to an institution for mental defectives.
After about a year licensed from there, the authorities reporting that under super¬
vision she has behaved well, showing great restraint and self-control. A few weeks
after again brought up for stealing and sentenced to twelve months’ hard labour.
In prison violent at times and further attempts at suicide. Re-certified, and
again removed to an Institution.

In all cases the early history is very valuable ; it necessitates much careful
inquiry and research, and takes time to collect. I must take this opportunity
of saying how much we are indebted to the Essex Voluntary Association for
kindly placing at our disposal much valuable information as to early history in
several cases from the county of Essex.

A few words as to Borstal detention for young adults. Borstal detention is not
at all suitable for mentally defective persons. The Borstal institutions are for
the express purpose of teaching occupations which shall fit the young delinquent
for industrial life outside, and for reformation of character. Mental defectives are
a source of much trouble; they tend to contaminate and corrupt the normal
inmates. The Commissioners always strongly recommend to the courts that
young persons suffering from mental defect should not be sentenced to Borstal
detention.

And now as regards procedure when a case comes before the court. It is of
the utmost importance, I think, that a mental defective should be dealt with by
the court of competent jurisdiction under sect. |8 of the Act, rather than that a
sentence should be passed with a view to action under sect. 9. Prison is not a
suitable place for the detention of mental defectives if it can possibly be avoided.
Dr. Potts will, I hope, tell us of the procedure which has been adopted at
Birmingham, but I may say that the Prison Commissioners are endeavouring
to co-operate with the Birmingham justices, by setting aside a portion of the
hospital wings—both male and female—for the reception of such cases on remand
as they are compelled to send into prison for observation and report.

It is intended to appoint a whole-time medical officer of the prison service in
order that he may devote himself as part of his duty primarily to the examination
of these mental cases. Where an expert medical practitioner is appointed with
whom the justices can confer, very valuable co-operation and consultation can be
arranged between him and the medical officer of the prison in certain cases which
for some reason or other must be remanded to prison.

In conclusion I should like to say a few words as to the use of prisons as
“ places of safety” under the Act. If it is admitted that prisons are unsuitable
for the detention of mental defectives, they are unsuitable for use as “ places of
safety.” Unfortunately there is often much delay in finding an institution to take
the case; consequently the court cannot make an order, but directs that a petition
be presented when an institution has been found, as provided for in sect. 8. A
mental defective may thus be detained in prison for some time—perhaps two or
three months. If no institution can be found, the person cannot be kept indefinitely
and has to be discharged. No doubt as institutions increase in number and
become available, this will be rectified.

I have perhaps said sufficient to indicate how important it is to have expert
medical advice available at the trial of these mentally defective persons, and I can
cordially support the resolution which is to be submitted to this meeting.

W. A. Potts, M.A., M.D. (Medical Officer to the Birmingham Committee for
the Care of the Mentally Defective ; Psychological Expert to the Birmingham
Magistrates) : During the war many authorities refrained from carrying out their
duties under the Mental Deficiency Act owing to the necessity for economy. That
reason for delay is now happily removed. As a matter of fact, however, it never
was an economy to ignore defectives who ought to be segregated. If you reflect
that 15 per cent, of all persons in prison are mentally defective, that 30 per cent, of
those in rescue homes are equally irresponsible, and a similar number of the women
in the maternity wards of the workhouse are of the same type, it requires no great
effort of the imagination to see that leaving these cases uncared for really means
keeping up more institutions and a larger staff of attendants than would be required
if such mental defectives were properly cared for from the first in a suitable institu¬
tion. Often during the war a mother, who might have been working at munitions,
was forced to stay at home to look after one defective child, when one attendant

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might have been looking after ten defectives in an institution. Even if neglecting
these cases meant economy now, it certainly does not mean anything of the kind for
future generations. It has been estimated that one criminal, the notorious Ada
Juke, known as “ Margaret, the Mother of Criminals,” cost the United States
1,300,000 dollars, owing to the fact that of her twelve hundred direct descendants,
nearly one thousand were criminals, prostitutes, paupers, inebriates, or insane. A
similar woman cost the Germans much the same sum ; of the German woman’s
direct descendants seventy-six were convicted of crime and several of murder.

One fallacy in connection with defectives is the idea that anyone can recognise
them. This is due to many people thinking only of idiots, and overlooking the two
higher grades, the imbeciles and the feeble-minded. These higher grades have a
greater potentiality for harm, and are a much more numerous class. Often only
doctors with special experience can recognise them. Not only do ordinary
people fail to see them, but often ordinary doctors do so, too; it is essential
that they should be examined by a medical practitioner who has had special
experience of such cases.

One reason why defectives are often overlooked is because many people do not
understand that mental defect is a disorder, not of the intellect, but of the mind ;
intelligence is only one province of the mind and may be unimpaired in mental
defect; the diagnosis rests on disorder of conduct and lack of adaptability to the
environment.

How then are magistrates to recognise such cases ? They cannot be expected to
diagnose them. What they should do is to refer to their expert all cases they do
not quite understand, especially when frequent repetition of the same offence,
unusual offences, or offences inconsistent with the home and general upbringing
of the delinquent, suggest the possibility of mental defect or some other
abnormality.

The medical examiner will never get all the cases he ought to have under the
Mental Deficiency Act unless some such scheme is adopted as that recently
inaugurated by the Birmingham justices, for which we are so greatly indebted to
their chairman, Mr. Beesley. Under this scheme are referred not only the
obviously mentally defective, but also those in whom there may be such a defect.
This scheme has already been the means of saving from prison young delinquents
who ought never to go to prison, because their crime is the expression of some
mental or physical abnormality which can only be properly dealt with in other
ways. Cases referred by the magistrates because the cause of crime appears to be
a complete mystery are not necessarily hard to understand when the prisoner is
thoroughly examined, and especially when methods are employed to see how far
mental and physical abnormalities, unsuitable occupations and surroundings are
responsible. Modern treatment can work wonders in many of these cases.

Mr. |ames Tabor (Chairman of the Essex County Committee for the Care
of the Mentally Defective), proposed the following resolution :

"That this meeting, realising the necessity of expert medical opinion
in doubtful cases under Section 8 of the Mental Deficiency Act, 1913, brought
before courts of summary jurisdiction, requests the Standing Joint Committee
to consider the provision of such expert medical assistance for all Petty
Sessional Divisions in the administrative County of Essex.”

He said that, owing to the war, the activities of mental deficiency committees had
been much restricted, but that possibly that had not been a bad thing for them, as
they were, so to speak, on probation, and could not have been as successful as they
had been if they had not carried public opinion with them. This he believed they
had done, and that now, with the cessation of hostilities and the issue by the Board of
Control of the circular of March 8th, 1919, they were ready for greater exertions,
and that any steps that they took would be supported by the public, even to the
extent of asking for further legislation, if necessary, to carry out their programme.
During the war they had concentrated their attention chiefly on the children passed
on to them by the Education Authorities, but now they would be in a position to
deal with adults also—a most important branch of their work. To enable this
to be done efficiently, magistrates, before whom many mentally defective persons
came, should be able to call in the assistance of a medical expert where there was
any doubt as to the best method of adjudicating upon their cases in their own
interests and in those of the community, for it was the high-grade defectives—

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defectives as to whose mental condition only an expert could speak definitely—who
were the greatest danger to the nation, and should be put under efficient control
that the supply of mental defectives in future generations might be cut off at the
source. He therefore trusted that the meeting would support the resolution then
and there, and that such of them as were magistrates would make full use of the
expert, if and when appointed.

Capt. A. J. Unett, D.S.O. (Chief Constable of Essex), seconded the resolution
which was passed unanimously.

Since the above report was in print we have received the following contribution
from Dr. Edgar Hunt, which we add with pleasure as a supplement to the report.
—Eds

SOME NOTES

on a representative meeting, convened by the Voluntary Association to discuss
the administration of the Mental Deficiency Act (with special reference to criminal
defectives), and held on May 29th last at River Plate House.

By Edgar A. Hunt, J.P., M.R.C.S., L.R.C.P., L.S.A., Medical Visitor to the
Justices under the Lunacy and Mental Deficiency Acts for the county of
Essex and the Borough of Colchester, Chairman of the House Committee of
the Royal Eastern Counties’Institution for Idiots, Imbeciles and the Feeble¬
minded, etc.

1 will deal first with the main resolution, which was proposed by Mr. Jame
Tabor and carried unanimously, vie., “ That this meeting, realising the necessity
of expert medical opinion in doubtful cases under section 8 of the Mental Deficiency
Act, 1913, brought before courts of summary jurisdiction, requests the Standing
Joint Committee to consider the provision of such expert medical assistance for
all petty sessional divisions in the administrative county of Essex.”

When 1 voted for this resolution I was under the impression that what was
intended was the appointment of one mental expert for the whole county—a new
whole-time official—a medical man, if possible, somewhat after the style of Dr.
Potts, of Birmingham.

But a circular letter of Miss Nevill—the excellent and indefatigable organising
Secretary of the Essex Voluntary Association for the care of the Mentally Defec¬
tive—dated July 3rd, states “ until after the appointment by the various benches of
a court doctor, who is a practical mental expert, etc.,” surely it is not fora moment
contemplated that a mental expert is to be appointed for each bench of magis¬
trates ! Real mental experts are few and far between. In the old days before the
Mental Deficiency Act was passed—in the course of an extensive general practice
extending over a long period—l used to be astonished at the ignorance of medical
men generally about mental disease. Again and again they refused to sign certi¬
ficates under the Lunacy Act when there was no doubt a certificate should have
been signed in the interest of both the patient and the public. I wonder disasters
have not been more frequent than they have been owing to this unreasonable
refusal to certify. Heaven knows there have been many more than there ought
to have been ; and where there has not been disaster there has frequently been a
large amount of sorrow, distress, worry and expense to the relatives which they
might and ought to have been spared. If there was difficulty in getting cases
certified under the Lunacy Act, there is ten times as much difficulty under the
Mental Deficiency Act—this was well brought out and ably commented on during
the meeting. I do not hesitate to say that under present conditions the usefulness
of the Mental Deficiency Act is being much impaired because of the inability of
numbers of medical men to deal adequately with the cases brought before them.
I am not in a position to judge how mental defect is now being dealt with at the
various schools of medicine. I entered at St. George’s in 1874, and in my time
the education'imparted to students in mental disease was lamentably inadequate.
It is obvious that a special training is now required to enable students to act at all
properly in the carrying out of the Mental Deficiency Act when they become
qualified. It may be such training is being given, and I hope it is. How
necessary it is is shown by a single case of much interest which came under my
notice in one of my recent official visits. The lad concerned is undoubtedly feeble¬
minded, and has been classed as such by one or two experts. He is a section 8

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case, and an appeal is impending. Jn connection with the necessary legal pro¬
ceedings several medical men have been consulted, and no less than four of them
—and some of them were medical men of considerable standing—have definitely
certified that the lad is not feeble-minded. When in doubt classify the case as
“ backward " is a frequent refuge for the inexperienced practitioner. They fail to
see why the patient is “ backward ”—fail to see that he (or she) is “ backward ”
because of mental defect. The mental expert appointed to guide the justices must
be a really able, capable and practical man, one whose opinions must be sound,
and whose decisions must be able to stand even very hostile criticism. I hope the
folly—if it is contemplated—of attempting to find a mental expert in every petty
sessional area will be nipped in the bud. I trust that one mental expert, in the
true sense of the word, may be appointed for the whole county. He would neces-
• sarily act rather on behalf of the authorities ; the medical visitor to the justices
must continue to exist and must act rather on behalf of the public, and while he
must do his best in every way to promote the beneficial working of the Mental
Deficiency Act, must never lose sight of the " liberty of the subject ” side of the
question.

“ A boy may not be able to make a good Latin verse, but nevertheless he may
be able to make a very good table,” was one of the many pithy sayings of my
famous headmaster, the late Edward Thring, of Uppingham. Now, there are some
such boys (and girls) in institutions, and their cases call for very special considera¬
tion. I come now to that most important point, vie., the provision of some suitable
place (or places) in the county where mental defectives can reside when allowed
out on licence—when allowed out on probation for varying periods provided they
are kept under proper care, supervision and control. In many cases we have found
that the home accommodation of such cases is utterly inadequate, that while it was
very right and proper these cases should be allowed out on probation, it would be
worse than useless to allow such cases to spend their period of probation at home.

I have in my mind an institution to which lads are sent who have been guilty of
some crime—frequently some very trivial offence, and have been dealt with under
Section 8. A good many of these lads are high-grade feeble-minded ; some of
them are undoubtedly cases of “ late development ”—a subject which requires an
article to itself, and that not a short one if full justice is done to it; the majority
have not had a chance—bad parents, bad homes, their start in life has indeed been
a poor one. Many of these lads—these “ street arabs ”—are embryo hooligans of a
bad type. But not all—very far from it. And it is not right that all who have
been found mentally defective in some degree should be condemned practically
to "imprisonment for life” after committing some trivial offence. The mental
enthusiast might say they are to have the benefit of “ life-long care.” " The man
in the street ” protests against them being "shut up” for life.

Now, in such an institution as the one I am referring to there is a small pro¬
portion of cases which ought to be given every chance to prove themselves worthy
of freedom and to regain their liberty—perhaps not as perfect mentally, but who
nevertheless may make useful law-abiding citizens and wage-earners.

It is obviously no easy matter to find anyone who is mentally perfect. That may
seem a startling statement, but the mentally perfect would possess the talents of a
senior wrangler, a senior classic, and a master of every subject calling for the
exercise of brain power! Where is such a person? A certain proportion of
defectives if given a fair chance may become useful members of society. I am
fortunate in having had to work with a number of justices and lady visitors who
are all reasonable and level-headed and who are not “ cranks.” Many of these are
sure that the question of the continued confinement of certain cases will be raised
before long in the House of Commons. It is a matter of some surprise to myself
that some of those who opposed the Mental Deficiency Act—rabid cranks on the
question of the " liberty of the subject ”—have not already caused a stir in the
legislature about such cases as those I am dealing with.

It is everything for all concerned in the working of the Lunacy and the Mental
Deficiency Acts to have “ public opinion ” with them—to have the support and
sympathy of the public. And I must say in Essex we have been successful in
obtaining this. At last interest in the subject has been aroused, and the general
public recognises the necessity for, and the advantage of, the Mental Deficiency Act.

A few suitable cases—now confined—should be allowed out on probation, and there

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should be a “half-way house” between confinement'and liberty—possible ultimate
liberty, of which cases should have the opportunity of proving themselves worthy.
My idea is such “ probation home or hostel ” should be the residence of the medical
mental expert for the county, that he should have under him a resident head
attendant and head nurse for the male and female sides. To this hostel could be
sent those borderland difficult cases, on the mentality of whom it is impossible to
decide at a single interview. To this home cases could be sent on remand ; they
would be under supervision possibly for some time, and after the decision about
their mental state had been arrived at, that decision could be reported to the
justices before whom they had come in the first instance.

This hostel should be a real training home in which males and females could be
taught what they were found to be most fitted for, and by the practice of which
they might be able to earn a living. As they made good progress they would
gradually be allowed more and more liberty. The period of probation would be
renewed and extended, but all the while, until discharged, the certificates would
hold good, and in case of necessity—for breaches of discipline, insubordination,
misconduct or for other reasons—the cases could be sent back to where they came
from or to institutions thought perhaps more suitable for their particular grade, to
continue in confinement.

The finding of a suitable “ guardian ” for these cases on probation is an extremely
difficult matter. There is a “ Society for the After-care of the Insane ”—there does
not seem to be one “ for the after-care of the feeble-minded.” It seems to me here
is a large field for voluntary philanthropy, if the State cannot at present undertake
the matter.

But I hope an amended Act will insist upon the provision of such “ half-way
houses ” by the local authorities.

By such an Act visiting justices ought to be invested with similar powers to those
they possess under the Lunacy Act—“ but that is another story.”

DEATH OF DR. MERCIER.

Criminologist and Physician.

In Dr. Charles Arthur Mercier, whose death occurred at Bournemouth yesterday,
the world of medicine in the department ofjpsychiatry loses one of its most brilliant
and distinguished ornaments. A subtle dialectician, a keen and logical debater,
a psychologist, and a philosopher, he was also a practical alienist physician.

Of Huguenot extraction, and the son of a clergyman, he spent his early life in
Scotland, and he owed much to a capable and generous-minded mother, to whose
memory he was always unflinchingly loyal. The family being left badly off on his
father’s death, he joined a ship’s crew and went to Mogador, and afterwards entered
a woollen warehouse in the City. He then took to medicine, and from the outset
of his career as a student in the London Hospital he was marked for success. His
high graduation at the London University, together with his obtaining of the
Fellowship of the Royal College of Surgeons, seemed to foreshadow distinction
for him in the more purely practical aspect of the medical profession, but the bent
ofjhis mind was towards introspection and analysis. His great admiration for
Spencer, the philosopher of evolution, and his devotion to his teacher and friend,
Dr. Hughlings Jackson, led him to study mental diseases and neurology. He
gained an extensive as well as nn intimate.and accurate knowledge of insanity in
its various aspects by holding the post of medical officer in two large public
asylums—the Bucks County Asylum and the City of London Asylum at Stone—
and until the last few years he was the resident physician of a private asylum near
London, where he was the personal and devoted friend of the patients under his
care. He was greatly attracted to the legal aspects of mental diseases, and the
quality of his mind might best be described as forensic and analytic. His stern
logic led him at times to appear to over-advocate a weak claim. Dr. Mercier was
essentially the champion of the weak against the strong. It was through his
support and strenuous advocacy that a Bill was more than once introduced by
Lord Halsbury, then Lord Chancellor, into the House of Lords to legalise the

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treatment of insanity in its incipient stages, for insanity was only too well known
to Dr Mercier to be curable indirectly in proportion to its duration. He continued
to urge with unremitting persistence the necessity for increasing the number of
the scandalously overworked Lunacy Commissioners.

An effective speaker, Dr. Mercier might have attained even greater distinction
in the legal profession than that which he achieved in psychiatric medicine. He
was an invaluable member of a deputation, for his cold convincing logic could be
relied upon in the face of countless difficulties to justify his point or to prove his
argument. Those who were favoured with his confidence appreciated his striking
independence, his clear intellectual ability, and his strong moral nature. His
friendship was real for those he liked, even when these disagreed from him. His
unflinching courage made him a strong opponent, yet, unlike many combatants, he
had no venom in his nature. In debate he was as often effective by a humorous
exposure as by his uncompromising logic. As a writer he was clear, incisive, and
accurate—almost a purist in the use of the English language. He was as widely
known in America as he was in this country, and a visit he paid to Boston a few
years ago brought him an enthusiastic welcome from the charmed circle of lawyers,
medical men, and literary critics of the American academic world.

Dr. Mercier’s most intimate work for the benefit of the insane was chiefly
known to mental experts, who were his colleagues on the Council of the Medico-
Psychological Association, as well as on its Parliamentary and Educational Com¬
mittee, where his special qualities were most valued and appreciated. Some time
back he served as President of the Medico-Psychological Association as well as of
the Psychiatry section of the British Medical Association Congress at Oxford.
He was a member of the Departmental Committee in regard to the treatment of
inebriety, and he gave expert evidence before the Royal Commission on the Care
and Control of the Feeble-minded as the representative of the Royal College of
Physicians of London. Like his teacher, Herbert Spencer, he had a great power
of generalisation based upon a wide acquaintance with biology and the natural
sciences. Besides special text-books upon psychology, he contributed articles to
medical and ether periodical literature as well as to various encyclopaedias and
dictionaries. He also contributed a number of letters to The Times. London
University (for which he was examiner in his special subject) awarded him the
degree of Doctor of Medicine in Mental Diseases, accompanied by its gold medal
for special merit. He was a member of many learned societies, and he took a
particular interest in the work of the Medico-Legal Society. He was a Fellow
of the Royal College of Physicians. It was only last January that the Swiney
Prize was awarded to him for his work on Crime and Criminals ; this was the
second time that that honour had been conferred on him, for ten years ago he
won it for his book on Criminal Responsibility. In 1910 he stood, though
unsuccessfully, for the Waynflete Chair of Philosophy at Oxford, and soon after¬
wards his New Logic appeared, a volume in which he attacked what he conceived
to be Aristotelian logic with great vigour, but with an insufficient comprehension
of the subject. Indeed, logic, both theoretical and practical, was not always his
strong point, logician though he claimed to be; and in his miscellaneous writings,
outside his own special subjects, there were occasional faults of reasoning. But
in a comparatively short life he did a prodigious quantity of hard, intellectual
work, and his interests were so many that it is not surprising if in his parrrga his
pen sometimes ran away with him.

He was married, but his wife predeceased him for a number of years, and he
has left no family.

A correspondent writes:

Might I be allowed to add a note to your obituary notice of Dr. Mercier?
Dr. Mercier was twice married. His first wife died a considerable number of
years ago. In 1913 he married Miss Mary MacDougall, whose early death in
1915 was a severe blow to him, coming as it did at a time when the progressive
failure of health which marked the last fifteen years of his life had reached a stage
which would have quelled a less robust spirit. Since then he had been living more
or less in seclusion at Bournemouth. But physical infirmity was never able to
damp his intellectual ardour. Practically bereft of sight and hearing, he none the

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314 NOTES AND NEWS. [Oct.,

less kept up his literary and speculative interests, and only a few weeks ago was
writing to a friend of a new book that he had a mind to write. His intellectual
zest and keenness were undimmed. His death was quite unexpected, and was due
to pleurisy contracted at the end of last week.— Times, September 4th, 1919.

EXAMINATION FOR NURSING CERTIFICATE.

List of Successful Candidates.

Final Examination, May, 1919.

Chester County. — Margaret Langton, Edith Taylor, Beatrice Lewis, Edith Emily
Williams, Betty Williams.

Cheshire, Macclesfield. —Cecilia Moore, Minnie Wigglesworth, Elizabeth Ellen
O’Connor.

Cumberland and Westmorland. —Ethel Mary Howe.

Dorchester. —Beatrice May Message, Anna Hennessey, Dorothy Isabel Evett,
Annie Maud Mary Atkins, Agnes Bridget McDonnell.

Essex, Severalls. —Mabel Blanche Button, Evelyn Gray, Florence Reddiford,
Mabel Gertrude Taylor.

Glamorgan, Bridgend. —Catherine A. Thomas, Muriel Owen, Bridget Alysions
Neville, Winifred Elinor Preece.

Kent, Barming Heath. —Hannah Helene E. Hardingue, Eva Gladys Wood,
Phyllis Mary Evans, Gladys May Bishop, Hannah J. Kirby, Veronica Mawdsley,
Laura Violet Killian.

Kent, Chatham. —Mary Hotton, Amy A. Wellard, Mary Angus.

City of London. —Ethel Florence Tucker.

Cane Hill. —Mary Connell, Rose Elizabeth Martin, Daisy Ella Martin, Elsie May
Payne, Harriette May Pauli, Nellie Louisa Mary Perrey, Gladys Garrood Smith,
Leelia Kearney.

Hanwell. —Isabella Davies, Marie Plumb, Minnie Elizabeth Lelean, Louise Scott.

Leng Grove. —Rose Alice Ethel Message, Annie Jane Jones, Honoria Martha
Byrne, Lilian Margaret Blythe, Albert James Ring.

Colnty Hatch. —Alice Taylor, Nora Annie Coles, Myra Compton, May Good,
Margaret K. M. Westcott, Jessie Myrtle Bingham.

Banstead. —Winifred Constance Bright, Phyllis Stribbling, Elizabeth Rose
Neighbour, Lucy Jordan, Margaret Priscilla Day, May Gladys Waylan, Florence
Ada Devey, Lucy Eleanor Pownall, Jessie Elsie Dawson

Fountains Temporary. —Jessie Macdiarmid, Edith Morrison.

Napsbury. —Annie Laundon, Lucy Downes, Elsie G. Rogers, Ethel Mary Davis,
Annie Keziah Richardson.

Notts County. —Florrie Leeson, Annie Gamble, Betsey Todd, Irene Ethel Godber.

Shropshire County. —Frances Nellie Dodd.

Staffs, Burnt-wood. —Annie Gibson.

Staffs, Cheddleton. —Mary Ellen Watters, Gladys Ethel Chaplin, Charity Elinor
Rooney, Mary Frances Coyle.

Sussex, Hellingley. —Ada Kathleen Redfern, Rose Brett, Bertha Elizabeth Miles,
Margaret Mary Clarkson.

Worcestershire, Barnsley Hall. —Harry Milhouse Storr, Frank Walton, Ellen
Lee Tomkys.

Birmingham, Winson Green. —Emma Benton, Rose Adelaide Shilvock.

Hull City. —Maude Miller, Agnes Senior, Annie Hunt, Jenny Bate, Emmeline
Grayshon, Annie Kirby.

Leicester Borough. —Mabel Wakefield, Isabella Catherine Johnston, Lillian Soar,
Edith King.

Notts City. —Blodwen Davies, Jane Riley, Daisy Branston.

Sunderland Borough. —Ronald W. G. Dean, Mary Hewitt.

York City. — # Elizabeth Rains.

Norwich City. —Winifrede Alice Mayes.

Bethlem Hospital. — Rose Amelins Huss, Alice Maud Martin.

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Original from

PRINCETON UNIVERSITY

1919 ] NOTES AND NEWS. 3 I 5

Bootham Park. —*May Boyes, Mary Black, Christina Watt, Florence May
Mitchell, *Amy Walker.

Brislington House. —Miriam Andrews, Mabel Elizabeth Doling.

Camberwell House. —Lillian Bateman, Jessie Webster, Gertrude Izod.

Colon Hill. —Mary Vincent.

Middleton Hall. —Muriel Chesher, Ada Bruce.

St. Andrew's, Northampton. —Ralph Leonard Haynes, Ralph Neal Easton.
Ticehurst. —Louisa Ford, Martha Wootten, Emily Charlotte Fry, Ivy Victoria
Holtham.

Warneford, Oxon. —Evelyn Emily Swadling.

York, Retreat. —*Margaret Emily Wilmot, Ethel Barbara Davison.

Aberdeen Royal. —Williamina Burr, Elizabeth Anderson, Annie J. E, Gordon,
Florence Watson.

Aberdeen District. —Mary J. Gerrard, Jessie S. Roy, Florence Stephen, Catherine
Crichton, Leslie D. Duncan, Lily J. Reid, Mary A. Thomson, Helen McLean.

Ayr District. —Janet T. McCulloch, Jane B. McKellar, Elspeth G. Kirkwood,
Donald Cowan, David Reid, George Burns, Agnes Shankland Malloch, Janet
Sutherland MacKenzie, Jane Fulton White, Agnes Bain Haig, Margaret
Mathieson, Agnes Boyle Cowan.

Banff. —Jennie Murray Burnett, Maggie Ann Stewart, Susan Mackintosh.
Crichton. —John Laurie Campbell, William Francis Farrington, Mary Campbell,
Mary MacFadyen, Mary Tait, Sarah Johnstone McLean, Rebecca McQuarrie,
Maggie Gordon Matthew, Adelaide McAdam, Mary Ann Waite Starkey, Elizabeth

j ane Beaton, Lena Ellen Weston, Molly Graham, Margaret Eliza Kennedy, Jean
ohnstone Ross, Jean Quinn, Mary Fraser Edgar, Annie Mary Weir.

Gartnavel. —Betty Orr, Catherine Cameron, Mary Mackenzie, Ethel Ellen
Ferguson, Catherine T. Robertson, Molly McCann, William Arrol.

Gartloch. —Flora Robertson, Christina MacAskill, Margaret Findlay, Morag
Kennedy, Janet McK. Shennan, Isobel McC. Parker, Catherine Campbell Galbraith,
Kathleen Connolly, Margaret Grey Summers.

Woodilee. —Helen Horn Brown, Jessie Ann Cook, Agnes Cowie Hamilton,
•Georgina H. Wilson.

Craig House. —Kathleen Chisholm, Mary Cochrane, Ruby Swanson.

Edinburgh Royal. —Elizabeth M. Ewing, Mabel Brown, Muriel M. Pond,
Margaret Weir Fleming, Janet Williamson, *Ina M. Nicolson, Maggie C. Dower,
Jessie W. Johnstone.

Elgin District. —Isabella Hadden, Ann B. Strathdee, Lily L. Taylor.

Hawkhead. —*Jeannie Lovie Corbett, Isabella K. Russell or Macdonald, Dorothy
Dawe.

Lanark. —Elsie Campbell, Jean McHardy, Mary McHattie, Annie McLaughlin,
Catherine Smith.

Midlothian and Peebles. —Mary Keith, Agnes G. Lemmon.

Melrose. —Margaret Webster.

Montrose Royal. —Williamina Denchar Allan, Janet Crombie, Isabella Jane
Ferrier, Matilda Neave Guthrie, Robina Canning McKay, Jane Nicolson, Alice
Smith, Margaret Charlotte Sutherland, *Margaret Tierney, # Rachael Smith.

Murray. —Elspeth Hazel Macdonald Baillie, Helen Sharp Brown, Elizabeth
Maclean, Jean R. C. Buchan.

Riccartsbar, Paisley. —Mary B. Morrow, Elizabeth Jane Dawson, *Jane Bishop
Alexander.

Mullingar. —Joseph Farrell, Cecilia McDonnell, William Flanagan.

Omagh. —Maria Haddon, Isabella Mary Gay, Margaret Lynn, Mary C. Morris,
Mary McGonagle, Catherine Bella McNulty, Bridget Sweeney.

Portrane. —Margaret Gilmartin, Catherine Tighe, Patrick Healy.

Richmond. —Elizabeth Dalton, Martha Connell, Michael Purfield.

St. Patrick's. —Ida Jordeson, Thomas Mullarney, Michael Joseph O’Neill.

Fife and Kinross. —Johan McDonald, Catherine Fraser Wilson, Angusina Murray
Rhind, Jessie Ann Taylor, Agnes Gordon Robertson, Esther Stark, Marion Waddell
Coffield.

Warwick County. —Dela Everall, Evely Rochford.

* Passed with distinction.

LXV. 2 2

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316

NOTES AND NEWS.

[Oct

Preliminary Examination, May, 1919.

Cumberland and Westmorland. —J. B. Ferguson, E. B. Smith, S. Tracey,

J. Hardy, O. L. Sainty.

Chester County. —F. Carman, S. Bretherton, E. Mackay, E. O'Keefe, E. Walley,
N. Hiron, D. Price, M. H. Jones.

Macclesfield. —L. Newbold, J. R. Lyne, E. M. Clewlow, H. A. Belfield.

Dorset County. —W. T. Hunt, H. F. Fox, K. Riglar, F. Dean.

Essex, Severalls. —J. T. Harper, E. Wilson, D. Wilson, E. Taylor, M. Smith,
E. M. Pullen, G. Morgan, E. Kenyon, H. Henfrey, J. Hudson, R. A. T. Grant,
E. M. Denley, D. G. Deary, E. M. Calver, A. E. Bailey, E. A. Barton, M. Arthur.
Essex, Brentwood. —W. L. E. Kennard.

Glamorgan, Bridgend. — B. Bowen, L. Davies, M. John, L. Jones, A. Roberts,

G. Vaughan, C. A. Davies, G. M. Richards.

Isle of Man. -E. M. Kelley, A. L. Knight.

Barming Heath. — M. E. Shaw.

Claybury, L.C.C. —L. Clare, M. B. Hyland, E. Godden, W. Roberts, E. Redden.
Cane Hill. —J. A. Ishmael, C. Moran, G. M. Rumble, D. M. Drake, R. A. Fraser,
S. T. Wilson, A. M. Purdy, D. L. Skelton, A. Keating, B. Croxford, D. T. Shep¬
herd, M. C. Jones.

L.C.C., Hanwell. — M. Baker, A. Frost, A. Turner, A. L. Lear, J. Jones, D.
Granger, E. B. Sawyer, L. Archer, H. Vernon.

L.C., Colney Hatih. —L. K. Gentry, A. L. Downs.

L.C, Banstead. —L. Maguire, A. McBrien, A. Crowe, K. O’Shea, J. M. Hurley.
L.C., Long Grove. —M. A. Barry, M. G. Burns, G. M. Howell, C. M. Povey,
L. Stevenson, S. T. Williams.

Notts City. —L. McGuinness, M. L. Barrett, H. Coope, J. M. Glennon, M. A.
Jourdan, N. Wolgate.

Shropshire County. —E. Bray, L. Morgan.

Surrey, Netherne. —N. C. Brown, D. M. Pitman, A. L. Ward, H. Bakewell.
Sussex, Hellingley. —G. F. Bath, A. M. Tanner, F. B. K. Knight, F. M. Shook,

H. Peddle, J. F. Challenor, B. McPartland, N. Nuttall, N. F. Fahy.

Worcester, Barnsley Hall. —L. Clifton, D. W. Wilson, W. L. Porter, G. M.
Licence, R. Burton, J. W. Durrant, W. L. Griffiths.

Yorks, Storthes Hall. —A. M. Duffield, T. Reddick, A. Sharpe.

Winson Green. —C. C. Griffiths, B. Bosworth.

Derby Borough. —Dora Twigge, Evelyn W. Lee.

Brighton Borough. —C. L. Thomson, B. M. Fidler, E. Ayres, R. J. Wingrove,

K. E. Clifford, F. Phillips.

Leicester Borough. —E. M. Griffin, A. Hurren, H. M. Babb.

Hull City. —J. W. Ellerker, J. Hemmingway, M. Hardie, R. Nicholson,
J. Richardson, M. L. Willoughby, L. Rowley, B. A. Patrick.

Norwich City. —M. E. Wilson, L. Sturman, F. M. J. Tooke, C. M. Holland,
C. E. Gould, F. G. Garland, H. E. M. Foster.

Sunderland Borough. —M. E. Bailey, J. Collins, K. Edwards, M. Fagan,
G. Goodings, C. Lawson, A. G. Press, J. Pybus, E. M. Wanless.

York City. —F. M. Swift.

Caterham. —G. L. Potter, H. C. Woodward.

Leavesden. —G. M. Howes, D. M. Maycock, C. E. Pulford, G. F. V. Fry,
S. Rowney.

Bethlem. —K. A. Hughes, W. D. Tindall, M. King, N. Waite, M. Tweeddale,
C. Gill.

Bootham Park. —J. C. Warren.

Brislington House. —E. G. Fynes, E. M. Matthews.

Camberwell House. —W. J. Witts, A. S. Prince, H. E. Buckley, D. G. Pears,
E. Rowlands, G. M. Haynes.

Coton Hill. —H. Somers, D. Taylor, G. Hodson, F. Heathcote.

St. Andrew's Hospital. —W. E. Isom, E. E. Munday, B. O. Goode, O. Gibbons
N. Buckley, M. J. Browne, M. A. Leslie.

Warneford, Oxford. —E. M. Dean, G. J. Harris, H. Davies, F. C. Redding,
J. A. Tutty.

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PRINCETON UNIVERSITY

19 19 '] NOTES AND NEWS. 317

Aberdeen Royal. —J. Duncan, A. M. Fraser, J. Sorrie, A. Duncan, A. Davidson,

L. E. Milne.

Aberdeen District. —A. B. M. Milton, J. G. Wilson, J. S. Beaton.

Ayr District. —Patrick McGlynn, J. McNicoI, M. E. Smith, A. Henderson,
E. L. N. Smellie.

Banff. —Donald Matheson, J. Watson, E. C. Brodie.

Crichton. —A. Hendry, J. Callanden, M. B. Edine, D. J. McDonald, A. Duncan,
J. Ferguson, L. Shelbourne, K. A. M. MacLeod, J. C. Muircroft, M. McLugash.
Craig House. —M. F. Simpson, S. Rodden, J. G. Nicolson, M. Cremin,

M. Wixted.

Edinburgh Royal. —J. M. Grant, E. M. Gray.

Fife and Kinross. —A. V. Rodden, C. Nuthall, W. Young, E. Allan, A. W.
Anderson, A. C. Mather, B. Hadden, W. Anderson.

Gartnavel. —J.- McPherson, A. O’Donnell, B. Sharkey, M. Rennie, J. M. A.
Rennie, E. Bailie, M. McLellan, C. Macdonald, B. Levy.

Woodilee. —L. O'Rourke, N. Edwards, A. Mulgrew, J. Walkinshaw, M. Cart¬
wright, A. N. Campbell, M. Kelly, S. Johnston, K. Ross, J. Begbie, P. Keogh,
W. Dunsmore, E. M. Wilkie, C. Lyons.

Gartloch. —G. McLellan.

Hawkhead. —A. D. Glendinning.

Inverness. —J. J. Morrison.

Lanark. —J. B. Robertson.

Midlothian. — A. Bell, M. Hamilton, H. King.

Melrose. —E. Graham, J. J. O’Hara, T. F. E. O'Hara.

Murray. —J. W. Dean.

Ballinasloe.— M. Goode, A. Finnerty, M. C. Quigley, M. Hynes, P. Gauley,
J. Gilleece, G. Jennings, P. Tapley, M. Mee, J. Naughton, T. McGann,
E. O'Connall.

Mullingar. —B. Geoghegan, K. Fitzsimmons, T. Farrell.

Omagh. —M. E. Baird, J. McCanny, A. McDermott, C. Quinn.

Portrane. —E. Brady, R. Cox, F. Byrne.

Richmond. —M. Kavanagh, E. Deasy, A. Fitzsimmons, M. Dunne, J. Hall,
M. Crowe, F. Moore, M. Murphy, P. McNally, P. Brennan.

St. Patrick's. —F. M. Montague, M. Corcoran, J. K. Boyd, A. Maguire.

Scottish National Inst. —J. Cairns.

Fountains Temporary. —F. M. W. Gill, F. Fray, D. L. Gilbey, 1 . Gregory.
Darenth. —L. Radley, A. Stone, A. E. Crawley, E. L. Wollaston, M. Morley,
A. Dunford, D. L. Dunn.

Warwick County. —B. Callanan, N. Hall, H. Greenway, L. Murphy, E. A.
Gilligan, M. Wright, E. A. Prestwich, C. J. Hawker, A. Rogers, C. Blount,
G. Burgess, T. Dearl.

Montrose. —M. A. I. Belnaves, M. France, F. N. Henry, A. Smart, A. C. Smith.

NOTICE TO CONTRIBUTORS.

N.B. —The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to Ltx(a) of the
Articles of Association, “ all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Pagers read at Association Meetings should, therefore, not be published in other
Journals without such sanction having been previously granted.

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PRINCETON UNIVERSITY

INDEX TO VOL. LXV.

Digitized by

Part I.—GENERAL INDEX.

Abbasiya Asylum, report, 1917, 131
Alcoholic psychoses, 167

Alkali agents in the treatment of delirium tremens, 121

American Medico-Psychological Association, Presidential address, by James V.

Anglin, M.D., 1
Appointments, 140, 217
Artes et Medicina, 96

Asylum administration as effected by present events, Dr. Wolseley Lewis’s

scheme, 124

,, „ some present-day problems connected with, 198

„ Workers' Association and the Medico-Psychological Association, 283

Balance sheet, 277

Board of Control and the Ministry of Health, 280 •

Calcium, uses of, in excited cases, 109
Cerebro-spinal fluid in mental disease, cytology of the, 249
Chapin, John, obituary, 46, 57
Clinical neurology and psychiatry, 119
„ notes and cases, 109, 202, 25S
„ psychology, present position of, 141
Colin, M. le Henri, welcome to, 285
Correspondence, 135
Council, election of, 275
,, report of the, 275
Criminal actions, factors of, 87
Criminology, 205

Cytology of the cerebro-spinal fluid in mental disease, 249

Delirium tremens, treatment of, by spinal puncture, stimulation and the use of
alkali agents, 121
Delusions, genesis of, 187

Dementia paralytica, treatment of, with subdural injections of neosalvarsan, 24
„ prtecox, 167

Dinner, annual, at York, 289

Editors’ report, 278

Education Committee, report, 279

Egypt, report for the year 1917 from the Lunacy division, being the 23rd annual
report on the Government asylum at Abbasiya and the 6th annual report on
the asylum of Khanka, 131
English war psychology, 65

Environment, influence of, on psychic secretion, 180
Epilepsy, 170

,, clinical studies in, 119

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Original from

PRINCETON UNIVERSITY

INDEX.

319

Epilepsy in twins, notes on two cases, 262
„ mental content in, 119

Epileptic attacks, psychological and therapeutic value of mental content, during
and following, 119

„ constitution, personality study of the, 119

„ the true, 119

Epitome of current literature, 44, 117, 209, 273

Examination for nursing certificate: list of successful candidates, 314
Expeditionary force, British, mental wards with the, 152

Feeble-mindedness in British Expeditionary force, 161
Fits, a group of, 202

Focal infections, r 6 le of, in the psychoses, 274

General paralysis, war fatigue as a cause of, 307
German war psychology, 65
Goitre and the psychoses, 235
Griffith, A. Hume, obituary, 46, 60

Herbert, Thomas, obituary, 46, 62
Hypnotic suggestion, notes on a case treated by, 258
,, „ discussion, 284

Infective factors in some types of neurasthenia, 16
Influenza, psychoses associated with, 121
Insane, pseudo-hermaphroditism in the, 209
Insanity, confusional, 163
,, delusional, 165

Ireland, sixty-seventh annual report of the Inspectors of Lunatics for the year
ending December 31st, 1917, 263
Irish Division of the Medico-Psychological Association, 130

Khanka Asylum, report, 1917, 131

Lebanon, Syria, Mental Hospital at, 46
Logan, Dr., death of, 46
Logic, mysticism and, 111

Lunacy Legislation, sub-committee of the Medico-Psychological Association of
Great Britain and Ireland, report, 36, 47
Luncheon at York, report of speeches, 287

Mania, 168

Manic-depressive psychosis, so-called lucid interval in, 44
Maudsley Lectureship, report on the, 211
Medicina et Artes, 96

Medico-Psychological Association, proposed new bye-laws, 211

» » >, meetings, 45, 122 (special), 129, 211

„ „ „ seventy-eighth annual meeting, 275

,, „ „ and the Ministry of Health, 283

„ „ Society of Paris, greetings from the, 123

Melancholia, 167
Members, election of, 212

Mental deficiency, conference convened by the Essex Voluntary Association, 304
,, content in epilepsy, 119

,, disease, cytology of the cerebro-spinal fluid in, 249
,, instability, 162

„ wards with the British Expeditionary Force, 152

Mercier, Dr. C. A., obituary, 263, 314
Military training, war neuroses and, 273
Ministry of Health and the Board of Control, 280
Mould, George Wm., obituary, 122, 136

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PRINCETON UNIVERSITY

INDEX.

320

Mysticism and logic, 111

Neosalvarsan, treatment of dementia paralytica with, 24
Nervous debility, 162

Neurasthenia, infective factors in some types of, 16
Neuroses, war, and military training, 273
Northern and Midland Division meeting, 212
Notes and news, 45, 122, 211, 275

Obituary.—Ballard, Capt. E. F., 61
Chapin, John, 46, 57
Griffith, A. Hume, 46, 60
Herbert, Thomas, 46, 62
Logan, Dr., 46
Mercier, Charles A., 263, 312
Mould, George YV., 122, 136
Reid, William, 46
Spensley, Capt. F. O., 46
Wigglesworth, Joseph, 216, 288
Occasional notes, 263

Paralysis, general, 168

Paris, Medico-Psychological Society of, greetings from, 123
Parliamentary Committee report, 280
Pierce, Bedford, elected President, 275

Presidential address on psychiatry a hundred years ago, with comments on the
problems of to-day, 219
Prison reform, 215
Prizes, presentation of, 288
Pseudo-hermaphroditism in the insane, 209
Psychasthenia, 170

Psychic secretion, the influence of environment, 180

Psychiatry a hundred years ago, with comments on the problems of to-day, 219
Psycho-analysis, paper on, 204
Psychology, clinical, present position of, 141
„ war, English and German, 65
Psychoses associated with influenza, 121
„ goitre and the, 235

,, in the Expeditionary forces, 101

„ role of local infections in the, 274
Psychosis, manic-depressive, so-called lucid interval in, 44

Registrar, notices by the, 63, 140
Reid, William, obituary, 46
Report of the Council, 275

„ of the Editors, 278

,, of the Education Committee, 279

„ of the Parliamentary Committee, 280

„ of the Sub-committee on English Lunacy Legislation, 36, 47
„ of the Treasurer, 276

,, on the Maudsley Lectureship, 211

Reviews, 109, 204

Scottish Division of the Medico-Psychological Association, meetings, 56, 214

Secretary, resignation of Dr. R. H. Steen, 123

Soutar, Dr. J. G., retirement of, 136

South-Eastern Division, meeting, 214

South-Western Division, meeting, 213

Spensley, Capt. F. O., death of, 46

Spinal puncture in the treatment of delirium tremens, 121
Stupor, 170

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PRINCETON UNIVERSITY

INDEX.

321

Steen, R. H., resignation of, as secretary, 123
Stimulation in the treatment of delirium tremens, 121

Treasurer’s report, 276
Twins, epilepsy in, 262

Unconscious, Why is the unconscious? 117

War fatigue as a factor of general paralysis, 301
War neuroses and military training, 273
War psychology : English and German, 65
Wiglesworth, Joseph, obituary, 216
Wounds, self-inflicted, 157

Part II.— ORIGINAL ARTICLES.

Anglin, James V., presidential address delivered before the American Medico-
Psychological Association, 1

Brunton, G. L., on the cytology of the cerebro spinal fluid in mental disease, 249
Cathcart, Col. E. P., psychic secretion : the influence of environment, 180
Chambers, W. D., mental wards with the British Expeditionary force: a review of
ten months' experiences, 152

Colin, Henri, war fatigue as a cause of general paralysis, 301
Dougall, Major Wm., present position of clinical psychology, 141
Donkin, H. Bryan, factors of criminal actions, 87
Grimbly, Alan F., Artes et Medicina, 96
Helweg, Hj., see Schroder, Geo. E.

Lewis, H. Wolseley, scheme for asylum administration as effected by present
events, 124

Maudsley, Henry, war psychology: English and German, 65
McDowall, Colin, genesis of delusions: clinical notes and discussion, 187
Medico-Psychological Association of Great Britain and Ireland, report of English
Lunacy Legislation Sub-committee, 36
Nicolson, D. D., appreciation of Dr. George William Mould, 138
Pearce, O. P. Napier, psychoses in the Expeditionary forces, 101
Phillips, Norman Routh, goitre and the psychoses, 235

Pierce, Bedford, psychiatry a hundred years ago, with comments on the problems
of to-day: presidential address, 1919, 219
„ „ -some present-day problems connected with the administration of

asylums, 198

Robertson, W. Ford, infective factors in some types of neurasthenia, 16

Savage, Sir George H., obituary notice of Dr. George William Mould, 136
Schroder, George E., and Helweg, Hj., some experiments on treatment of dementia
paralytica with subdural injections of neosalvarsan, 24

Part III.—REVIEWS.

Cole, R. H., Mental Diseases, 266

Coover, John Edgar, Experiments in Psychical Research, California, 1917, 270

Glucek, Bernard, Studies in Forensic Psychiatry, London, 266

Jelliffe, Smith E., and White, W. A., Diseases of the Nervous System: a Text¬
book of Neurology and Psychiatry. Second edition : Philadelphia and New
York, 1917, 109

Jones, Ernest, Papers on Psycho-analysis, London, 204
Long, H. W., Sane Sex Life and Sane Sex Living, London, 267
Mercier, Charles A., Spirit Experiences, London, 272

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PRINCETON UNIVERSITY-

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322 INDEX.

Parmelee, Maurice, Criminology, New York, 1918, 205

Rignano, Eugenio, Essays in Scientific Synthesis, 114
Robie, W. F., Rational Sex Ethics, London, 267
Russell, Bertrand, Mysticism and Logic, London, 1918, 111

Sixty-seventh Annual Report of the Inspectors of Lunatics (Ireland) for the Year
ending December 31st, 1917, 263

Part IV.—AUTHORS REFERRED TO IN THE EPITOME.

Cotton, H. A., 274
Gordon, A., 44
Hoppe, H. H., 121

Jones, Ernest, 117

Maurice, Dr., 117
Menninger, Karl A., 12

Nicoll, Dr., 117

O’Malley, Mary, 209
Pierce, Clark L., 119
Rivers, W. H. R., 117, 273

ILLUSTRATIONS.

Photograph of George William Mould, 65
Photograph to illustrate Dr. Toledo’s paper, 262
Photograph of Joseph Wiglesworth, 141
Tables to illustrate Dr. Brunton’s paper, 255, 256

~T-\

ADLARD AND SON AND WEST NEWMAN, LTD., IMPR., LONDON AND DORKING.

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