Full text of "The Journal Of Mental Science. 46.1900 Minnesota"

See other formats

Google

Uber dieses Buch

Dies ist ein digitales Exemplar eines Buches, das seit Generationen in den Regalen der Bibliotheken aufbewahrt wurde, bevor es von Google im
Rahmen eines Projekts, mit dem die Bucher dieser Welt online verfligbar gemacht werden sollen, sorgfaltig gescannt wurde.

Das Buch hat das Urheberrecht uberdauert und kann nun offentlich zuganglich gemacht werden. Ein offentlich zugangliches Buch ist ein Buch,
das niemals Urheberrechten unterlag oder bei dem die Schutzfrist des Urheberrechts abgelaufen ist. Ob ein Buch offentlich zuganglich ist, kann
von Land zu Land unterschiedlich sein. Offentlich zugangliche Bucher sind unser Tor zur Vergangenheit und stellen ein geschichtliches, kulturelles
und wissenschaftliches Vermogen dar, das haufig nur schwierig zu entdecken ist.

Gebrauchsspuren, Anmerkungen und andere Randbemerkungen, die im Originalband enthalten sind, finden sich auch in dieser Datei - eine Erin-
nerung an die lange Reise, die das Buch vom Verleger zu einer Bibliothek und weiter zu Ihnen hinter sich gebracht hat.

Nutzungsrichtlinien

Google ist stolz, mit Bibliotheken in partnerschaftlicher Zusammenarbeit offentlich zugangliches Material zu digitalisieren und einer breiten Masse
zuganglich zu machen. Offentlich zugangliche Bucher gehoren der Offentlichkeit, und wir sind nur ihre Hiiter. Nichtsdestotrotz ist diese
Arbeit kostspielig. Um diese Ressource weiterhin zur Verfugung stellen zu konnen, haben wir Schritte unternommen, um den Missbrauch durch
kommerzielle Parteien zu verhindern. Dazu gehoren technische Einschrankungen fur automatisierte Abfragen.

Wir bitten Sie um Einhaltung folgender Richtlinien:

+ Nutzung der Dateien zu nichtkommerziellen Zwecken Wir haben Google Buchsuche flir Endanwender konzipiert und mochten, dass Sie diese
Dateien nur fur personliche, nichtkommerzielle Zwecke verwenden.

+ Keine automatisierten Abfragen Senden Sie keine automatisierten Abfragen irgendwelcher Art an das Google-System. Wenn Sie Recherchen
liber maschinelle Ubersetzung, optische Zeichenerkennung oder andere Bereiche durchfiihren, in denen der Zugang zu Text in groBen Mengen
niitzlich ist, wenden Sie sich bitte an uns. Wir fordern die Nutzung des offentlich zuganglichen Materials fur diese Zwecke und konnen Ihnen
unter Umstanden helfen.

+ Beibehaltung von Google-Markenelementen Das "Wasserzeichen" von Google, das Sie in jeder Datei finden, ist wichtig zur Information liber
dieses Projekt und hilft den Anwendern weiteres Material liber Google Buchsuche zu finden. Bitte entfemen Sie das Wasserzeichen nicht.

+ Bewegen Sie sich innerhalb der Legalitdt Unabhangig von Ihrem Verwendungszweck miissen Sie sich Ihrer Verantwortung bewusst sein,
sicherzustellen, dass Ihre Nutzung legal ist. Gehen Sie nicht davon aus, dass ein Buch, das nach unserem Dafiirhalten flir Nutzer in den USA
offentlich zuganglich ist, auch flir Nutzer in anderen Landem offentlich zuganglich ist. Ob ein Buch noch dem Urheberrecht unterliegt, ist
von Land zu Land verschieden. Wir konnen keine Beratung leisten, ob eine bestimmte Nutzung eines bestimmten Buches gesetzlich zulassig
ist. Gehen Sie nicht davon aus, dass das Erscheinen eines Buchs in Google Buchsuche bedeutet, dass es in jeder Form und iiberall auf der
Welt verwendet werden kann. Eine Urheberrechtsverletzung kann schwerwiegende Folgen haben.

Uber Google Buchsuche

Das Ziel von Google besteht darin, die weltweiten Informationen zu organisieren und allgemein nutzbar und zuganglich zu machen. Google
Buchsuche hilft Lesern dabei, die Biicher dieser We lt zu entdecken, und unterstiitzt Au toren und Verleger dabei, neue Zielgruppen zu erreichen.
Den gesamten Buchtext konnen Sie im Internet unter http : //books . google . com durchsuchen.

This is a reproduction of a library book that was digitized
by Google as part of an ongoing effort to preserve the
information in books and make it universally accessible.

Google” books

https://books.google.com

OJl^r Ctbrarg of

(fUoaa

THE JOURNAL

| °F

I MENTAL SCIENCE

EDITORS:

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

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

ASSIST ART EDITORS:

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

VOL. XLVI.

London v■v

J. & A. CHURCH I;ii:Lr :1; V

7, GREAT MARLBOROUGH STREET,.

MDCCCC,

Digitized by L.oooLe

“ In adopting our title of the Journal-of Mental Science , published by authority
of the Medico-Psychological Association , we prcfess 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 ,

Digitized by LjOOQle

THE

JOURNAL OF MENTAL SCIENCE

[<Published by Authority of the Medico-Psychological Associate
of Great Britain and Ireland .]

No. 192 [X.“T] JANUARY, 1900. Vol. XLVI.

Part I.—Original Articles.

Abstract of a paper on the Necessity for Isolating the
Phthisical Insane. By Eric France, M.B., B.S., Second
Assistant Medical Officer, London County Asylum, Clay-
bury.

Followed by a discussion by Sir William Broadbent,
Bart, Sir J. Crichton-Brown e, Prof. Clifford Allbutt,
and others, at the General Meeting of the Medico-Psycho¬
logical Association, London, 9th November, 1899.

I have no intention of tracing the history of tuberculosis in
asylums through the official obscurity of the past fifty years.
This point has already received careful investigation at the
hands of Dr. Crookshank in the admirable essay he has recently
published; ( l ) nor are we here concerned with any comparison
between the mortality from tubercle among asylum inmates
and the mortality from tubercle among the general population,
inasmuch as deductions drawn therefrom are liable, among
other errors, to those fallacies which occur when two communi¬
ties whose environment and susceptibility differ are compared as
regards the mortality of any particular disease.

& What we are concerned with, I take it, is the position which
tubercular mortality holds in asylums at the present time, and
^Jffie means to be adopted to remedy this state of things. I
^Mave therefore to lay before you very briefly some of the salient

>- XLn 241435 ‘

Digitized by

# ISOLATING THE PHTHISICAL INSANE. [Jan., I9OO.

points with regard to the incidence of tubercular disease
among the insane and its prevalence compared with other
diseases ; to urge the necessity for some means being taken to
reduce that prevalence; and finally, to suggest some scheme by
which such an end might be attained.

The tables and charts herewith presented show the mortality
from tubercle as compared with some of the most fatal
diseases in asylums. The figures are compiled from the blue-
books of the Commissioners in Lunacy, and from the annual
reports of the Asylums Committee of the London County
Council, referring to the years 1895-6—7-8 inclusive.

It may be remarked that 1895 was the first year in which
the returns of causes of death, as shown in the blue-books, were
sufficiently comprehensive to warrant comparison with subse¬
quent years. The charts are drawn absolutely to scale.

It is gravely to be feared that the figures I have quoted are
very far from accurately representing the number of patients
actually suffering from phthisis in the asylums of England and
Wales.

As it is impossible, from a statistical point of view, to return
more than one cause of death for each patient, it is easy to
understand that evidence of active tubercle may be found in
many patients who are shown as dying from some other
disease.

In Claybury Asylum and at Colney Hatch and Cane Hill,
where the post-mortem records have been kindly examined for
me, a marked disparity exists between the statistical returns
and the number of cases in which active tubercle was found at
death, as is shown in the following table:

1898.

Certified deaths
from tubercle.

Active tubercle
found P.M.

Claybury

. 28

Colney Hatch

. 26

Cane Hill

• 13

I 12 *

* These figures do not include 10 doubtful cases.

It will thus be seen that at these three asylums the number
of patients dying with active tubercle, as compared with those
certified as dying from this cause, practically stand in the pro¬
portion of 2 to 1.

Digitized by

Google

TABLES AND CHARTS
Elucidating the paper by Dr. Eric France.

Digitized by

Google

TABLE I. —Showing Average Daily Residents , Total Deaths (all causes ), and Deaths from seven of the most

fatal diseases in 1895-6-7-8.

4 ISOLATING THE PHTHISICAL INSANE, [Jan.,

*XJ3JU39AQ

4 8I*U3JU3

•J3DUB3

Nj*

»o

•WljqdaN

206

944

236

•Biuoumaud

tJ-

Tf-

•oipuoiq

pUB

Bfuouinduj

'SipjOO

\00

.to

snqaoj^

•apjaqnx

d I

•sisXjBJBd

IBidUdQ

»o

•S38I1B3

1 IB ‘sqjBdp

0 ?

l^°L

*s;UdpiS9I

XuBp

vo.

o8bi 3 Ay

•

CO 1

Digitized by VjOOQle

1900.]

BY ERIC FRANCE, M.B,

Chart I.

All Asylums.—England and Wales.

Showing total mortality in seven of the most fatal diseases from 1895 to 1898
fe inclusive.

Total deaths from all causes during same period . 28,841

Average daily residents during same period .... 303.632

Digitized by CjOOQle

ISOLATING THE PHTHISICAL INSANE,

[Jan.,

Chart Ia.

All Asylums.—England and Wales.

Showing comparative annual mortality in seven of the most fatal diseases.

1895 and 1898.

1895® shaded. 1898=* white.

Digitized by

Google

Total Mortality (all causes ) to Average Daily Residents.

1900.]

BY ERIC FRANCE, M.B.

D
J
>•
c n

-J

•S ^

•sq^eap

IW 0; *!)!(03
uiojj sqjBap
jo 98 bju99 J9 j

<0 CO M 0 \

JTN

•■juappaj
9 #bj 9 ab o) si)!io3
uiojj sq)B 9 p jo

OOOI J 9 d OiJBy

cn vp y

*ij 9 )U 9 Sl(J

UlOJJ 9 qjB 9 Q

vp 00 vo co

w « « «

•*qiB 9 p
JBJOJ OJ opjoqnx
UlOJJ «qjB 9 p

JO 98 b)U 99 J 9 <£

do - vo ^r

lO VO io io

*tJQ 9 ptS 9 J 98 b
-J 9 AB OJ 9 pj 9 qnx
UlOJJ 8 qiB 9 p JO

0001 jod otje^i

00 JN JN V©

to 0 Vf V

* 9 pj 9 qnx

UlOJJ 8 qjB 9 Q

3 S' 3 - 8 1 f

° j

* 8 )U 9 p( 89 J
98 BJ 9 AB O)

sqjeop ibjoj jo

OOOI J 9 d OtJB^J

W JO

8 8 > * 3 v os

*S 98 nB 9 n«
*SqjB9p IBJOX

<S CO CO 00

00 00 o\

- Ct io

cC vo~ r>

* 8 JU 9 pi 89 J
iflCp 9 &BJ 9 A v

| € 5 €

** cn ds

c^ cn

Year.

to VO tNi CO

<§• $ £ S'

Average for the 4 years

Digitized by VjOOQle

ISOLATING THE PHTHISICAL INSANE,

[Jan.,

London County Asylum.

Table II. — Showing Average Daily Residents, Total Deaths
(all causes), and Deaths from six of the most fatal diseases
in 1895-6-7-8.

Year.

Asylums.

Average

daily

residents.

Total
deaths, all
causes.

General

paralysis.

Tubercle.

Morbus

cordis.

.2 2

| j!
1 -SE
l-o g S
£ Si cL

Cancer.

Colitis,

Enteritis,

Dysentery.

Hanwell . . .

*.964

164

Colney Hatch .

2,210

198

4 *

■a

>895 \

Banstead . .

2,027

169

Cane Hill . .

2.039

171

Claybury. . .

2,342

350

128

Totals . . .

10,59*

1,052

30*

130

Hanwell . . .

1,988

162

4 *

Colney Hatch .

2,412

216

4 *

i8g6^

Banstead. . .

2,303

182

Cane Hill . .

2,112

158

Claybury. . .

2,494

298

Totals . . .

11,309

I,0l6

265

Hanwell . . .

2,052

*47

■M

Colney Hatch .

2,580

240

Efl

1897 \

Banstead. . .

2,436

224

Cane Hill . .

2,202

176

■a

Claybury. . .

2,494

249

Totals . . .

u.764

*,036

253

127

Hanwell . . .

2,41s

246

■

Colney Hatch .

2,554

207

CBS

Banstead. . .

2436

*99

1 36

■

Cane Hill . .

2,213

*59

Claybury. . .

2,488

267

Totals . . .

12,106

227

128

Total,

4 years . . .1

4,182

1,046

482

302

222

118

Digitized by LjOOQle

BY ERIC FRANCE, t.B,
Chart II.

Digitized by VjOOQle

isolating’the phthisical insane, [Jan.,

Chart IIa.

London County Asylums.

Showing comparative annual mortality in five of the most fatal diseases,

1895-6-7-8.

1895 = shaded. 1896 =* black and white. 1897 — black. 1898 — white.

Digitized by CjOOQle

London County Asylum.

i 900.]

-J2 2 »
k a

^ 5 =s
s *s ^

«-TJ -r?

.. .. ^

•■? §>^

^ ^ -I

S « *

_^r .v»

” **<* ;;

5.5

S >2

t—

♦ .

BY ERJC FRANCE, M.B. # I

• * 8 qjB 9 p
IWI 01 s\x\\oj
uiojj sqjB 9 p

jo otoejaoxod

Q\ VO w> On

On « co to

•

* 8 jti 9 p} 89 j
93 bj 9 ab 0 } s;)! [03
uiojj sqjB9p jo

OOOI J 9 d OIJBtf

00 0 ~ CO

M « 01

*Xj 9 JU 9 sXq

‘•IJIJOJU3

*®!*!I°D

UIOJJ 8 qjB 9 Q

- CO ^ CO

ej e» ~ d

* 9 qjB 9 p
1*J0J oj opjoqnx
UIOJJ sqjB 9 p

JO 98 BJU 90 J 93

W 5 V) VI N

CO *0 W 00

« on « ~

c«

*SJU 9 piS 9 J 9 SB
• 19 AT OJ 9 pjoqn£

uiojj sqjB9p jo

OOOI i 9 d 9 jey

M to qo VO

« 60 0 b

•opjoqnx
tuojj sqjBOQ

■

O x

CO ON N CJ

* 8 JU 9 pi 89 i
93 CJ 9 AE OJ
sqjB 9 p rejoj JO

OOOI J 9 d OIJB^

co 0 0 0

$ & $ S'

•S 9 SnB 9 [[B
'•qjB 9 p [BJO£

01 vo *0 00

V) CO t > *

o m 0 q. 9^

* 8 JU 9 pi 89 I

X|!Bp oSBJJAy

ck S' s s

NO CO C^ -

0 ~ 2 2

Year.

10 vo 00

S' S' <2* S'

Average for the 4 years

Digitized by

Google

12 ISOLATING THE PHTHISICAL INSANE, [Jan.,

* * *

If it may justly be supposed that a similar proportion exists
in the other asylums of England and Wales, it is apparent that
the figures representing the incidence of tubercle in these insti¬
tutions must be doubled before they can be regarded as actually
representing the case. This fact alone would more than justify
•a vigorous attempt to reduce this heavy mortality, but there
are other reasons which should stimulate us to take some
decided action in this matter. Public interest has recently
been aroused in a gratifying degree to the importance of action
being taken against the tubercle bacillus. I need only refer to
the establishment of the National Association for the Preven¬
tion of Tuberculosis, and to the excellent work it is doing ; and
to the untiring efforts of the Medical Officer of Health for
Manchester—Dr. James Niven,( a ) and the Medical Officer of
Health for Sheffield—Dr. John Robertson,( s ) both of whom have
strongly urged the compulsory notification of phthisis. Dr.
Niven’s last annual report, and the special report on tubercu¬
losis published this year by Dr. Robertson, both contain much
valuable information, and will repay careful study. In each
report the obvious fact is strongly emphasised that notification
is essential to any coherent scientific attack upon this disease as
it exists among the general population. But we, as Medical
Officers of asylums, are in this more fortunate position. We
have no need to wait for such a thing before we can hope to
cope successfully with tuberculosis.

The time has now come when some definite effort must be
made to reduce this excessive mortality from tuberculosis
among the insane. I am glad to be able to state that the
Asylums Committee of the London County Council has this
matter under consideration.

The question remains, what is to be done? Two years ago
I urged upon this Association that if the prevention of the
spread of phthisis could be summed up in one word, that word
was Isolation .( 4 ) This opinion has the powerful support of Sir
James Crichton-Browne, who, in a speech at the Poor Law
Conference, said, “ Our greatly increased, and now exact
knowledge of the nature of tubercular disease, and of its mode
of propagation, makes it, in my opinion, obligatory upon those
having control of public institutions into which tuberculous
patients are received to arrange for their complete separation
from the other inmates.”

Digitized by

Google

1900.]

BY ERIC FRANCE, MlB.

No thoughtful person will now deny the necessity for
isolating the phthisical; and if the importance of isolation be
granted, the crucial point of diagnosis at once presents itself.
An early diagnosis affords the best opportunity of placing the
patient in such environment and under such treatment as is
most suitable for his recovery, and when isolated in the early
stages of the disease he has not begun to disseminate the
bacillus to the detriment of others.

Whatever means be adopted for definitely diagnosing active
tubercle in suspected patients, whether it be by a careful study
of their body-weight and temperature, or by a microscopical
demonstration of the tubercle bacillus in the sputum, or by the
inoculation method advocated by Sheridan Del£pine,( 5 ) it cannot
be too strongly urged that an early and accurate diagnosis
must be made if isolation is to be of real service either to the
patient or to the community.

We are well aware how little ordinary diagnostic rules and
methods apply to insane persons, and how frequent and great
is the difficulty in diagnosing phthisis in them. For these
reasons, as well as the importance of an early diagnosis, for
about eighteen months at the Northumberland County Asylum
(where the death-rate from phthisis was very high—about 40 per
cent, of the total deaths) I relied almost entirely on the diagnostic
power of single minute subcutaneous injections of Koch’s original
tuberculin. This method was adopted because, in the majority
of insane patients, physical signs in the chest were found to be
untrustworthy, misleading, and often paradoxical in the early
stages; and because the valuable method of microscopical
demonstration of the bacilli in the sputa was seldom pos¬
sible.

At that asylum I injected seventy-five cases with tuberculin,
and am satisfied, not only with the accuracy of its diagnostic
power, but also with its entire harmlessness, both in the tuber¬
cular and in the non-tubercular. Every patient was carefully
weighed at the beginning of each month, and every one who
had lost more than 5 lbs. in the month, or in whom gradual
loss of weight over a longer period had occurred, was examii\ed
and the cause of the loss of weight minutely inquired into.
If this could not be readily accounted for by some obvious
mental or physical cause, such as refusal of food, the patient’s
name was placed upon the “ suspected list.” The same thing

Digitized by VjOOQle

14 ISOLATING THE PHTHISICAL INSANE, [Jan.,

was done in the case of any patient giving at any other time
the faintest cause for suspicion of the presence of tubercle.

All those on the “ suspected ” list were then injected with
tuberculin in the following way:—The patient was put to bed and
the temperature was taken. The next day, with rigid antiseptic
precautions, I c.c. of a *ooi solution (made by diluting I c.c. of
Koch’s original tuberculin, issued under a guarantee of Dr.
Libbertz, who acts under the direct supervision of Prof. Koch,
with a *5 per cent, solution of carbolic acid) was injected
subcutaneously, and the temperature taken every three hours.
If the temperature rose 2° or more within the next twelve
hours tubercle was diagnosed.

With regard to the seventy-five cases injected, twenty were
non-suspects, or control experiments ; in none of these was a
reaction obtained. The remaining fifty-five were suspected of
having tubercle, and gave the following results:

55 “ Suspected ” Cases injected.

45 reacted. 10 did not react.

11 still live , of whom 6 had
merely local tubercular
lesions, viz. cervical
glands, strumous dactyl¬
itis, etc.; i discharged
mentally recovered; i
going downhill with
physical signs; 3 results
wanting.

5 no P.M.'s made. 4 certi- 5 died and P.M's made. 5 still alive
fied as “ phthisis pul- No trace of tubercle and healthy

monalis.” 1 certified as found in any. (July, 1899).

“general tuberculosis.”

34 died.

29 P.M. } s made.
Active tubercle
found in every
case.

Grave fears have been expressed that even single minute
injections of tuberculin might possibly re-awaken dormant
tubercle, or lead to its dissemination through the tissues. I
have been quite unable to discover any grounds for such fears.
Koch states that out of more than one thousand persons in
whom tuberculin was used diagnostically there was not the
least indication of dissemination of the disease.( 6 ) “These
facts,” says he, “should suffice to make us, once for all,
abandon the absurd idea of the possible stimulation of the
tubercle bacilli, and should encourage us to apply tuberculin to

Digitized by kjOOQle

1900.]

BY ERIC FRANCE, M.B.

the diagnosis of tuberculosis in the human subject” Since my
first paper was published on this subject tuberculin has been
tried, and its value as a diagnostic agent extolled by Dr. G. A.
Heron ( 7 ) and Dr. McCall Anderson ( 8 ) in this country; by
Dr. Japies T. Whittaker,( 9 ) Dr. Franklin T. White,( 10 ) and Dr.
Irving H. Neff( u ) in America; by Drs. C. F. Martin and
G. D. Robins, of the Royal Victoria Hospital, Montreal; ( 12 )
by Prof. Brieger, in a speech before the recent International
Tuberculosis Congress at Berlin,( 18 ) and by Prof. Clifford
Allbutt, who, in his address on the prevention and remedial
treatment of tuberculosis at the annual meeting of the British
Medical Association last August,( u ) referring to the diagnosis
of early tuberculosis and its attendant difficulties, says, “ Tuber¬
culin seems to be almost a certain test of the presence of
tuberculosis in its early stages. ... In England I think most of
us have been reluctant to arouse the reaction, but Dr. Turban
follows other German observers and Prof. Osier in assuring us
that he has never seen any harm ensue from it, although he
always keeps the patient in bed until the reaction has wholly
subsided. The old tuberculin is preferred for this purpose.
Of all our means of detecting early tuberculosis this may
prove the most valuable.”

It is to be clearly understood, however, that I advocate this
method of diagnosis only in those cases where the presence of
active tubercle cannot be definitely diagnosed by other means,
and that a monthly record of the true body-weight of asylum
patients is of the greatest importance, as I stated in detail in
my original paper in i897.( 4 )

Referring finally to the question as to how isolation may
best be provided for the phthisical insane, it would be beyond
the scope of this paper to do more than offer one or two sugges¬
tions, omitting structural, administrative, and financial details,
which must, of course, be left in the hands of those who adopt
this means of prophylaxis. I recently contributed a paper to
the Archives of Neurology, from the Pathological Laboratory of
the London County Asylums,( 15 ) referring particularly to
these asylums, and may be permitted to repeat it in part.
“ Two schemes at once suggested themselves : one is the
erection of a central isolation hospital for phthisical patients,
common to all London county asylums; the other is the
building of cheap temporary bungalows at each of these

Digitized by CJooQle

ISOLATING THE PHTHISICAL INSANE,

[Jan.,

asylums. Each scheme has its advantages. The selection of
a site, specially adapted by reason of its elevation and its soil,
is certainly in favour of a central hospital ; while the difficulty
and expense of the transference of patients appears to be the
chief argument against it. It is now held by eminent authori¬
ties that the successful treatment of phthisical patients depends
more upon how they are treated than where, more upon
perfect hygienic surroundings than upon climate and soil.( 16 )
The idea, therefore, of a bungalow built upon the estate of
each asylum appears to me to be a very attractive one.”

“In conclusion I should like to suggest that a temporary
bungalow should be erected as an experiment on the Claybury
estate. I am given to understand that such a building could
be obtained, which would meet all requirements and accommo¬
date twenty-five patients of each sex, that is 2 per cent, of
those in the main building, for a comparatively small sum.”

P) Journ. Merit . Sci., October, 1899. — ( a ) City of Manchester M.O.H.’s
Annual Report for 1898.—( 8 ) City of Sheffield, Special Report by M.O.H. on
the Prevalence of Tuberculosis, 1899.—( 4 ) Journ. Ment. Set., October, 1897.—
(*) Brit. Med. Journ., September 23rd, 1893.—( # ) Deut. med. Woch., April, 1897.—
( 7 ) Brit . Med. Journ., 1898, vol. ii, p. 77.—( § ) Ibid., 1898, vol. ii, p. 495.—
( 9 ) Trans. Assoc. American Physicians, 1897.—( 10 ) Boston Med. and Surg. Journ.,

1897. —( u ) American Journ. Insanity, January, 1899.—( u ) Brit. Med . Journ.,

1898. vol. i, p. 357.—( 13 ) Ibid., 1899, vol. i, p. 1348.—( 14 ) Ibid., 1899, vol. ii,
p. 1153.—( l5 ) “ The Prevention of Phthisis in the Insane,” Archives of Neurology,
from the Pathological Laboratory of the London County Asylums, 1899.—( 1# ) Vide
paper by Dr. A. Ransome on the “ Open-air Treatment of Consumption,” Brit.
Med. Journ., 1898, vol. ii, p. 69.

Discussion.

Sir William Broadbent. — I have come here with great
pleasure to endorse what I understood were the conclusions
arrived at by many officers in asylums, namely, that it is the
duty of those who are concerned in the management of asylums
to make provision for the isolation of phthisical patients. I
have heard with very great interest the paper, and havp seen
confirmed, as had generally been understood, that the mortality
from tubercular disease in asylums is, one might almost say,
enormous. Anyhow, it is so large as to demand very special
attention ; and unless we are to look upon our insane patients
as people whom it is desirable to get rid of, we must do our
best to keep alive those who are committed to our charge,
although asylum subjects. They are a melancholy spectacle,

Digitized by VjOOQle

igoo.]

DISCUSSION.

yet they are human beings, and it is our duty to do everything
that can be done for their welfare, and even for the prolonga¬
tion of lives which are not altogether the happiest.

One of the points of interest which one would have liked to
hear illustrated more completely was the comparison between
the mortality from phthisis and tubercular disease generally,
inside asylums and outside. It is understood of course that
that comparison could only be accepted up to a certain point;
that there are many considerations applying to inmates of
asylums which do not apply to those who are living an active
life outside. It would, however, have been a matter of great
interest to know exactly what the proportion was. Taking the
absolute prevalence of consumption, one questions what it is
due to. Of course I know less of the actual life in an asylum
than perhaps anyone here, but one can see that there must be
conditions which are extremely favourable to the dissemination
of tubercle. For a considerable portion of the twenty-four
hours the inmates of asylums are under cover. The necessity
for warmth—the warmth which is necessary for these enfeebled
organisations—must frequently interfere with efficient ventila¬
tion. You cannot teach an insane patient the precautions which
are necessary to prevent contamination of surrounding objects
by the sputum, and, as Prof. Clifford Allbutt pointed out in the
address already alluded to, it is not simply the mass of expecto¬
ration which can be collected which has t 8 be dealt with ; it
is the spray which is disseminated in the act of coughing which
is often richest in these tubercular germs. Whether these
conditions alone, the necessary confinement indoors, the neces¬
sary association in large dormitories, the difficulties of prevent¬
ing the expectoration from contaminating surrounding objects,
explain the great prevalence of tuberculosis in asylums, or
how far they are accountable for it, I am not prepared to
say. There is of course the other side, namely, the fact that
insane, people are weakly organisations, and probably more
predisposed from the fact of their disease as well as from
the necessary limitations to their outdoor exercise. We have,
therefore, in asylums exceptional conditions which favour the
dissemination of tuberculosis, and this would imply that special
precautions should be taken to prevent such dissemination.
For this end I can imagine nothing better than the plan
which has been proposed this evening,—that all patients in

XLVI. 2

Digitized by

• ogle

18 ISOLATING THE PHTHISICAL INSANE, [Jan.,

whom there is a reasonable suspicion of tuberculosis should be
tested by tuberculin. From all that I have heard regarding
this test, it is absolutely safe. There is no fear of any harm
being done to the patient, and reaction of it is undoubtedly
the most trustworthy evidence we can possibly have of the
existence of tubercle. Then it seems also that every large
asylum, surrounded as it is by extensive grounds, has facilities
for isolation and for treatment, and it has been a satisfaction to
me to hear so excellent a scheme propounded, and so far as
my judgment goes it is entirely deserving of support.

Sir James Crichton-Browne. —Your discussion this after¬
noon, founded upon the excellent paper of Dr. France, to which
I am sure we have all listened with the utmost attention, has
reference to the necessity for isolating phthisical patients
amongst the insane in lunatic asylums ; and I take it therefore
that that necessity is already recognised, and that it is the
method by which isolation may be economically and effectively
carried out that is henceforth most likely to engage your
attention. Now it seems to me that since the publication of
the statistics, marshalled and set forth in Dr. Crookshank’s
very able and lucid paper on pulmonary phthisis, to which the
medal of the Medico-Psychological Association was awarded,
reinforced and confirmed as they are by the tables and the
figures submitted to us to-day, it becomes an imperative necessity
to provide for th# isolation of phthisical cases in asylums.
Dr. Crookshank has shown that the official mortality from
phthisis in our asylums—and I can discover no flaw or fallacy
in his figures or his conclusions (and it is to be remembered
that the official mortality falls considerably short of the real
mortality),—he has shown that it is ten times that of the
phthisis mortality in the general population, and is four and a
half times that of the phthisis mortality in men from thirty-
five to forty-five years of age,—that is to say, in the particular
age group in which the mortality from phthisis is highest in
the general population. Dr. Crookshank has also shown that
whilst the mortality from phthisis in England and Wales has
fallen during the last thirty years by 30 per cent., there has
been no reduction in the mortality from phthisis in asylums,
at least during the last twenty years.

Making all possible allowance for errors in these statistics, sift
and rearrange them as you will, it is incontestably established, I

Digitized by VjOOQle

1900.]

DISCUSSION.

think, that phthisis pulmonalis is prevalent and is the cause of
death in our public asylums in this country to an unnecessary
extent; that it is to a very considerable degree generated and
propagated in them. Well, gentlemen, I have long held that
opinion. Dr. Crookshank says that in 1892 I recommended the
erection of detached blocks to be used as hospitals for consump¬
tion in connection with our public asylums, but long before that
I had advocated isolation. I hope I shall not be regarded as
egotistical if I quote a sentence or two from a paper of mine
that appeared in Brain in 1883, that is exactly one year
after Koch had discovered the special bacillus in tubercular
disease, and had shown that it could be isolated and culti¬
vated, and that the disease could be reproduced in its inocula¬
tion.

I said that in 100 general paralytic patients dying in the
West Riding Asylum, consecutive cases, in all of which general
paralysis was the certified cause of death, tubercular disease of
the lungs was found in 25 cases ; in 17 out of 80 men, and in 8
out of 20 women. In 6 of these cases only the remnants of past
phthisical disease were noted, crustaceous nodules, cicatrices,
etc.; but there was no room for doubt that in 19 cases the
disease had arisen during the course of the general paralysis,
and had been cut short by the natural termination of that
malady, which it had perhaps in some degree hastened. In
none of these had the disorganisation of the lungs spread to
the extent which we are accustomed to find in patients who
have died of phthisis. I go on to show the reasons that led
me to believe that the phthisis in these cases was contracted in
the asylum, and the special reasons why general paralytics suffer
in this way, and also to explain that the mortality was larger in
female lunatics in asylums than in males. I conclude with these
words : “ Until Koch’s theory is disproved it would be prudent
to act on the assumption that it is true, and to prevent the
close association of persons actually suffering from phthisis with
those who, from inherited tendency or deterioration of health,
are especially liable to contract the disease. A large number
of lunatic asylums have now detached hospitals for contagious
diseases, which fortunately stand empty for a great part of the
year, and it might be well to isolate in those buildings all cases
of phthisis. The experiment could do no possible harm, and
there is every prospect that it would be attended with benefit

Digitized by

Google

ISOLATING THE PHTHISICAL INSANE,

[Jan.,

to the victims of phthisis, and with safety to those who are in
danger of its attacks.”

From this extract you will gather that I then proposed the
isolation of phthisical cases in asylums, but at that time my
proposals fell upon deaf ears, and if I recollect rightly they
were ridiculed in certain quarters. I made these proposals
because I had been startled by the phthisis mortality in the
West Riding Asylum when I became its medical director about
thirty-four years ago ; because I had seen there dropping
around me from phthisical disease not only patients, but
medical colleagues, nurses, and attendants, in whom I felt sure
that the seeds of the disease had been sown during their
sojourn in the asylum ; because I had satisfied myself that
asylum phthisis mortality could be materially reduced by
attention to practical sanitation and hygiene, and because I
entertained the sanguine expectation that asylum phthisis
mortality might be still further reduced by measures calculated
to prevent the dissemination of infective material.

Nowadays, as Dr. France has told us, we are all tolerably
well agreed as to the merits of isolation, we are all agreed that
a stringent obligation rests now upon asylum medical authori¬
ties to provide means for separating phthisical from the non-
phthisical patients. But though we are theoretically agreed upon
that point, much remains to be done before practical effect can
be given to our agreement. Quite recently I saw a patient of
mine in the last stage of phthisis in a large public asylum in
this country, in a single room, the walls of which, the floor of
which, besides the bed and the bedding, bore visible traces of
dry phthisical expectoration. The single room occupied by
that patient opened into a large ward in which patients were
constantly passing to and fro, and they had access to the room
if they desired to enter it, and it is not improbable they
had whiffs of the tubercle bacilli as they passed the door. That
sort of thing should not be, but it is still to a large extent
unavoidable, for even where our asylum medical officers are
deeply convinced, as I believe most now are, of the necessity
for isolation, and eager to carry it out, there is still in many
cases no possibility of doing so because of deficiency of
accommodation for isolating and separating phthisical patients.
But, gentlemen, I venture to predict that that sort of thing
will not go on very long, for whenever it becomes generally

Digitized by VjOOQle

1900.]

DISCUSSION.

and popularly known that a certain proportion of lunatics in
our asylums, deprived of their liberty, for the protection of the
public or for treatment of affections of the brain and nervous
system, while detained there are liable to be infected by a
disastrous and often fatal, sometimes preventable disease, then
I say that there will be an urgent public demand for isolation,
and for preventive measures, above all for that primary pre¬
ventive measure that is of paramount importance—the separation
of the diseased from the whole.

I need scarcely remind you that in no class of phthisical
cases is isolation more absolutely essential than in those in
which phthisis is associated with insanity, for in those patients
it is impossible to secure the observance of any minor pre¬
cautions. It would be impossible to compel them to use
special spittoons or handkerchiefs, or observe strict cleanliness,
and there is nothing for it but their prompt removal from associa¬
tion with companions to whom they may become a source of
danger of lung contamination. Expense must not stand in the
way, and sure I am that whenever the Medico-Psychological
Association has definitely made up its mind as to the system
of isolation that ought to be pursued, then County Councils
will at once generously and freely provide the requisite funds.
The isolation of the phthisical insane is not by any means an
easy or simple problem. There are great difficulties and
obstacles in connection with it, but I feel sure that these will
speedily disappear when once our asylum medical officers have
taken the matter seriously in hand. In the meantime it does
seem to me that those existing detached hospitals for in¬
fectious diseases which are attached to so many asylums ought
to be as far as possible employed for isolation, so that
phthisical patients may be promptly removed from the wards,
where they are apt to be distributors of disease, and that where
no such detached buildings are available special wards should
be set apart for the phthisical patients. Very shortly, I have
no doubt, sanatoria and special buildings will spring up in
connection with our county asylums, provided singly by
counties in the case of the large and populous counties, and
perhaps in the case of small counties by several acting in con¬
junction. We shall have sanatoria in which isolation may
be thoroughly secured, and in which the modem sanatorium
or open-air treatment may be adequately carried out, combined

Digitized by

Google

ISOLATING THE PHTHISICAL INSANE,

[Jan.,

with that medical treatment of phthisis of which, I trust, we
shall never lose sight.

During the course of last summer I ventured to urge
upon my friend Dr. Hayes Newington, who is taking so
active and so useful a part in connection with the building of
the East Sussex Asylum, that he should there provide a sana¬
torium for phthisical patients on the plan of Dr. Burton Fanning’s
sanatorium at Mundesley—a simple wooden building with
verandahs, shelters, and all necessary appliances for open-air
treatment. In connection with some small asylums a chain of
villas might be a suitable means of providing for such patients ;
but whatever style of building be adopted all apartments ought
to have Parian cement walls and ceilings, so that they may be
cleansed from time to time by hot formalin spray, discharged
under pressure, the most powerful disinfectant known for use
on the large scale. Where wooden buildings are adopted I
would suggest that it should be stipulated that they are to
be burnt down always at the end of ten years. I am a
member of a small committee appointed to provide and
manage a sanatorium for middle-class patients in the neigh¬
bourhood of London, to be provided by the munificent advance
of £20,000 made by Mr. Lionel Phillips and Mr. Ruby. A
site has been acquired in the neighbourhood of Ascot, and every
effort is being made that the structure shall be as perfect as
possible in every respect. The plans of that building and
all particulars in connection will, I am sure, be at the service
of any asylum medical officer who may be interested in the
erection of a phthisical sanatorium. For the limitation—let
us hope for the ultimate extinction of asylum-bred phthisis—
isolation, that is to say, complete separation of tuberculous from
non-tuberculous patients, is the primary and essential measure.
But isolation is not everything. There are many other pre¬
ventive measures that must receive close and constant attention.
Even if we could at once weed out of our asylums to-day all
tuberculous cases, there would still go on the constant intro¬
duction into them of new cases in that early or incipient stage
of the disease in which diagnosis is so difficult. The seeds of
tubercle abound around us, and while our first efforts should be
directed to blow them away, to remove and isolate those
persons in whose bodies they have germinated and taken root,
and who have therefore become factories and storehouses for

Digitized by VjOOQle

1900.]

DISCUSSION.

their multiplication and preservation and distribution, we must
not neglect to deal with those conditions of the human soil
that are favourable to their reception, and those conditions of
the environment that are conducive to their growth. We must
not neglect to build up in every possible way the constitutional
vigour of our patients generally—and asylum patients are
almost invariably in a reduced state of health, and therefore
peculiarly susceptible to tuberculous infection—and to surround
them by conditions inimical to the life of the tubercle
bacillus. Counsels of perfection are not of much avail when
the mischief has been done, and when pecuniary considera¬
tions are against them ; but I cannot refrain from expressing
my opinion that our public lunatic asylums in this country
are a great deal too big, and that it is deplorable to see
them go on stretching out wing after wing, adding annex
to annex, climbing up three and even four stories. There
can be no doubt that there is danger in massing large
numbers of the insane Upon a limited area and in buildings that
are piled up to a great height; and I think we owe it entirely
to the constant vigilance and care of our asylum superin¬
tendents and medical officers if these dangers have not already
resulted in serious evils. But our asylums are not only too
big, but some of them are occasionally overcrowded, and
it is certain that there is no more prolific cause of tubercular
disease than overcrowding. Having regard to the habits of
the insane and to their modes of life, it seems to me that un¬
fortunately the allowance of cubic contents per head in asylum
accommodation was originally fixed too low, and that in
future an ampler allowance should be given. I think I could
point to some asylums where, as regards day-space, the patients
are too thick upon the ground. Then we have not only to con¬
sider overcrowding, but also that constant human saturation of
asylum buildings which is going on. I think I could point to
asylum dormitories in which every bed has been uninterruptedly
occupied night after night for five, ten, twenty years,—even, in
the case of one or two of the older asylums, for forty or fifty
years. In this connection I think the recent researches of Dr.
Mitchell Bruce as to the health of boys in training-ships pre¬
paring for the navy are deserving of very careful consideration.
He found that the loss of life from tubercular disease amongst
these boys is three times greater than in the general popula-

Digitized by VjOOQle

24 ISOLATING THE PHTHISICAL INSANE, [Jan.,

tion, and that the invaliding of these boys from the old long-
inhabited wooden ships was just twice as great as that from
the modern and new iron ships which are also used for training
purposes.

As regards house accommodation, it appears to me that it
should, like land, be left fallow from time to time ; that in every
asylum there ought to be a block or ward beyond its proper
accommodation, to which the patients from all the other blocks
and wards could be moved in succession, so that every block
might remain tenantless for a month every year, and be
thoroughly exposed to wind and weather. I think also that
asylum dietaries require revision. I do not suggest that they
are not sufficient, as has been found to be the case in some
prison dietaries. I believe they are ample; the amount of
waste that one sees about, the splendid condition of all
asylum pigs, attest the fact; but I do question whether
asylum dietaries are always sufficiently well balanced as
regards their different constituents, and whether they all
contain a sufficient amount of fatty elements. It is to be
borne in mind that an immense change has taken place in
the dietary of the population of this country generally since
asylum dietaries were fixed, by the importation of fish, of
foreign meat, foreign fruits, preserves, bananas, tomatoes, and
all sorts of articles. These articles have found their way down
to the very poorest classes of the community, and we must
remember that the asylum population in our public asylums
is not all drawn from these poorest classes. “ Pauper ”
asylums they are still called, but I think that word should be
abolished, for pauper asylums they are not in any true sense,
for a very large proportion of the population is not drawn
from the pauper class, but from the artisan and small trading
and even professional classes. We must remember that patients
drawn from these classes have been accustomed to varied and
good food, and that it cannot be conducive to their mental
tranquillity, therefore to their mental recovery, it cannot be
preventive against phthisis, that they should be relegated to a
monotonous fare. They should, I think, have a diet not
merely wholesome and sufficient, but varied and highly nu¬
tritious, and served in such a manner as to tempt the appetite
of sickly and nervous persons. Then the drying of clothes
is a matter deserving of attention. A large proportion of the

Digitized by VjOOQle

1900.]

DISCUSSION.

clothes is dried in darkness. In my opinion there is no
better disinfectant than sunlight. Then, again, I think that
where round asylums the earth comes close up to the wall we
ought to have asphalt to prevent that organic saturation of
the soil which is constantly taking place. With regard to
those special methods for the detection and arrest of phthisis
amongst the insane in which Dr. France has been the pioneer,
I think he was the first in this country to apply that harm¬
less and very valuable tuberculin test for the detection of
phthisis in lunatics in whom the disease is masked and very
difficult to recognise in the early stage. I would suggest that
whenever in the periodical monthly weighing of patients there
are grounds for suspicion of the existence of tubercle, the
tuberculin test should be employed. The whole question is
one of the greatest interest and importance, and one that the
Association will have to consider forthwith.

Prof. Clifford Allbutt. —I am glad for the excuse to
rise for a moment to add my testimony to the weighty and
lucid paper on which this discussion has originated ; and if Dr.
Harry Campbell will allow me to say so I think it will add
much to the well-being of us old men to know that the younger
men are carrying on the torch not only of knowledge, but of
enthusiasm for humanity in the way which has been shown to
us by the reader of that paper. Everything that I could
possibly have said has been said, and said in terms better than
I could, so that I would most gladly listen rather than inter¬
fere. I do not know that there a’re any points in which my
personal opinion is of very much importance. As regards the
bungalow, I think that is a very, very much better suggestion
for isolation than the proposal of central or relatively central
hospitals. It is of very great importance that patients should
be kept near their friends, and there is, I trust, now less and less
of that consigning to distant asylums which used to take place
on a large scale. I think if we were to begin removing patients
again to central hospitals we should set the public against
isolation, and also be, I think, very improperly intruding upon
the sphere of domestic affections by taking them from their
friends. Therefore I should certainly urge that wooden and,
as Sir James Crichton-Browne has said, combustible buildings
should be set up in asylums, and be established near them
on sites which are likely to be among the healthiest to be had

Digitized by VjOOQle

26 ISOLATING THE PHTHISICAL INSANE, [Jan.,

in the county. Another point I would insist upon is that of
early diagnosis. The reason why I spoke, though somewhat
timidly, in favour of the general use of the tuberculin test in
my address at Portsmouth was that at the Congress at Berlin
every experienced medical man I met assured me that the use
of this remedy is safe if employed with caution, the patient
being kept in bed until every sign of the reaction is over.
There seems to me to be strong testimony that it may thus be
without any danger whatever. When we take people away
from their friends and set them apart, and their liberty is
necessarily curtailed, we must be exceedingly careful what we
do with them, and you will agree with me that to try any
means which are in a crudely experimental stage would be
unpardonable. But I think the use of tuberculin now is so far
established that it may be very safely used without the possi¬
bility of its being said that anything in a crudely experimental
stage has been tried upon the patients. With regard to the
physical signs of phthisis, we very frequently hear of people
detecting the disease in the early stage by the stethoscope ;
this you never do. When pulmonary tuberculosis is manifested
by physical signs you have got disease considerably advanced.
If it goes a stage beyond this, and if the physical signs become
obvious, remember the disease is passing into the incurable
stage. I must say that I have been startled by the excellent
diagrams we have seen, which put so very distinctly and clearly
before us the relations of prevalence of the chief destructive
diseases of asylums to each other. Although specially busy
with lunacy and asylums for three or four years, I did not
quite realise that the disastrous effects of phthisis in our
asylums are so great as we see here. One thing more I should
like to say, and that is that I think it ought to be officially
known, that the continual tendency to increase the size of
asylums has been done in defiance of the protests of the Lunacy
Commission, which has urged to the utmost that no asylum
should henceforth be built for more than 1000 patients. This
opinion has been repeatedly communicated to the central
government and also to local governments. The Commission
had deliberately come to this conclusion, and I know that it
has been a matter of regret that their wishes have been set at
nought. I do not like the “tenantless ward ” plan. We find
that in all such cases of good resolution this system continues for

Digitized by

Google

1900.]

DISCUSSION.

the first two or three years, but you know that the tenant¬
less ward remains tenantless for a very short time only. The
two instances in my mind did not survive more than four or
five years. It would merely mean in the course of a few
years that all the wards would be occupied.

Dr. Weatherly. —It has been my privilege recently to
spend a month in one of the largest sanatoria in the world,
erected at a cost of nearly ;£ 100,000. In conversation with a
leading man there I learned that he believed that phthisis in
large institutions might be greatly prevented if we insisted on
thorough ventilation by day and night. If we would only
adopt the German style of windows in our asylums we should
have much better ventilation. My experience is that this
question of ventilation is much neglected in hospitals and
asylums because, as a nation, we hate draughts, and the poorer
classes especially object to fresh air indoors.

Dr. Hayes Newington. —Sir James Crichton-Browne’s
reference to my position as Chairman of the Building Com¬
mittee of a County Council tempts me to offer a few remarks.
I am sure that the discussion will bear very great fruit in
regard to the action of county councils. He is perfectly right
in saying that it is necessary that some scheme should be
formulated by this Association. As he said, I have had a good
deal to do with the designing of a large asylum in Sussex on
some new principles, and I have found it quite enough to
carry through even a few ideas of a medical nature, which
some non-medical people might call fads. I find there is a con¬
siderable belief growing in the public mind regarding points
which are already well established by us. But this matter is
obviously not set on a sure footing as far as we are concerned,
and one has had to be a little cautious in going to work. In
our sick wards there will be some nice little isolation dor¬
mitories, and, of course, plenty of single rooms can be set
apart. Our system is decentralisation as much as may be, and
there will be plenty of room for variation in other directions.
We have no less than 160 beds prepared for, but not to be
provided at present, some of which might be set aside for this
purpose. I must say that although my views have met with
every consideration from my colleagues, my hands on this
point would be infinitely strengthened by a proper scheme
drawn up by this Association. One quite foresees the tre-

Digitized by VjOOQle

28 ISOLATING THE PHTHISICAL INSANE, [Jan.,

mendous difficulties in planning an asylum—to carry out
ideas which are not consolidated as yet We should have to
make provision for the absolute wrecks; then there are others
that we know will become wrecks; and then there are others
that we know may and will go down unless looked after.
Further, it is very difficult to balance the physical needs and
the psychical needs in such cases. One would think it ex¬
tremely hard to send into a receptacle, whether burnable or
not, with a lot of cases that we know will die in a few months
in a degraded state of mind and body, recent cases of melan¬
cholia showing threatenings of phthisis. All those little points
have to be taken into consideration, and the difficulty I have
had in thinking over this matter very seriously since Sir James
Crichton-Browne gave me the most excellent advice last year,
is how we are going to deal with the phthisical needs of the
cases pari passu with the psychical. I take it that the proper
attitude of this Association is to accept the facts mentioned as
proving the necessity for special dealing with tubercular cases,
and then to set to work at devising the best methods.

Dr. Head.— We are agreed on the necessity for isolation
and for early diagnosis. Dr. France’s method is tuberculin.
That must be put upon its trial. At one of the large county
asylums nine elevenths of the male cases and two thirds of the
female cases that were found to have tubercle on the post¬
mortem table had not been diagnosed as tubercular till within
a few days before death. Why does this arise? Firstly,
because the medical officers have infinitely too many patients
to deal with. One to 500 patients is absurd. Secondly, the
diagnosis of these diseases in the insane requires very special
clinical knowledge. We have no treatise on phthisis in the in¬
sane ; why not ? We have treatises on phthisis in children and in
adults. It is said that the diagnosis of phthisis in the insane
is infinitely difficult. Of course that is true ; so would be the
diagnosis if you applied the methods of the adult to the child.
Tubercle takes quite a different course in the child compared
with the adult. Therefore the signs are said to be paradoxical.
The signs of phthisis in the insane are not paradoxical; they
are as definite and as much a part of the clinical features of
phthisis in the insane as are the otherwise paradoxical signs of
tubercle in children. Asylum medical officers should have
fewer patients to deal with, and we should have a treatise on

Digitized by VjOOQle

igoo.]

DISCUSSION.

phthisis as it appears in the insane. Then we shall be able to
adopt Dr. France's diagnostic plan, which is one which will
require very careful carrying out.

Dr. Jones. —I agree with Dr. Head that auscultatory
methods require a lot of time, study, and experience to justify
conclusions in the sane; how much more difficult must this be
among the insane who are unable to assist the diagnosis ! With
reference to early diagnosis, it seems to me that Dr. France
has suggested a most valuable symptom in the change of body-
weight, and a great many of us rely very considerably upon
this symptom. I am sure that every superintendent throughout
the country would like to have one medical officer to every 112
patients, but what would happen ? The maintenance rate
would go up, there would be an investigation as to the high
expenses.

Dr. France.— In reply to Sir William Broadbent, who
desired to have the ratio of deaths from phthisis outside asylums
and the ratio inside, I may repeat that I came to the conclusion
that such comparisons are apt to be fallacious, and that Dr.
Crookshank has fully discussed the point. I understand Sir
James Cricftton-Browne to state, on the authority of Dr. Crook-
shank, that there has been no reduction in the death-rate in
asylums during the last twenty years. Either Dr. Crookshank
or myself must be wrong, because during the last four years I
find that the ratio of deaths from tubercle in all asylums in
England and Wales has fallen in relation to the average
residents from 15*8 per thousand in 1895 to 14 6 in 1898,—
not a big drop, but in the right direction. In London county
asylums it has fallen during the same period from I2’2 to 10*6.
Dr. Head said that medical officers in asylums have too many
patients to deal with. This depends to a certain extent of
course upon energy and ability. Dr. Head proceeds to say
that physical signs in the early stages of phthisis in the insane
are not paradoxical. On my first appointment to an asylum
five years ago I had but recently qualified, and then believed
that I could detect phthisis and other diseases in the chest of the
insane with the same facility as in the sane. I soon found out
my mistake. If Dr. Head will give time and attention to these
problems, he will also come to the conclusion that in many cases
the physical signs are paradoxical, as Sir William Broadbent
has pointed out, and as those present evidently believe.

Digitized by VjOOQle

30 MENTAL STATE OF AUGUSTE COMTE, [Jan.,

The President. —I am sure you will wish me to thank the
gentlemen who have come here this afternoon for their very
eloquent speeches. Our distinguished friend Sir James Crichton-
Browne has said many things which must prove subjects for
our consideration. I have pleasure in acknowledging how
much obliged we are to him for the very able way in which
he has dealt with the subject.

The Council of the Association have not been indifferent
to this very serious question, and have prepared a resolu¬
tion, which I am asked to bring before the meeting, viz.:
“ That it be referred to the Council of the Association to con¬
sider as to the appointment of a sub-committee for the investiga¬
tion and collection of evidence, and for practical suggestions as
to the isolation of phthisical patients in asylums.”

The President having put the resolution to the meeting, it
was unanimously accepted.

On the Mental State of Auguste Comte . By William

W. Ireland.

In the Revue Philosophique de la France , tome xlv, 1898,
there are three articles filling eighty-seven pages on this subject,
by Dr. G. Dumas. In order to appreciate their importance it
may be well to give a short review of what was previously
made known of the mental aberrations of that philosopher by
his friend and biographer, M. Littr^ 1 )

Auguste Comte was bom on the 19th January, 1798. His
parents were Catholics, his mother especially was dominated by
the beliefs of that church. Delicate in health, with a weak
digestion, he was from the beginning fond of study. When no
older than twenty-four, Auguste Comte had begun to plan that
system of philosophy which embraced so wide a view of the
sciences. On the 19th of February, 1825, when about twenty-
seven years of age, he married Caroline Massin, who is described
as a bookseller. M. Littr£ adds in a note the date of the trade
licence of Mademoiselle Massin, October, 1822, and tells us
that Comte became acquainted with her through M. Cerclet, a

Digitized by

Google

1900.]

BY WILLIAM W. IRELAND.

man known amongst the innovators of the times, and who was
one of the witnesses to the marriage. M. Comte’s family
objected, and Auguste Comte would have used the prescribed
formalities to dispense with the parental consent had not the
damsel been opposed to this. The required consent was at
length accorded. As M. Comte admitted no theological belief,
the marriage was purely civil. A few months after he took his
wife to Montpellier, where she was well received. At this time
he had nothing to depend upon save teaching mathematics and
writing on scientific subjects. In April, 1826, he commenced
a course of lectures in Paris to a distinguished audience, but
after three lectures the course was interrupted by an attack of
mania, said to be caused by excessive mental work and quarrels
with the St. Simonians. This outburst was ushered in slowly
by an unusual irritability and acts of violence to his wife. On
the 14th April Comte made a determined attempt to drag his
wife with him into a lake, and they were only saved from
drowning by the strength and courage of the young woman.

On the 18th of April, 1826, Auguste Comte was placed
under the charge of Esquirol. During this detention his
mother made a formal effort to get her son withdrawn, in order
to place him in a religious establishment. In the application
she named Madame Auguste Comte as “ the person with whom
he lived,” and attributed his derangement to her conduct. This
irregularity was the cause of the failure of the application.
After being under Esquirol’s care for seven months and a half
Comte was withdrawn by his wife, no way improved. She was
confident that no treatment would succeed if the person
directing it did not know the character of her husband. With
some general medical directions from Esquirol, Madame Comte
carried out her plan of treatment, which was to endeavoifr to
procure whatever he desired, and to cross his wishes as little as
possible. Living alone with him on a small allowance from
his father, she indulged his whims and endured his threats.
Once, when she was out on some message, he left the house and
threw himself into the Seine. He was rescued with difficulty.
Not recognising the validity of a civil marriage, Comte’s
mother got an order from the Archbishop of Paris that they
should be married by a priest. After the ceremony Auguste
Comte signed his name, adding the words “ Brutus Bonaparte.”
At the end of the year 1828 Comte had completely recovered

Digitized by VjOOQle

MENTAL STATE OF AUGUSTE COMTE,

[Jan.,

his health and vigour. In 1832 he was made examiner in
mathematics for the £cole Polytechnique, which assured him a
competent income. This post required his travelling to different
parts of France. To judge from his letters, the duties were by
no means light. He complains that for six years he had not
enjoyed entire leisure for twenty days at a time. As examiner
he excited lively opposition with only a vague support. His
anti-theological views, of which he made no secret, also caused
irritation amongst the zealous Catholics. The uncertain nature
of his tenure—for he required to be re-elected every year—kept
up a feeling of insecurity and dependence. Though well
qualified for his duties, he merely discharged them to gain an
income in order that he might be able to go on writing the
Systkme de Philosophique Positive . To this work Auguste
Comte during twelve years devoted all his spare time, following
a course of study and contemplation severely marked out,
avoiding all distractions, seeking no side ways of popularity, and
refusing to modify his views for either fear or favour. The last
of the six volumes appeared in 1842, with a preface containing
reflections upon Arago and others so unpleasing to the Council
of the Polytechnic School, that for 1844 he was not re-elected
to his post of examiner, and thus, on the completion of the
work which was to change the social condition of mankind, the
author found he had lost the greater part of his income.

In the Systhne de Philosophie Positive Comte exposed a new
arrangement of the sciences, clearer and more comprehensive
than any hitherto attempted. He traced the genealogy of
knowledge, beginning with the most simple and general, and
descending to the more complex and special, and showed that
it was in this way that the sciences had been successively
evolved. It was at once a lucid arrangement, a useful method,
and a history of the growth of human knowledge. His method
is of service in all the sciences together, and in each of the
particular sciences. Beginning with mathematics, astronomy,
and physics, he descended to chemistry, biology, and history,
and sought to construct a new science of sociology. In the
execution of this great plan, covering the whole field of human
knowledge, Comte shows prodigious and sustained powers of
mind. Few are even able to follow him all the way.

His method of literary work is explained by M. Littr£. In
composing a volume of his System Comte thought over the

Digitized by VjOOQle

1900.]

BY WILLIAM W. IRELAND.

outlines without putting anything to paper. He then passed to
the division, and on to the details. After the general plan came
the special plan of every part. When this was accomplished
Comte said his volume was made. When he sat down to write
he found without fail all the ideas which formed the weft of his
work, and introduced them in their order and connection. His
memory sufficed for all. When he had a certain number of
leaves written out he sent them to the press, and kept up with
the printing, making scarcely any change in his proofs, of
which he never saw more than one. Though such a proceeding
might be favourable to unity of conception, it was fatal to
compactness of expression and polish of style ; hence his books
are prolix, diffuse, and full of repetitions. Students of his
philosophy generally prefer the versions which have been made
by his disciples and admirers. The best exposition for English
readers is the book of John Stuart Mill, Auguste Comte and
Positivism .

In France the work attracted little notice and sold slowly.
A few copies got to England. A well-merited recognition of
the first two volumes was given by Sir David Brewster in the
Edinburgh Review (July, 1838), and a digest of the whole work
was published by Miss Harriet Martineau.

Comte was saved from pecuniary distress through Stuart
Mill, who got three of his friends, Grote the historian, Sir
William Molesworth, and Mr. Raikes Currie, to contribute 5000
francs, the equivalent of the salary which he had lost. Comte
benignly accepted this subsidy, and made a dignified remon¬
strance when it was not continued the next year. To the end
of his days his disciples contributed enough to provide for his
wants, which, though whimsical, were scarcely extravagant.
Comte thought he had a right, in doing a work for the benefit
of the whole human race, that he should be kept above destitu¬
tion. He made little endeavour to disguise the very high
opinion he had formed of his own merits. He regarded it as
no compliment to be compared to Bacon, and deemed himself
the equal, if not the superior, of Descartes and Leibnitz, and to
this valuation Stuart Mill and Littrd give their adhesion. It
is not thought in good taste that a man should proclaim his
own mental superiority save by guarded implications, yet it is
important that one should accurately gauge his own capacity,
and he who undertakes great tasks must know that he possesses

XL VI. 3

Digitized by

Google

MENTAL STATE OF AUGUSTE COMTE,

[Jan.,

great mental powers. During the intense application of mind
required for the composition of his great work, he was several
times subject to crises threatening a return of the cerebral
excitement of 1826. Madame Comte showed her anxiety by
repeatedly consulting physicians about symptoms which she
had observed in her husband, principally sleeplessness and
irritability of temper. One of these nervous crises was noted
in 1838, another in 1842, and a third in 1845. Aware of the
danger of a relapse, Comte had what he called his system of
cerebral hygiene. He abstained from coffee, tobacco, wine, and
all excitants; was careful of his diet, and tried to avoid painful
emotions. He found too many chagrins in his own house.
Madame Comte was evidently a woman possessing great
literary talents, and took a deep interest in her husband’s
pursuits. He was solicitous to have her opinion upon his
writings, and was angry when, instead of compliments, she
proposed improvements or gave criticisms. In a letter to
Stuart Mill the philosopher complains that his works have been
prepared and accomplished under the heavy weight of material
embarrassments, and in the midst of painful and absorbing
troubles resulting from the £#aj*-continuity of civil yrar, the
domestic duel,—that is to say, he had long been quarrelling with
his wife, which ended in August, 1842, in a complete separation.
In such disputes the woman generally gains the sympathy of
those who take a gossiping interest in the affair, as she is
more willing to state her grievances. There is no question
that. Madame Comte did this to M. Littrd, who interceded for
her and remained her defender to the last M. Comte confided
the departure of his wife to Stuart Mill in a letter in which he
says, “ Married for more than seventeen years, through a fatal
inclination, to a woman gifted with a rare elevation of mind
both moral and intellectual, but brought up in vicious principles
and following a false appreciation of the necessary condition of
her sex in the human economy, her total want of inclination
for me has never permitted her affectionate disposition to
compensate for her unruly and overbearing tendencies.” When
we consider that M. Littr6 was an admirer and a disciple of
Auguste Comte, and was, moreover, a man who led a worthy
life, we are naturally disposed to follow him in taking the part
of Madame. Nevertheless the information given by Dr. Dumas
leads us to think that M. Littr£ has misled his readers by

Digitized by VjOOQle

1900.]

BY WILLIAM W. IRELAND.

leaving out some facts and bringing others into prominence.
Dumas roundly asserts that the causes of Comte’s insanity in
1826 were excess of work and domestic chagrins, Madame
Comte having quitted the house to live with a lover. Dumas
tells us, “ His wife deceived him ; four times she quitted his
house, and she made his home life hard and jangling.” “ During
seventeen years of cohabitation,” wrote Comte to Littr£, “ I have
often conceived thoughts of suicide, to which I should probably
have yielded had the bitterness of my domestic situation not
been neutralised by the increasing sentiment of my social
mission.” Comte feared the combination of intellectual strain
with painful emotions. This occurred in 1842, the date of the
fourth departure of his wife, the result being another nervous
crisis. This time he refused to allow her to return, although
he continued for eight years to correspond with her by letters,
in which he showed an interest in her welfare and took for
granted her sympathy in his fortunes. He paid her an annuity
of 3000 francs, which in two years he reduced to 2000. In a
letter to Littr£ he writes that, though her conduct was very
licentious, she never showed a real attachment to any one.

Two years after this final separation Comte met with
Clotilde de Vaux, then about thirty years of age. She is
described as a lady of amiable manners, with fair silky hair,
languid blue eyes, and soft and delicate beauty. Her husband
was in prison for some infamous crime, and she was living with
her parents. She had literary tastes and wrote weak stories
and verses. Acquaintance began by the lending of books, and
aesthetic conversation soon ripened into a deep passion on
Comte’s part. There was a “ crise d’amour,” during which he
kept his bed for eight days. The lady managed so to balance
her attractions and repulsions as to keep the philosopher
hovering round her. Her love, if warmer than friendship, was
Platonic ; not so his. Comte had much in his nature both of
Famour gout and Famour passion. To the first Madame de
Vaux accorded no indulgence. To quote M. Dumas, “elle
lui conseillait de chercher ailleurs des soulagements, et Comte
r£pondait en termes precis: * Vous exag^rez, Clotilde, la
grossi&ret^ masculine, du moins chez les nobles types. Elle
nous permet en effet le piaisir sans amour, mais seulement
quand notre cceur est libre ; lorsqu’il se sent vraiment pris,
cette brutality nous devient impossible. J’ai dti longtemps

Digitized by

Google

MENTAL STATE OF AUGUSTE COMTE, [Jan.,

recourir, comme tant d’autres, k ces ignobles satisfactions
puisque toutes relations sexuelles avaient d 6 jk cess 6 dans mon
triste manage, un an avant votre propre mariage. Mais depuis
que je suis k vous, ma continence, quoique parfois douleureuse,
est toujours peu m^ritoire parce que je ne pourrais pas
vivre autrement.’ ” The weak state of Madame de Vaux’s
health gave a sober colouring to her fancies. “ For a year,”
wrote she to her impassioned admirer, “ I ask every evening if
I have the strength to live till the morning. It is not with
such thoughts that one can do inconsiderate acts.” Another
time she seemed more yielding. “ Since my misfortunes,” she
wrote, “ my sole dream has been maternity, but I have never
thought of associating in this rdle save with a man who was
distinguished and worthy to understand it. If you believe
that you can accept all the responsibilities attached to family
life, say so, and I will decide my lot.” Comte lost no time in
accepting the responsibilities, only to find that the aspirant to
maternity had changed her mind. This caused him deep
distress. Six weeks after he wrote, “ Although the convulsive
agitation has almost disappeared, my sleep remains insufficient,
—if not as to its total duration, already about normal, at least
for its depth and continuousness.” Truly the philosopher knew
little of woman’s heart. During a year of intimacy, which was
always becoming closer, Clotilde was wasting away from con¬
sumption, and in 1846, at the commencement of her thirty-
second year, she died in the arms of Auguste Comte, after
having received extreme unction.

In a letter to Madame Comte he announced his liaison with
Madame de Vaux, and recounted the death of that lady who
had become his eternal colleague and his veritable spouse.
This attachment had brought out the affective and sentimental
side of his character. We have frequently occasion to notice
how simple people give to general ideas a particular applica¬
tion, but one requires to converse with philosophers to observe
particular impressions being generalised into doctrines. Al¬
though much of Comte’s system of Politique Positive had been
formed in his mind before he met with Madame de Vaux, the
influence of this passion modified in many respects the charac¬
ter of his speculation. His political philosophy showed a great
falling off, which his enemies ridiculed, his more critical
admirers deplored, and scarcely any of his disciples entirely

Digitized by VjOOQle

1900.]

BY WILLIAM W. IRELAND.

followed. No man can be master of all the sciences. Even in
Comte’s first work when he came to biology there was a falling
off; his remarks on psychology were of little depth ; his inter¬
pretations of history, though much admired by some, were, in
my opinion, superficial and often incorrect, and he showed an
ill-grounded contempt for political economy. Nevertheless
M. Comte firmly believed that his studies in the exact sciences
were but a prelude to his scheme for reorganising society, for
changing the face of the world. For proposing changes in the
social constitution he lacked the essential qualification that he
should know something of human nature, yet he knew nothing
of the nature of the ordinary man, and indeed little of the
nature even of the philosopher; hence his scheme for the
reorganisation of society was absurd, and even if it could be
carried out there is no reason to believe that it would make man¬
kind any happier. For about twenty years he abstained from
reading the newspapers, even from scientific periodicals. He
only read a few favourite poets. Thus, while preparing
schemes for the salvation of society, he would not feel the pulse
of the world. Unlike other social reformers, Comte did not
propose to level ranks or to divide property. The proletaires
were to be deprived of all political power, and their destinies
determined by an intellectual bureauracy who would classify
them like specimens in a museum. Labour was to be directed
by chosen captains of industry. France was to be divided into
seventeen small republics. He had regulations for the smallest
particulars of daily life, for he had no sense of the ridiculous.
There were prayers and an elaborate ritual with no God. Men
were to be taught to love others better than themselves, and, as
a reward for labours in the cause of humanity, seven years
after a man’s death it was to be solemnly adjudged whether
his remains should be disinhumed, to be buried in the sacred
wood which was to surround every temple, where the living
should pay a make-believe worship to the Grand &tre y —he might
rather have said the Grand Nfant.

One of his fancies was that our earth, before man came upon
it, once possessed intelligence and will, and may have used its
physico-chemical activity, so as to render its orbit less eccentric,
and have modified its own shape by a judiciously planned
series of explosions. Our benevolent planet may also have
rendered the inclination of its axis better fitted to the wants of

Digitized by

Google

38 MENTAL STATE OF AUGUSTE COMTE, [Jan.,

the Grand £tre. This, at first proposed as a fiction, was in the
end nourished into a belief as perfecting the unity of his
system, and making up the Trinity which his disciples were
enjoined to glorify, i. e. Humanity, the Grand £tre ; Space, the
Grand Medium ; and the Earth, the Grand Fetish.

If Comte had gone on studying biology, psychology, and
sociology with the same mental power and application which he
had brought to the exact sciences treated in the Systime de
Philosophic Positive , he had written his name much higher in
the history of philosophy; but intoxicated with self-conceit,
he fancied that he had reached such a height of wisdom through
his studies in the exact sciences and his perfection of method,
that a few easy deductions were sufficient to enable him to
prescribe solutions for any remaining question in the com¬
plicated subjects of psychology, morals, and sociology. Thus,
after recommending as a part of his system the refuted locali¬
sations of Gall, he set himself to construct a cerebral topography.
He assumed a priori eighteen mental faculties to exist in given
regions of the brain, and founded upon this assumption without
waiting for any confirmation from anatomy or physiology. He
regarded all his previous studies as but a preparation for his
social scheme, and declared that all scientific pursuits should be
treated as an idle waste of time if they could not be proved to
have a direct bearing upon the welfare of humanity. “ All
books were to be destroyed save about a hundred, and all
animals and plants thought useless to man were to be extirpated.”
There is no doubt that if Comte had held the power, he would
have carried all these absurdities into practice. Indeed, he
believed that the world’s acceptance of his doctrine was so
near, that if he lived to be as old as Fontenelle or Hobbes he
would enjoy the dignity of being recognised as the grand high
priest of a regenerated humanity. A few disciples gathered
round him, who regarded him with veneration. Auguste Comte
died in 1857, of an internal cancer, at the age of sixty. He
left a long testament, with his usual attention to minute details.
The disposal of his estate could not be carried out without the
consent of his wife.

Comte left the furniture in the Rue Monsieur le Prince and
all his books and manuscripts to thirteen executors, who were
to keep the rooms as a museum and to publish the manuscripts.
The annuity of 2000 francs was to be offered to Madame

Digitized by VjOOQle

1900.]

BY WILLIAM W. IRELAND.

Comte, and in the event of his widow refusing her consent to
the conditions of the will, he left in the power of the executors
a sealed paper, which, he declared, contained a secret so grave
that if it were divulged his unworthy spouse would be aban¬
doned even by her principal defender (M. Littrd). Not heed¬
ing this threat, Madame Comte refused her consent to the will,
and declared herself heiress. The executors recoiled at making
use of the secret, and proceeded by legal methods; they
declared themselves the creditors of M. Comte, and thus
brought the furniture and books to a sale. These were
bought up by the Positivists. Madame Comte, who, according
to Littrd, could have entered a preferential claim to most of
the money, waived her rights that her late husband's debts
should be paid ; but the struggle was for the possession of the
manuscripts. Apparently Madame Comte wished to prevent
the publication of the testament, which was injurious to her,
and of the amorous correspondence of her husband with
Clotilde de Vaux. She demanded that the will should be
annulled on the grounds that M. Comte was insane,—in fact,
had never entirely recovered from the attack of 1826. This
ground was afterwards abandoned ; but she pleaded that he was
mad when he made the will.

The matter was not called before the tribunal of the Seine
before the end of 1869, and it was a year ere it was decided.
The advocate employed by Madame Comte made much use of
the philosopher's writings for facts indicating insanity. He
recounted the theatrical performances by which Comte sought
to keep fresh the memory of his sweetheart. By his passion
for Clotilde he had learned to subordinate to the heart the
whole of human life. Sentiment ought always to dominate
the intelligence. “To become a perfect philosopher,'* he
wrote, “ I wanted especially a passion at once deep and pure,
which made me sufficiently appreciate the affective side of
humanity. Such emotions exercise an admirable philosophic
action in placing the mind at once at the true point of view,
which by the scientific way one can only attain by a long and
difficult elaboration.'* Five days after the death of Clotilde he
instituted prayers, which he recited three times a day before
the couch on which the adored one used to be seated. He
recalled her memory, and gave her thanks for ennobling his life.
Once a week he went to her tomb, to which he also made

Digitized by

Google

40 MENTAL STATE OF AUGUSTE COMTE, [Jan.,

an annual confession of what he had done during the year.
He recommended every disciple to fix his thoughts upon the
three forms of womanhood—the mother, the daughter, and the
wife. If one or other were not adorable enough, the votary
might put some other woman in the place. Comte himself
had for his three guardian angels Madame de Vaux, his mother,
and a young woman who acted as cook.

Dr. Dumas observes that the mystic has need of images,
sometimes of very vivid ones, and often this persistent image
becomes transformed during an ecstasy into an hallucination.
It seems to have been so with Auguste Comte. Longchamps
tells us(*) that one day Comte had his eyes fixed upon the
memento of Clotilde, when he beheld her lying deadly pale as he
had seen her for the last time. Comte falls on his knees, calls
her and blesses her, speaks of his grief, of his despair. He im¬
plores her to help him, for she alone could make life supportable
to him and give him courage. After a time he rose, calmer and
more resigned. From that day Comte endeavoured to reproduce
by his will the beloved vision. Every morning and evening he
saw Clotilde. He knelt before her altar, and renewed his
resolution to live for her and for humanity. It appears from
the testament that this hallucination was sometimes auditory
as well as visual. Dumas adds it is evident that Comte was
never the dupe of his hallucination, that he led up to it and
made use of it in order to sustain his mystic passion.

The image of Madame de Vaux transfigured and magnified
appears everywhere in his later speculations. Through this
shallow and sickly Frenchwoman all women were to be glorified
and held up for men’s adoration. In obedience to a fancy,
which he did not favour during Clotilde’s life, her sentimental
admirer proposed a theory which should free the whole sex
from the selfish brutalities of instinct, and render husbands
superfluous. To use Comte’s own words, “si l’appareil mas-
culin ne contribue k notre g£n£ration que d’apr&s une simple
excitation, deriv^e de sa destination organique, on con£oit la
possibility de remplacer ce stimulant par un ou plusieurs autres
dont la femme disposera librement.”

It may be said that one could make a case against the
sanity of many a speculative philosopher by collecting his
whimsical theories and leaving out his sensible ones. More¬
over much of what men in modem Europe write to or about

Digitized by VjOOQle

1900.]

BY WILLIAM W. IRELAND.

their sweethearts is mere inflation of style, though men in love
often do commit sillinesses which they may come to smile at
themselves. Comte's admirers advance that Descartes and
Leibnitz, in their readiness to follow the principles which they
had laid down to logical consequences against common sense,
were guilty of absurdities as great, or nearly as great, as
Auguste Comte; they do not say as many absurdities. We
have no time to consider this serious accusation against these
two philosophers.

Dumas observes that Comte’s pride differs from that of the
megalomaniac—that it was justified by his achievements in
philosophy, and no doubt these were great; but his pride was
extravagant, though whether it passed the limits of sanity may
be a question between his admirers and his critics. One of his
disciples, M. Allou, has published a certificate signed by seven
medical men, amongst whom is Dr. Congreve of London, and
Dr. Robinet of Paris. These physicians state that “ they all
having known Auguste Comte during the last years of his life,
from 1850 to 1857, and having all seen him during this time,
some daily and others at intervals, certify that they have never
perceived in him, in his conversation, in his actions, nor in any
of his writings, the least trace of intellectual or moral derange¬
ment, of mental alienation, nor of monomania of any kind what¬
soever ; that they have never observed anything amiss about
him, nor had the least suspicion of such ; and that, on the con¬
trary, Auguste Comte had always appeared to them as enjoy¬
ing, and having enjoyed till the last moment of his life (without
speaking of his incontestable genius), the most complete lucidity,
a most extensive and well-balanced memory, a perfectly sane
judgment, and a correct reason, steady calmness, strong per¬
severance, and the most generous disinterestedness, which are
the mental and moral characteristics most opposed to those of
insanity.”

In 1870 the tribunal before which the case was pleaded
rejected the accusation of insanity, and declared the testament
valid so far as it did not prejudice the rights of Madame
Comte. They decreed that the manuscripts of M. Comte
should be restored to the executors of the will. The court
also ordered that the sealed paper should be destroyed, and
some passages injurious to Madame Comte should be sup¬
pressed in publishing the testament. Dr. Dumas lets us know

Digitized by VjOOQle

COMPARATIVE LUNACY LAW,

[Jan.,

that the purport of the sealed paper is now no longer a secret.
The revelation which Auguste Comte held over his wife was,
that before her marriage Caroline Massin had been a prostitute,
and that her name was inscribed in the register of the Pr^feture.
We are not told whether Comte became aware of this before or
after his marriage. At any rate it did not cause Littr£ to
abandon her; on the contrary, he always speaks highly of her
solicitude for her husband’s welfare and her devotion to his
memory. It is to be hoped that this attempt to strike at the
woman who bore his name was the worst act of a life otherwise
honourable.

Without questioning the justice of the court’s decision it may
be said that during the last years of his life the fine intellect
of Auguste was deranged to a notable degree. Even warm
admirers like J. S. Mill and E. Littr£ mourn the decadence of
a great genius. In the words of Dr. Dumas, after the mania in
1826 il cotoy a la folie ; though by his system of hygiene and
mental regimen he escaped such another attack, he was
subject to severe nervous crises, and remained for the rest of
his life a “neuropath.”

( J ) Auguste Comte et la Philosopkie Positive, par E. Littr£, Paris, 1864. (*)
Revue Philosophique, p. 178.

Comparative Lunacy Law . By A. Wood Renton, Esq.,
Barrister-at-Law.

Considering the closeness of the ties which the existence
of such bodies as the Medico-Psychological Association have
created between alienists throughout the world, it is surprising
that so little attention has been paid to the comparative side
of the medical jurisprudence of insanity. In the spring of
1898 there was published in New York a treatise by Dr.
Clevenger and Mr. Bowlby, an American barrister ( Medical
Jurisprudence of Insanity, or Forensic Psychiatry , 1898, Lawyers’
Co-operating Publishing Company, 2 vols., pp. 1356), in which
excellent work in this direction, so far as England and the
United States are concerned, was done. The book is a
monument of labour. Every conceivable branch of forensic

Digitized by VjOOQle

1900.]

BY A. WOOD RENTON.

medicine is discussed with learning and ability, and an admir¬
able index, both of cases and of subjects, renders fairly access¬
ible to the reader the otherwise bewildering mass of legal
information which the editors have so industriously accumu¬
lated. It is not, however, specially of efforts of this kind that
it is desired to speak in this paper. The problems of lunacy
law and lunacy administration with which civilised countries
have to deal are, to a great extent, similar. It would obviously
be of immense international importance if the solutions at¬
tempted of these problems in different parts of the world and
the results of such experiments were systematically chronicled
from time to time, so as to give the lunacy authorities, lawyers,
and experts of the chief countries of the globe the benefit of
each other’s experience. It may be of interest to select some
instances of the manner in which different countries have dealt
with questions that are constantly arising. Take first inter¬
diction and curatory. The voluntary and judicial interdiction
of Scots law is sufficiently familiar to alienists (for full informa¬
tion on the subject see Stair, i, 6, 37 ; iii, 8, 37 ; Bankt., i, 7,
118 ; Ersk., i, 7, 53 ; Bell, Com., 139, Prttt., S. 2123 ; Fraser,
P. and C., 554).

In England the only analogue is to be found in the law as
to catching bargains and undue influence. In France, how¬
ever, an elaborate system of interdiction is in force. A person
of full age who is in a usual state of imbecility, insanity, or
madness is to be interdicted, even if such condition is accom¬
panied by lucid moments (Civ. Code, Art 489). Any relative
is allowed to apply for the interdiction of his relative. In like
manner, any married person may do the same for his wife or
her husband (Art. 490).

In case of madness, if the interdiction is not applied for by
the husband or wife or the relatives, the Republic’s Attorney
(Public Prosecutor) must do so; and in cases of imbecility or
insanity he can likewise apply for the same against a person
who has no husband or wife or parents (relations) known (Art.
491). All applications for interdiction shall be made to the
Tribunal of First Instance (Art. 492). Acts of imbecility,
insanity, or madness shall be stated in writing. Those who
apply for the interdiction shall produce the witnesses and
papers (Art 493). The tribunal shall order the family council( l )
to give its opinion on the condition of the person whose inter-

Digitized by VjOOQle

COMPARATIVE LUNACY LAW,

[Jan.,

diction is sought for (Art. 494). Those who have applied for
the interdiction cannot form part of the family council; never¬
theless the husband or wife and the children of the person
whose interdiction is sought for can be admitted without having
the power to vote (Art 495). After having received the
opinion of the family council the tribunal shall examine the
defendant in the judge’s room ; if he cannot appear there, he
shall be examined at his home by one of the judges appointed
for that purpose, attended by his clerk. In all cases the
Public Prosecutor (Procureur de la Rtpublique ) shall be present
at the examination (Art. 496). After the first examination
the tribunal shall, if necessary, appoint a temporary adminis¬
trator to look after the person and property of the defendant
(Art. 497). A judgment upon an application for interdiction
can only be rendered at a public sitting after the parties have
been heard or summoned (Art. 498).

If the tribunal rejects the application for interdiction, it can
nevertheless, if the circumstances require it, order that the
defendant shall no longer be allowed to go to law, compromise,
borrow, receive capital or give discharges therefor, convey or
mortgage his property without the assistance of a counsel, who
shall be appointed to him by the same judgment (Art. 499).
In case of appeal from a judgment rendered in the Court of
First Instance the Court of Appeal may, if it deems it necessary,
again examine the person whose interdiction is applied for, or
have him examined by a commissioner (Art. 500). All decrees
or judgments ordering interdiction or the appointment of a
counsel shall, at the instigation of the plaintiffs, be docketed,
served upon the parties, and recorded, within ten days, among
the notices which must be posted in the court room and in the
offices of the notaries of the district (Art. 501). An inter¬
diction or the appointment of a counsel shall take effect from
the day of the judgment. All acts performed subsequently by
the interdicted person, or without the assistance of a counsel,
shall be void by right (Art 502). Acts previous to the inter¬
diction can be annulled if the cause of the interdiction notori¬
ously existed at the time these acts were performed (Art. 503).
After the death of an individual the acts performed by him can
only be attacked on account of insanity, if his interdiction had
been pronounced or applied for before his death, unless the
proof of insanity results from the very act which is attacked

Digitized by VjOOQle

1900.]

BY A. WOOD RENTON.

(Art 504). A husband is by right the guardian of his
interdicted wife (Art 506). An interdicted person is assimi¬
lated to a minor as to his person and as to his property. The
laws on minors shall apply to the guardianship of interdicted
persons (Art 509). The income of an interdicted person
must be specially used to better his condition and hasten his
recovery. The family council may direct that he be taken
care of at his residence, or be placed in an asylum, or even in
a hospital, according to the symptoms of his disease and the
amount of his fortune (Art. 510). Interdiction ceases with the
causes which have given rise to it. Nevertheless the with¬
drawal thereof shall only be obtained by following the rules set
down to obtain an interdiction ; and the interdicted person can
only resume the use of his rights after a judgment ordering the
withdrawal of such interdiction (Art. 512).

The German system under the new civil code (which came
into operation on January 1st, 1900) resembles the French,
but presents a sufficient number of distinctive points to justify
a brief sketch of it. A person is incapable of managing his
affairs, and also disqualified from at any time instituting legal
proceedings with effect, who is in a condition of disordered
mental activity excluding the free exercise of the will, unless
the disorder is only a temporary one, and still more so who is
placed under guardianship (Dormundung) on account of mental
disease (s. 104). In the latter case the effect of the guardian¬
ship is to put the lunatic in the same legal position as a minor
who has completed his seventh year (s. 114). The validity of
a contract into which he enters without his guardians’ consent
depends on whether the contract is beneficial to him or not (s.
108). A unilateral contract which he makes without the above-
mentioned consent is ineffectual (s. 111); he cannot draw up
a will (s. 2229), but he can revoke a will formerly made
(s. 2253). On the other hand, he possesses unlimited capacity
for such arrangements as he, after his lawful guardian has
authorised him to enter into contracts as to service or work,
makes in regard to the entry on or abandonment of service
or work of the permitted kind, or the fulfilment of the obliga¬
tions resulting therefrom (s. 113). It is worthy of notice how
much more detailed the German system is than the French
with reference to the extent and the consequences of the inca¬
pacity. The idea of authorising a certain area within which

Digitized by VjOOQle

COMPARATIVE LUNACY LAW,

[Jan.,

the insane ward may exercise his own discretion as to contracts
and engagements is an ingenious and interesting one. A
person of full age, who has been placed under guardianship, has
a curator as his legal guardian (s. 1896). A major for whose
subjection to curatory a motion is made can be be placed under
interim curatory if the judicial authority think it necessary for
the prevention of serious danger to his person or property
(s. 1906), and a person under interim curatory is, in regard to
capacity, in precisely the same position as a minor who has
completed the seventh year of his age (s. 114).

By Section 52 of the Civil Procedure Rules, as modified by
the law of May 1st, 1898, a person is capable of instituting
legal proceedings if he can, according to the common law, bind
himself contractually. The application to have a pension
subjected to curatory can be made by spouses, by a relative,
by the lawful guardian proposed for the person alleged to be
insane, and further by the Public Prosecutor to the Land-
gericht. The proceedings are in the first instance instituted in
the court of the Amtsrichter, which corresponds roughly to
the English county court or Scotch sheriffs court. The prac¬
tice of this tribunal is to enter into a personal examination of
the alleged lunatic in presence of one or more competent experts,
and to receive other evidence as to his mental condition. It
can, in particular, sequester him up to six weeks in a medical
establishment if this seems necessary owing to his state of
health. The decision of the Court on a question of curatory
can be impugned in an action by the insane person himself, by
his lawful guardian, by the persons otherwise entitled to apply
for curatory, and also by the Public Prosecutor. The pro¬
cedure is substantially identical with that in other civil pro¬
ceedings. If the insane person again becomes mentally sound,
the supersedeas of the curatory can be applied for by himself,
his legal guardian, or the Public Prosecutor. Here again the
decision rests with the Court of the Amtsrichter. If the
application is refused, an action can, as before, be instituted,
and the case will be decided by means of it.

The main interest of the above analysis of the provisions of
French and German law as to the interdiction and curatory of
the insane consists in the light that they throw upon the lines
on which a system of dealing with “ borderland ” cases, from
the legal standpoint, can be worked. It may have yet to be

Digitized by VjOOQle

1900.]

BY A. WOOD RENTON.

considered whether some machinery of the kind is not needed
in England. The law as to “ catching ” or unconscionable
bargains does not protect the class of persons who in Scotland
or France may be interdicted. The law of undue influence is
a weapon of most uncertain action. Something might be done,
if necessary, by an extension of the summary procedure estab¬
lished by Sect. 116 of the Lunacy Act, 1890, to cases of
“ facility.”

The next point to which, in surveying the field of compara¬
tive lunacy law, we may call attention is the similarity of the
manner in which civilised countries, both in the Old World and
in the New, have solved the chief problems of lunacy adminis¬
tration. The necessity for the interposition of a judicial check
on the commitment of the insane (with special procedure, in
most instances, for dealing with cases of emergency), for the
regular official visitation of all classes of receptacles for the
insane, the importance of classifying patients according to the
nature and severity of their malady, and of keeping mechanical
restraint within the strictest bounds, the protection of patients'
correspondence, the right of access to them of their friends,—
these and all the other ordinary questions which the adminis¬
tration of asylums presents have been settled in Britain,
France, Germany, and the United States on identical lines.

“This similarity is partly due, no doubt, to the fact that civilised
nations, brought face to face with the same administrative problems,
will naturally light upon similar solutions of them. But its origin is
mainly attributable to historical causes. The typical modern asylum
system is the product of the great movement for reform which, asso¬
ciated in England with the name of William Tuke, in France with the
names of Ren£ and his disciples, and in America with that of Ray,
swept almost simultaneously over both the Old World and the New at
the end of the eighteenth and during the first half of the nineteenth
century. The points of contact between the lunacy laws of modern
Europe and America are the heads of the reformation which that
movement demanded and accomplished.” {Journal of the Society of
Comparative Legislation , N. S., vol. i, p. 272.)

There are other features in comparative lunacy law which
are instructive. There is a growing tendency in English-
speaking countries to supersede the old formal inquisition by
such a summary system as Sect. 116 of the English Lunacy
Act, 1890, embodies. The question of the civil capacity of
the insane i9 being gradually freed from external standards, and

Digitized by VjOOQle

PHYSICAL SIGNS OF INSANITY,

[Jan..

made to depend, as it ought to do, on the facts of particular
cases. Room is being found in the criminal law for the plea
of moral insanity and the theory of modified responsibility. It
may be noted, in conclusion, that a bold step has just been
taken by Germany. The new Civil Code (s. 1569) recog¬
nises the lunacy of a spouse as a ground of divorce, but only
where the malady continues during at least three years of the
union, and has reached such a pitch that intellectual intercourse
between the spouses is impossible, and also that every prospect
of a restoration of such association is excluded. If one of the
spouses obtains a divorce on the ground of the lunacy of the
other, the former has to allow alimony, just as a husband,
declared to be the sole guilty party in a divorce suit, would
have to do (ss. 1585, 1578). The inquiry which this paper
has initiated might easily be carried further, but perhaps
enough has been said to show the lines on which useful work
might be done.

0 ) A family council is composed of six blood relatives in as near a degree of
relationship to the lunatic as possible; if there are not six, relatives by marriage
are then chosen. Such a council is always presided over by the Juge de Paix of
the district where the lunatic is domiciled (Civil Code, Arts. 407 and 408).

The Physical Signs of Insanity, By F. Graham Crook-
shank, M.D.Lond., late Assistant Medical Officer North¬
ampton County Asylum.

It is disappointing to anyone trained in modem clinical
methods, and accustomed to hear alienists urge with so much
insistence that insanity is a brain disease, to find so little appa¬
rent attention paid to what may be called the physical signs of
insanity.

It would be foolish to declare that these physical signs have
not been observed. But is there not a tendency to speak of
them merely as interesting phenomena met with amongst the
insane, and to forget that they are consequences of -those brain
changes which make up the somatic background to what we
call insanity ? Have we not of late somewhat neglected the
old-fashioned method of induction from clinical observations ?

The stigmata of degeneration, it is true, have had attention

Digitized by VjOOQle

1900.]

BY F. GRAHAM CR00KSHANK, M.D.

enough. But they are not physical signs of insanity ; they are
merely marks—valuable, no doubt—of a general protoplasmic
vice which reveals itself, so far as the brain is concerned, by
idiocy, criminality, insanity, eccentricity, or wayward genius.

We must believe that the physical phenomena of insanity—
no less than those of sanity—are, if not strictly dependent on,
at least the concomitants of certain activities or changes, cellu¬
lar or molecular, of brain tissues. And unless there are brain
cells whose activities are aimless as far as the body is concerned,
and are simply the concomitants of physical states, and unless
in insanity the brain changes are restricted to these hypothetical
cells, we must admit that the cellular activities which accompany
insane states of mind have some resultant effects on the physical
economy.

It is to these resultant effects—the necessary result of any
brain disease accompanied by insane states of mind—that in
the first place we assign the term “ physical signs of insanity.”
But it is sufficiently obvious that, at least in the case of general
paralysis, there are modifications of physical functions the result
of changes in brain cells whose activities so far as we know are
not accompanied by conscious or vividly conscious states of
mind. Such modifications are not necessarily physical signs of
insanity, inasmuch as they may be the result of purely local
brain affections, tumours, etc. But when occurring in the insane
they are direct evidence of the insanity being, as we believe it
is, connected with brain disease.

Attending the out-patients of any large hospital one fre¬
quently enough sees patients who, when tested, fail to recognise
or to correctly name objects presented to them. We are told
that such persons labour under amnesic defects ; and the defect
is regarded as a physical failure and located in one or other
brain convolution. In every asylum one may see scores of
patients exhibit these particular amnesic defects ; though, to be
sure, in their case the defect is only one of many disabilities,
and hence does not stand in strong relief. Should we not do
well to endeavour to analyse, no less carefully than our col¬
league of the out-patients, this amnesic defect, and to localise
the peccant convolution ? It is true that in the one case the
pathologist will find a small haemorrhage, or may be a throm¬
bosis. In the asylum cases no organic change may be found.
Yet a failure of function has an anatomical situation not a whit

XLVI. 4

Digitized by

Google

SO PHYSICAL SIGNS OF INSANITY, [Jan.,

the less real because it does not happen to have a gross
“ organic ” cause obvious to our dull eyes.

Now Dr. Hughlings Jackson has enunciated the remarkable
law, that in every case of insanity a negative lesion of highest
centres exists, which causes some paralysis, sensory or motor
(Journal of Mental Science , iii, 1888). Dr. Jackson’s
evidence, however, relates almost entirely to the insanities of
epilepsy and to post-epileptic states; and though Dr. Anderson
has brilliantly discussed general paralysis, and Dr. Mercier
coma, there seems to have been but little attempt to correlate
what observations have been made of the physical signs of
insanity in the widest and popular sense of the term.

Many valuable hints, it is true, are scattered through Dr.
Francis Warner’s papers, and Dr. Turner has contributed some
accurate clinical observations {Journal of Mental Science ,
i, 1892).

But Dr. Turner’s observations, which were concerned chiefly
with the asymmetry of expression seen in the insane, would
have been more valuable if he had expressed the physical
signs in terms of the nerve centres responsible rather than in
terms of the muscles involved. As Dr. Turner says, it is by
studying paralyses accompanied by physical states that we shall
be enabled to identify the cortical sites whose integrity is
necessary for the accomplishment of those physical changes
whose psychical concomitants are peripherally expressed by
muscular contraction. But in nerve centres movements not
muscles are represented, and some of the movements seen in
insanity, and called movements of expression, depend really on
lower (not cortical) centres, and have little, if any, conscious
accompaniment. Hence the apparent dislocation of expression
and emotion in insanity. A spasm or weakness of one half
the face, and affecting one half the occipito-frontalis, cannot
depend on cortical changes. It must be the fault of the
seventh nucleus or nerve. Hence to speak of asymmetry of
“ expression ” in cases exhibiting this sign is incorrect.

No one expects the psychical state of a tabetic with double
ptosis to be necessarily that of sleep or repose; and no one
talks of abnormality of expression in such cases.

The essentials of expression do not lie in peripheral muscular
arrangements; these may be more or less brought about from
different levels. What is important is the state of those brain

Digitized by VjOOQle

1900.] BY F. GRAHAM CR00KSHANK, M.D. 51

cells whose activities are accompanied by the appropriate
emotion or other conscious state.

We should then clinically attempt to express the physical
state of the insane, (i) in terms of the peripheral resultant,
(2) in terms of the governing brain region involved. It is so
that we describe a case of brain tumour ; it is so that we
should describe a case of insanity from brain decay or intoxi¬
cation.

The most obvious of the physical signs of insanity are, of
course, those muscular arrangements truly expressive of the
predominant insane emotion. We do not cry because we are
sad, as most would say; nor are we sad because we cry, as
others would say. We are sad, and we cry, that is all that we
know. But the crying, whether in sanity or insanity, is the
physical sign of the emotion ; the resultant of those cellular
activities which are the physical concomitants of sadness.

Psychologists have detailed the motor resultant of these cell
states ; and Jackson summed the matter up once and for all
when he said, “ The emotional centre represents all parts of the
body, though doubtless the heart and viscera first and most.”
And a full acceptance of this proposition entails one or two
interesting consequences.

I see a man daily who suffers from an overwhelming sense
of anxiety, fear, dread ; no very uncommon case. The physical
signs of his insane emotion are precisely what psychology would
lead us to expect; he displays weak voluntary innervation ; a
certain amount of vaso-constriction ; a contraction of certain
facial muscles, and, most important, a rapidly-acting heart.
His pulse rate is 120. There is no discoverable cardiac disease
in the ordinary sense of the word ; there is no reason to sup¬
pose any.

His rapid pulse rate is simply a part of the expression of his
predominant emotion.

We are bound to recognise that there is representation of
the heart in the highest brain levels, inasmuch as one result of
the activities of those brain cells whose changes are accom¬
panied by psychical changes is a rapid cardiac action. In this
insane man the rapid pulse rate is, in fact, a physical sign of
brain disease—of perversion of function of the higher brain levels.

There is cardiac representation in the lowest level—that we
know. We know of no conscious state accompanying outgoing

Digitized by VjOOQle

5 *

PHYSICAL SIGNS OF INSANITY,

[Jan.,

processes from that level: if any accompany the incoming
processes they must be the ordinary organic cardiac sensations.

It is most probable, then, that the viscera, like the muscles,
or rather like movements of the muscles, are represented at
more than one brain level. And, just as many of the psychical
states corresponding to certain highest level muscle actions—
crying and other modes of expression—are those we call
emotions, so it seems that the psychical activities correlated
with highest level visceral representations are “ emotions ” or
complex states. For example, take respiration. With lowest
level interference with respiration we have no conscious state;
with voluntary changes in respiration we have certain simple
conscious states; with highest level changes in respiration we
have complex states of consciousness of which the change is a
physical sign, e.g. with the arrest of respiration, attention
(Ribot).

The cortical representation of viscera, if a fact, has still
further importance. It is true that many think a “ visceral
delusion ” proof of visceral disease, and are innocently surprised
that so little relief is gained by treatment of the viscus. Is not
the visceral delusion a proof, not of visceral disease, but of dis¬
order of the “ visceral centre ? ” The peripheral morbid con¬
dition, if any, is surely a physical sign of the brain disease.
A woman has sexual delusions—central failure. Surely the
local pelvic congestion is a physical sign of the central state,
just as the tachycardia of my just-quoted case is a physical
sign of the brain disease and insane psychosis.

Who would seek to cure a lesion of the Rolandic area by
treating the resultant palsy locally ? And who would think the
brain tumour an “ effect ” of the paralysed hand ? Yet such
seems to be the logic of alienists who clamour for gynaecolo¬
gists and general physicians instead of seeing in these uterine
congestions, cardiac irregularities, and so forth, physical signs
of disease of certain brain areas, disease none the less real
because it may depend on no very gross lesion.

Certainly in some cases, as in that of a lad I know who
thinks he has monkeys at his heart, there does exist organic
visceral disease. But the fault lies with the central nerve cells,
in this case the cardiac centre cells, which, perhaps of never
great stability, break down functionally and for association
under extra strain.

Digitized by VjOOQle

1900.] BY F. GRAHAM CROOKSHANK, M.D. S3

As a rule, the condition of the special viscus of a patient
with delusions relating to that viscus, depends on functional
perversity of the central cells representing that viscus, no less
than does the twitching of a thumb in Jacksonian epilepsy
depend on a lesion of the Rolandic cortex.

If any proof were wanting of the elaborate way in which
visceral movements and functions are represented in the highest
brain levels, it is surely to be found in the phenomena of vascu¬
lar " stigmata,” and in experiments such as that of Ribot in
which, by concentrating attention on a finger tip, pain or dis¬
comfort is felt as a result of very localised vaso-dilatation.

It is very probable that just as we see motor or sensory
derangements from affections of different brain levels, so
visceral delusions may be able to arise at more than one
level. At any rate hallucinations may be due to failure at the
periphery or lower levels, while delusions are of more central
origin.

But to return to the physical signs of insane emotions.
Bearing in mind what has been already pointed out, that ap¬
parent incongruities of expression do not really depend on the
mechanism of expression at all, but on low level or peripheral
and independent changes, we should be able, from a study (I)
of certain muscular dispositions; (2) of certain visceral states,
to deduce at any rate the predominant tone of feeling in the
insane, as certainly as we do in the sane. And moreover, the
abnormal persistence of certain muscular dispositions or visceral
conditions is evidence of nerve disease, actual and localisable, just
as the abnormal persistence of an idea or tone of feeling be¬
comes proof of insanity.

Leaving now those physical signs indicative of changes in
the brain cells correlated with emotional states, we may direct
attention to other clinical evidences of local brain disease in
insanity. If any case under consideration be one of “ general
paralysis,” hesitation is not shown in naming anatomical situa¬
tions as the probable seat of cell changes causative of the
muscular states. Yet there is a curious reluctance to do so in
cases of ordinary insanity. Though certainly Sir J. Crichton-
Browne has pointed out how the abnormal persistence of certain
gestures and movements of the insane must be due to abnormal
functional activity of certain cortical regions, in the Rolandic
area probably.

Digitized by VjOOQle

54 PHYSICAL SIGNS OF INSANITY, [Jan.,

Again, if certain symptoms of insanity, such as incoherence,
defects in writing, failure of powers of recognition, inability to
read aloud correctly—all familiar enough in cases of mania and
dementia—if all these be studied carefully, isolated, so to speak,
they are seen to correspond closely with the aphasias, amnesias,
agraphias, and so forth, of the hospital clinic. They are all
signs of definite disorder of function of the brain—physical
signs of brain disease. Why, then, do we not employ the
ordinary clinical terms in describing our cases of insanity, in¬
stead of vaguely stating “ patient is lost ; confused and inco¬
herent.” Certainly there is this difference: the lunatic is
unaware of his defect; his paraphasia is one symptom among
many. The paralytic may be aware of his defect, and it stands
out crisply in the clinical picture.

Again the blunting of sensation met with in dements, and
the great increase in reaction time, is surely a physical sign, no
less than in tabes, of direct nerve failure.

The general motor weakness of persons with melancholia is
obvious enough ; why should we not call this paresis? If it
were marked on one side of the body only we should do so ;
as it is general we ignore it, or talk of lack of will power. But
surely it is a weakening of muscular power depending chiefly
on defective central nerve activities.

In mania of the acute and delirious types surely excessive
reflex activity is obvious, and the movements are inco-ordi-
nated.

Dr. Mercier has suggestively shown that every case of coma
is really a case of total paralysis. And in advanced dementia
is there not very real paresis, .with almost total loss of truly
“ voluntary ” movements ?

I know an asylum attendant of great sagacity and native
shrewdness. He is always in the habit of speaking of feeble
patients as “ much paralysed,” and incurs no little ridicule in
consequence. But I remember the case of an old man, to
most people a case of senile mania, who displayed restlessness
and great weakness. The attendant in question persisted in
saying the man was much paralysed. At the post mortem
disseminated cerebral sarcomata were found, subcortical and in
the motor areas. The man was paralysed truly enough.
Would he not have been so, save for the name, if the failure of

Digitized by VjOOQle

1900.] BY F. GRAHAM CROOKSHANK, M.D. 55

his Rolandic areas had depended simply on lack of nutrition
and arterial disease ?

The motor weakness, the feebleness of advanced dementia,
is true paralysis, a physical sign of disease of the middle level.
In fact, if, looking at motor physical signs alone, we consider
that in melancholia there is general weakness of innervation
(especially of finer highest level actions), that in mania there is
failure of complex co-ordinated movement, and unfettered
activity of lower states, that in deep dementia only automatic
and quasi-automatic movements are retained, and that in coma,
where the bodily powers, together with the mental, fine to the
vanishing point of death, practically only movements of the
vaso-motor and respiratory organs persist; we have the “ types
of insanity”—melancholia, mania, dementia, and amentia—
arranged in the order which Dr. Sankey years ago declared to
be the clinical order. And this order of the “ types ” or rather
“ stages ” of insanity corresponds in essentials, if not super¬
ficially, to the order of the stages of general paralysis.

The physical signs of a comatose man, whether the coma be
due to trauma, poisons extrinsic or intrinsic, or to organic
disease, are, as Dr. Mercier has shown, those of a man in
whose brain all functions above the lowest (bulbo-spinal) level
are abrogated.

Respiration is of the bulbar type; no modifications of
respiration or circulation can be produced by stimulation of the
highest centres.

Voluntary movements are not performed ; only the lowest
“ most organised ” of automatic movements.

Sensation is absent and so are sensory processes. In
dementia sensory processes, though not absent, are greatly
blunted ; new complex movements cannot be acquired ; such
movements as are performed are only “ organised ” habitual
movements.

Reflex activity, though not abolished as in coma, is very
sluggish, and it is almost impossible to produce, through the
mechanism of the highest level, pupillary, cardiac, and respi¬
ratory changes. In fact, with the disappearance of the emotion,
the power of expression has gone. Speech is limited ; amnesia
is profound ; agraphia and alexia, mind blindness, and word
deafness very common. In fact, the physical signs are those
of a brain in which the cortical faculties are reduced almost to

Digitized by VjOOQle

56 PHYSICAL SIGNS OF INSANITY, [Jan.,

the uttermost, and, in katatonia and allied states, it is to the
basal ganglia that control of the musculature seems abandoned.

In mania the physical signs clearly enough seem those of
unfettered reflex activity, of destruction of highest controlling
levels. The exaltation and excess of nerve tension spoken of
by some writers mean, not real excess of nerve action, but
uncontrolled action of a lower type, the exaltation being merely
as the spasm of the legs in lateral sclerosis. The finest and
most complex movements are badly performed; sensation, so
far from being more acute, is actually blunted.

The state of the viscera—the cardio-vascular and respiratory
viscera—demonstrates also the loss of highest controlling
powers. The physical signs of mania, in fact, are the signs
of a brain in which the highest level is degraded, and functions
of the body are governed and ordained by the middle level.

But in melancholia the physical signs, well enough known,
the sluggish innervation, the poor circulation, the feeble respi¬
ration, the impaired acuteness of sensation and sensory pro¬
cesses relating to the external world,—all point to a general
enfeeblement with commencing decay or impairment of the
highest level.

Looking in this way at the physical signs of insanity, one is
forced to ask, was not Sankey right in calling the chief types
of insanity (melancholia, mania, and dementia) stages of one
progressive process ?

Is not every case of insanity in a sense a case of general
paralysis—a stage in a progressive dissolution of brain, some¬
times partial, sometimes general, sometimes arrested, more
often not to be arrested? Is it not the fact that the more
complex the causation of an insanity, the wider the brain area
seriously affected, the less curable the lesion, the more the
clinical picture resembles that of a stage of general paralysis ?
The term “general paralysis” is, of course, a convenient one
for certain brain dissolutions which run a certain course and
have more or less well ascertained causes and pathology. But
the cases confounded clinically with the general paralysis of
the text-books are those of general brain dissolution from
alcoholism, from general arterial disease, meningeal disease, or
disseminated tumours. Is not general paralysis, then, not a
thing apart, but the perfect example of progressive brain disso¬
lution, imitated more or less perfectly by the other insanities.

Digitized by VjOOQle

1900.]

BY F. GRAHAM CR00KSHANK, M.D.

It is true, and herein lies the chief difference, that the
abrogation of brain function in the ordinary insanities is less
often due to gross and permanent organic changes; but then,
the more general and the more permanent the change, the
closer becomes the resemblance to a stage of true general
paralysis.

As Hughlings Jackson said, in every case of insanity there
is a negative lesion causing sensory or motor paralysis, and it
is to the observation and enumeration of these paralyses—the
physical signs of insanity—that our clinical efforts should be
applied.

So far I am afraid I have dealt chiefly with generalities. I
will endeavour to enumerate some of the physical signs of brain
disease in the insane. Some classification is necessary, and at
present it seems best to follow anatomical and clinical paths,
though there necessarily must then be some confusion between
physical signs of insanity—signs met with only in the insane,
and physical signs of brain disease met with in the sane as well
as in the insane,

Let us take first the cranial nerves and the nerve tracts from
the nucleus to the cortex:

1. Perversions of smell in delusional insanity, indicating
aberrant functioning or faulty associations of highest centres,
probably in gyrus fomicatus.

Blunting of sense of smell in dementia, indicating defect
from highest centre downwards.

2. Perversions of the sense of sight in delusional insanities
indicating defects or faulty associational paths in highest visual
centres ; marginal convolutions.

Hemianopias in post-hemiplegic insanities, and in insanities,
associated with unilateral gross lesions, indicating disease in
occipital lobes or lower tracts.

General failure of visual acuteness, colour sense, etc., most
marked in dements ; general failure of visual nerve-paths.

(Word and mind blindness in cases of mania and dementia,
failure of cortex around marginal convolutions.)

3. Recurrent and temporary palsies and spasms ; mydriasis
(unilateral), ptosis, squint, myosis, and retraction of eyelids
(upper), indicative of functional disturbance in the third nucleus
or any of its component parts. Seen chiefly in manias.

4. Squint (oblique), occasionally with maniacal excitement.

Digitized by

Google

58 PHYSICAL SIGNS OF INSANITY, [Jan„

5. In dementia, general blunting of sensory processes con¬
nected with fifth nerve.

6. Internal squint common in mania; usually due to tem¬
porary weakness of one external rectus ; defect of sixth nerve
or part of nucleus.

7. Facial spasm and weakness; asymmetry of frontal
muscles, indicative of defects in seventh nucleus.

8 . Auditory hallucinations and delusions; in most cases
probably defect, associational or otherwise, of highest centres:
temporo-sphenoidal lobes.

Deafness (general) in dementia. Word deafness and amnesic
aphasia in chronic mania, dementia, etc., failure (extensive) in
temporo-sphenoidal lobes.

Vago-glosso pharyngeal nerve .—Tremor and deviation of
tongue—perhaps a central defect.

Spinal accessory nerve. —Shallow, slow respiration without
emotional variation, in dementia.

Lack of expectoration power—of laryngeal and palatal
reflexes—in advanced dementia.

Sympathetic system (cervical ganglia). Paralytic myosis ;
unilateral and bilateral flushings of face ; unilateral sweatings ;
seen in various forms of mania, and especially in epileptics.

Sensory tracts .—Repeated observations have shown sensation,
and so necessarily sensory processes, those of touch, heat, cold,
and pain, to be blunted in melancholia, more so in mania, more
in dementia ; we know them to be abolished in coma.

Spinal reflexes we find, like all nervous processes, sluggish in
melancholia, in mania exaggerated from loss of cerebral inhibi¬
tion, and in dementia almost in abeyance.

Movements; functions of the motor tract. —As indicating
disturbance of the highest (motor) level, we have—in melan¬
cholia—a difficulty of imitating new movements; in cases of
deeper dissolution a failure of execution of higher movements ;
in advanced and acute mania a failure of all complex move¬
ments other than those purely automatic; in dementia a
restriction of movements to a few well-organised (voluntary)
movements.

Looking at muscular states we have, indicative of general
nerve failure, the loss of tone in melancholia ; indicative of
greater failure of higher levels, the low level “ reflex ” tone of
mania. In other cases we have more complicated conditions

Digitized by VjOOQle

1900.]

BY F. GRAHAM CROOKSHANK, M.D.

indicative of varying depths of dissolution ; the katatonic,
cataleptic rigidity of some cases, the total paralysis and
flabbiness of coma.

The general wasting of some cases of insanity doubtless
means cord invasion (anterior horns), just as the greyness of
hair, skin conditions, and bedsores indicate disturbance of what
are called trophic centres. All these because general are less
obvious than if partial.

We have sluggish peristalsis in melancholia, and sphincter re¬
laxation in mania and dementia—doubtless dependent on failure
of the appropriate cord centres, just as priapism in mania is no
less a sign of cord activity (morbid, unfettered) than when the
spine is fractured or we have a myelitis.

Certain other signs must specially be mentioned.

We are inclined to connect a feeble, small-volumed pulse—■
that of poor innervation—with melancholia, a bounding, dilated
one—that of diminished inhibition—with mania, one unaltered
by emotion with dementia. So, too, one is inclined to connect
a sluggish medium pupil with melancholia, one in which there is
spasmodic myosis or mydriasis with mania—again the unvary¬
ing pupil with dementia.

May I now venture to anticipate some objections and
criticisms ?

One may be told that these “ paralyses ” of insanity are not
the paralyses of the hospital ward.

Certainly, there is a difference; the hemiplegic has will, but
no power. The comatose general, paralytic and, in less
measure, the dement, has neither will nor power. That m
mania the paralyses are transient is true enough; in other
cases it is, in fact, the universality of the paresis that prevents
us seeing it.

Again, it may be said that many of these signs that have
been mentioned are not “ paralyses ” at all; that an internal
squint of a maniac or a smoothed left forehead is not due to
paralysis of a sixth or seventh nerve, but to excessive action of
a third nerve or of the opposite seventh. It may be ; but in
any case there is localised disturbance of brain function. The
detail matters little; the real point is that these things are
evidence of brain disease, even though the disease be purely
functional. Perhaps some one will see that all this is obvious ;
that one flogs a dead horse.

Digitized by VjOOQle

60 RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.,

My only answer is that in no text-book that I know of are
the physical signs of insanity set forth or mentioned as evidence
of brain disease. Perhaps it is a question of description and
expression ; still the proper expression of facts is surely a
matter of importance.

We have to-day in medicine, and in our speciality in par¬
ticular, a vast and unwieldy accumulation of facts. It seems
to be forgotten that the proposition of hypothesis is a necessary
part of induction, and that without theory there is no useful
observation. Let us be unafraid then of cultivating a whole¬
some imagination, corrected by, and not in opposition to,
observed facts.

On some of the Rarer Skin Diseases affecting the
Insane . By Theo. B. Hyslop, M.D., Medical Superin¬
tendent, Bethlem Royal Hospital; Lecturer on Mental
Diseases, St. Mary’s Hospital; Demonstrator of Psychology,
Guy’s Hospital.

It would be quite impossible during the few minutes at my
disposal to deal in an exhaustive manner with the numberless
varieties of skin affections met with in asylum practice. I have
therefore selected from an immense mass of material a few of
the rarer affections, and shall deal with them in such a way as
to call for your experiences and criticisms rather than make
any personal attempt to lay down the law with regard to any
of them.

While fully recognising that some skin diseases may be
classed among the neuroses, I believe that several writers on
this stibject have classed as neuroses diseases which are not
more prevalent among the insane than the sane, and which on
inquiry have no distinct relationship or evidence of neurotic
origin. All asylum physicians are familiar with the brown
muddy tints in mania, the cracked and scurfy conditions in
melancholia, hypochondriasis, and stupor; also the brown dis¬
coloration in general paralysis somewhat suggestive of Addison’s
disease. Attention has also been directed to pallor, leaden
hues, mottlings ; the wine-coloured skin of dements ; the semi-

Digitized by VjOOQle

1900.] BY THEO. B. HYSLOP, M.D. 61

transparent, thin, pale, glossy skins of the scrofulous; the
ecchymoses of dements and paralytics, and the so-called “ in¬
sane fingers.” I shall in this paper, therefore, take little or no
account of these, or of the various affections of the hair, nor
shall I deal with the innumerable perversions of the cutaneous
senses. My remarks will be confined to the questions of—
Anomalies of pigmentation.

Pseudo-pellagra.

Herpes.

Pemphigus.

Adenoma sebaceum.

Feigned diseases.

Pigmentation .

I shall not discuss or even mention some of the various un¬
healthy conditions associated with the abnormal deposit of
pigment in the tissues of the skin. The pigmentation due to
diseased states of the blood, as in ague, syphilis, malignant
disease, chronic rheumatism, various cachexiae, etc., are very
well known, as are perhaps also the almost innumerable
instances due to reflex irritation from the abdominal and pelvic
viscera. Dr. Long Fox, in his book on the Influence of the
Sympathetic on Disease , has cited a large number of
authorities and cases. He there refers to the influence of
certain violent emotions in the production and deposit of
pigment, and regards emotional pigmentation as a sympathetic
disorder. Other observers have reported cases in both sexes
of partial pigmentation of the face due to anxiety. One such
case (under the observation of Dr. Fox) was so marked as to
give rise to fear of Addison’s disease, but the pigmentation
passed away when the anxiety was removed. Laycock quoted
a case of a woman who during the French Revolution incurred
the anger of the Parisian mob, and with difficulty escaped being
hanged in the streets. Her terror caused a gradual black dis¬
coloration of the whole body, and this remained with her
until her death thirty-five years afterwards. The tint was
deeper on the neck and shoulders than on the face ; on the
face and chest the tint was the same ;• it was less deep on the
abdomen and legs ; the joints of the fingers were blacker than
other parts; the soles, palms, and folds of the inguinal region

Digitized by VjOOQle

RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.,

paler. In this case the change was gradual. In another case
of Laycock’s, an hysterical woman, under pressure of grief,
showed melasma of the forehead, eyelids, and face, with hyper-
aesthesia of the affected surfaces. This condition occurred
during successive pregnancies, therefore it is questionable how
far it was of the reflex or of the emotional type.

I have here three photographs of a case of dementia show¬
ing well-marked pigmentation over the body. The pigmenta¬
tion is of old standing and probably due to liver trouble.

The photographs (i and 2) well illustrate this abnormal con¬
dition due to emotional causes. The patient became intensely
depressed in consequence of long-sustained business worries
and anxieties. There were symmetrical patches of brown pig¬
ment on his forehead, neck, fingers, and round his eyes. Later
in the attack he developed patches on his penis and glans, also
on his pubes, buttocks, anterior axillary fold, back, and thighs.
The deposit of pigment on the forehead was confined to a V-
or pear-shaped area having its angle at the root of the nose,
and spreading upwards and outwards quite symmetrically to
the supra-parietal region. At the end of a year he had become
demented, but when he left us the pigmentation was gradually
disappearing. I was unable to trace the case further. A case
is quoted in the Annales Midico-Psychologiques for 1876 of
melanopathia in a demented general paralytic. Slight darken¬
ing of the skin of the eyelids was first observed, and during
eight days this discoloration increased in extent and intensity.
Each side of the eyelids and skin over the malar bone presented
an absolutely black colour, while a narrow black band crossed
the upper part of the nose and united these patches. Seven
days later the colour began to fade, and in fifteen days had
completely disappeared. At no time were there any inflam¬
matory signs or special mental symptoms. Irritation of the
pelvic organs is accountable for discoloration either in patches
or all over the face. Sometimes these patches are quite sym¬
metrical, as in the illustration.

Dr. Swayne has published a case in the Obstetrical Transac¬
tions (quoted from Long Fox). The subject was a blonde of
rather florid complexion, with brown hair and blue eyes. At
the time of her confinement there was a peculiar appearance
of the skin of both forearms and hands. There was a very
general discoloration of the skin of the forearms, more

Digitized by VjOOQle

JOURNAL OF MENTAL SCIENCE. JANUARY. 1900

To illustrate Dr. Hysi.op’s paper.

jltizedbyGoOg''"'"'' & *”’• lmf -

No. 1. No.

Digitized by VjOOQle

JOURNAL OF MENTAL SCIENCE, JANUARY, 1900.

No. 2 .

To illustrate Dr. Hyslop’s paper.

Digitized by Goc

,-fdlard & Son , imp

Digitized by

1900.]

BY THEO. B. HYSLOP, M.D.

marked on the dorsal than on the palmar aspect. On the
dorsal aspect it occupied all the surface of the arms, and existed
in patches on the hands, the knuckles, and all the fingers. The
skin in these spots was of a rich yellowish-brown colour, or as
dark as the skin of a mulatto. The skin had been similarly
affected in each preceding pregnancy, and the dark colour first
appeared about the end of the third month, and increased pari
passu with the development of the areola, until it attained its
acme at the time of labour. After delivery it soon began to
diminish in intensity, and in about three months had entirely
disappeared. Her mother had two children, and in each of her
pregnancies both the arms and neck were spotted in a similar
way; and, being a very fair woman, the discoloration was
still more evident than in the daughter.

Pseudo-pellagra .

I have seen three female cases in which the backs of the
hands have quickly (within forty-eight hours) become intensely
brown or even almost black, perhaps as the result of short
exposure to the sun. This discoloration was in each case
followed by desquamation. In none of the cases was I able to
obtain evidence of reflex irritation, nevertheless I was not satis¬
fied that the result was due solely to exposure to the sun. So
remarkable were the conditions, that I endeavoured to obtain
information about their nature from many sources. It was
suggested by Dr. Sand with, of Cairo, and by an Italian
physician who saw the cases, that the condition was allied to
pellagra. I have since found that Dr. F&vre in 1878 described
pellagroid affections as occurring in the insane, especially during
spring and summer, and attributable to exposure to the sun.
They are found on all parts exposed to the sun, but chiefly on
the back of the hands. The skin assumes an earthy colour,
becomes wrinkled and fissured, in some parts thick, in others
thin and glistening. The epidermis is broken up into scales,
attached by their centres with edges curled up, in some parts
forming little heaps, beneath which the skin is red, with slight
serous oozing. These pellagroid affections are to be distin¬
guished from true pellagra.

Dr. F&vre has also described a condition (“ peau anserine ”)
known to most of us as occurring in persons suffering from
great debility. Here the skin, without exposure to the sun,

Digitized by VjOOQle

64 RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.,

becomes dry and tawny like rumpled parchment, without either
inflammation or exfoliation.

As early as 1867 Dr. Brunet wrote a paper upon the effects
of insolation upon the insane. His observations were derived
from experiments performed in the asylum at Mort. He found
that exposure to the sun was attended by acute inflammation
of the skin, with redness, pain, and tension, and in severer
cases of phlyctenulae containing serum, blood, or pus. When
sero-purulent effusions occurred, the superficial parts of the
epidermis appeared to be mortified. Sometimes there was
fever and insomnia, and even gastro-intestinal irritation with
diarrhoea. It terminated by desquamation of the cuticle or
persisted in the chronic form.

The chronic state was characterised by reddish-brown dis¬
coloration of the skin, a loss of elasticity, Assuring, and
peeling of the epidermis. The desquamation in slight cases
was simply furfuraceous and painless, but in severe cases plates
of skin were dislodged after acquiring the form of blackish crusts.
Brunet compared these conditions to those of pellagra, in which
there is a special inflammation of the digestive canal through¬
out, an erythema of the skin accompanied by desquamation
and Assuring, and a grave lesion of the nervous system marked
by vertigo, tremor, and unsteady gait, a painful sensation along
the spine, and a remarkable disturbance of the intellectual
faculties. In the three cases I observed there were no sym¬
ptoms other than the local skin affections which were incidental
to the insanity, and not the cause of it. Moreover in each
case the characteristic spinal tenderness of pellagra was com¬
pletely absent. In one case a residence of fifteen years under
a tropical sun had failed to affect a skin which, during an
attack of insanity, became affected as the part result of a brief
exposure to our own sun.

M. Brierre de Boismont has given an exhaustive discussion
on the connection between pellagra and insanity ; the con¬
clusions being that insanity, while undoubtedly being a fre¬
quent complication of pellagra, ordinarily does not appear
until after the pellagra. This, however, is not invariably the
case, as has been shown by Legrand du Saulle in an excellent
article in the Gazette des HSpitaux (1864), where he has cited
cases in which the psychical disorder preceded the alterations
of nutrition and the cutaneous phenomena.

Digitized by VjOOQle

1900.]

BY THEO. B. HYSLOP, M.D.

I find in the Journal of Mental Science of 1866 a report by
Dr. Howden of a case of pellagra occurring in the Montrose
Royal Asylum. In this case the erythema and diarrhoea did
not appear until six months after the mental symptoms. The
eruption affected the hands, face, and neck, and latterly the
upper surface of the feet (which were habitually uncovered).
Exposure to the sun’s rays always exaggerated the symptoms,
and recovery ensued with the onset of winter. Dr. Howden
regarded this as a sporadic case of pellagra, but I am inclined
to think that the diarrhoea and the eruption may have been
accidental in their coincidental occurrence, and that the con¬
dition may have been pellagroid. Since Lombroso’s work on
pellagra was published in 1869, clearly proving the relationship
between pellagra and the special poison from the maize, I have
been unable to find any records of true cases of pellagra occur¬
ring in British asylums. Posssibly, however, the pellagroid
condition of the hands may have been observed by many.
I exhibit photographs of two cases of pellagra, for the use of
which I am indebted to Dr. Selvatico d’Estense.

Roussel used the term pseudo-pellagra for those conditions
similar to pellagra as seen in chronic alcoholism with peripheral
neuritis and in dements and general paralytics. All the cases
I have seen have been females suffering from mania of an
intractable type. It is difficult to account for these partial pig¬
mentations. If we assume that there is a paretic state of the
vaso-constrictors, we are still at a loss to explain the local
distribution.

Loss of Pigment

Long Fox states that when loss of pigment seems to depend
on emotional causes, it does so by their acting as paralysers of
the cerebro-spinal nerves. He has described an instance in
which patches of ivory-white morphoea occurred on the temple,
the side of the nose and upper lip, in association with uterine
troubles. Godlee records a case of vitiligo in which there was
a strong nervous influence.

I can only recall one case of insanity in which there was
evidence of local pallor (other than morphoea), and which could
hardly be regarded as an instance of loss of pigment. A single
woman, aged forty-six, suffering from mania of the recurring
type, before each attack had a patch of white on her upper

XLVI. S

Digitized by

Google

66 RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.,

lip. This remained unchanged for two or three days until the
maniacal symptoms had fully developed, and then it dis¬
appeared. Each attack was ushered in in this way. So far as I
am aware this is quite a rare symptom. I was unable to
determine any relationship between its existence and any
disturbance of the uterine functions. Dr. Savage tells me that
he has seen in some cases of insanity white patches appearing,
only to disappear with recovery.

Herpes and Pemphigus.

Herpes is not uncommon in the insane, and doubtless all of us
have seen many cases. Mickle records an interesting case
of general paralysis with acute herpes zoster over front,
inner, and partly outer side of left thigh, with some«pem-
phigenoid blebs. The herpes extended upward from the groin,
trending outwards above the crest of the ilium to the sacral
and lower lumbar region. An isolated patch of it over inner
side of head of tibia. No complaint of pain. The eruption
left cicatrices. I have seen several cases of herpes in the
region of distribution of the superior branch of the fifth nerve
in the later stages of progressive paralysis. The occurrence of
pemphigus blebs on the fingers, forearms, feet, and legs in the
last stages of general paralysis is interesting from many points
of view. Ddjerine found the nerves of the subjacent parts
undergoing a process as of atrophied breaking up and involution
in a case where pemphigus blebs appeared on the forearms and
legs shortly before death.

It is very difficult to determine the aetiology of these blebs
and bullae, and since I studied Kohner's writings on pemphigus,
which purport to prevent the frequent mistakes in diagnosis
between syphilitic and bullous affections, I have found far
greater difficulty. In all the cases I have seen there has been
a history of syphilis, and the patients have been in the last
stages of general paralysis. The affection has seldom been
polymorphic, and there has been no evidence of herpetic
distribution. They have not been pruriginous nor erythema¬
tous. In one case I saw many years ago there was a bullous
eruption associated with high temperature, but in the cases of
general paralysis here referred to there was no definite relation¬
ship between the eruption and the temperature.

Digitized by VjOOQle

1900.]

BY THEO. B. HYSLOP, M.D.

Inasmuch as the relationship of general paralysis to syphilis
still forms a problem for controversy, and we are not clear upon
the question as to whether general paralysis is syphilitic in
nature or in origin only, I think it advisable to speak of the
eruption as “ pemphigus parasyphiliticus.” F&vre says he has
seen pemphigus develop with the cure of insanity—a kind of
critical eruption. Dr. Savage says he has never seen such
cases; nor have I ; but all are agreed as to their unfavourable
import in general paralysis.

Adenoma Sebaceum.

About twelve years ago, when I was Assistant Medical
Officer at the Royal Albert Asylum, I saw two cases of this
rare affection. Since then I have only come across one case,
and that was also in an idiot. The cases at the Royal Albert
have been fully described by Dr. Shuttleworth, to whom I
am indebted for the use of his notes and the accompanying
photograph (3). The affection is characterised by a chronic
eruption of minute, warty-like nodules distributed over the
face, usually affecting by preference the cheeks, but subse¬
quently spreading to the forehead and chin. It has been
termed the “ butterfly disease ”— epithelioma adenoides cysticum ,
—and one case shown by Dr. Fletcher Beach was christened
“ fibroma rubrum ; ” but adenoma sebaceum is the name applied
to it by Radcliffe Crocker and others.

So far as I can ascertain, the reported cases are only about
twenty in number. According to Brooke, Jacquet and Davies
in 1887, under the title of “ hydradtnome eruptif? first de¬
scribed the affection. Crocker, however, claims that Rayer,
Addison, and Gull reported the first cases, but that it was not
positively recognised as a distinct disease until Balzar fully
described it In the American Journal of Psycho-asthenics
(March, 1899) Dr. Barr, Chief Physician of the Pennsylvania
Training-school for Feeble-minded Children, has given a de¬
scription of three cases.

The lesions are roundish convex papules, varying in size
from a pin's point to that of a split pea. The majority are of
a bright crimson; others may be slightly coloured or trans¬
lucent and waxy. When the papules are very numerous and
thickly grouped they are apt to assume a cinnamon or brownish

Digitized by VjOOQle

68 RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.,

tint, occasionally paling on pressure. As a rule, the lesion is
symmetrical, but Crocker reports a case in which it was uni¬
lateral, and in one of Barr’s cases the eruption was symmetrical
except that the right side of the forehead was affected and not
the left. It is usually confined to the face, and most abundant
on the sides of the nose and the naso-labial folds, where it is
sometimes confluent. A few scattered lesions may be present
at birth or appear gradually in early childhood, or they may
suddenly increase in number but not in size at puberty. The
disease, once established, is stationary, although the papules
occasionally undergo involution, leaving insignificant scars,
which in time fade.

It is not uncommon to have other affections of the skin
associated, such as fibromata of the hair-follicles, pigmentation,
or true warts. Colloid milium and acne papules or pustules
may also add to the disfiguration.

There is now in Bethlem a case of some interest, and at one
time suggestive of adenoma sebaceum. A lady suffering from
puerperal mania of prolonged and intractable type has lesions
affecting her cheeks, nose, naso-labial folds, chin, and (as shown
in the accompanying photograph, 4) a triangular or almost pear-
shaped area in the centre of the forehead, the lower angle
resting between the eyebrows and extending over the forehead
to the hair. This case is of double interest inasmuch as the
milium, acne, and seborrhoea supervened upon pigmentation of
the pellagroid type, and the affection covered an area on the
forehead very similar to that in the case of pigmentation asso¬
ciated with melancholia already described.

Feigned Diseases .

The last case I have to mention in this incomplete series is
of interest, and opens a large field for collective experience.
It is that of a single lady aged thirty years, who came to
Bethlem six years ago suffering from melancholia with hysteria
and uncontrollable impulses. Her family history was bad,
there having been insanity, phthisis, and alcoholism in her near
relations. She herself had been hysterical for eleven years,
manifested from time to time by inability to walk, see, or talk,
also by quasi-syncopdl attacks. Seven years previous to her
admission she had a sore on her finger, which she kept open

Digitized by VjOOQle

JOURNAL OF MENTAL SCIENCE, JANUARY, 1900.

Ir Vv#

No. 4.

To illustrate Dr. Hyslop's paper*.

Digitized by Googl htlnrd P? Snn, Imf'-

Digitized by VjOOQle

1900.]

BY THEO. B. HYSLOP, M.D.

for months, and finally had the nail removed. This sore she
ascribed to a dog-bite. Two years later she had a sore heel
and sore fingers and toes, followed by affections of the soles of
her feet and palms of her hands. These were treated as skin
disease. Two years later sores appeared on her left leg and
\eft side. After consulting more than twenty medical men it
was at last suggested that the condition was self-inflicted, and
with due precautions improvement ensued. With this im¬
provement, however, the patient became fretful and refused
food. She also feigned delirium, and had to be held down for
several hours by attendants. In spite of vigilance she managed
to cause sores on her hands and feet, and some ulceration of
her gums. Finding that she was beginning to develop suicidal
tendencies, her friends had her removed to Bethlem.

On admission she was suffering from hysterical melancholia
with impulsive tendencies. Her catamenia had been irregular
during the previous twelve months. On examination it was
found that her right pupil was larger than her left, but both
acted well to light and accommodation. Her superficial
plantar reflexes were absent, and there was defective localisa¬
tion and some analgesia of her left leg and foot, while the
sensation of the right leg and foot was only slightly impaired.
She also had other sensory disturbances and some loss of
memory. Her acts were governed by impulses to which she
said she was subject, and whose origin she could not explain.

She had a number of scars on her left leg extending from
the knee to the ankle. There were about forty discrete ones,
and others which had run together. They were rounded,
pigmented (colour disappeared on pressure), and a few slightly
depressed below the general surface. Some of the scars were
evidently of old standing, and had become pale and fibrous-
looking. They were all on the inner side of the leg. She
had similar old wounds on the left hip, the right thigh, and on
the extensor aspect of the right forearm. All these were self-
inflicted, and done by scraping with a pair of scissors, and then
by rubbing in ammonia. She said the process had been
accompanied by a considerable amount of pain, but that she
had felt an uncontrollable impulse to do it, and that she had
generally done it in her room either on going to bed or early
in the morning. She again ascribed the beginning of the
affection to a “wee bite from a dog,” which she treated by

Digitized by VjOOQle

70 RARER SKIN DISEASES AFFECTING THE INSANE, [Jan.

scratching and rubbing in ammonia. She was seen by nearly
all the skin specialists, and had undergone a course of Weir
Mitchell treatment, but without result.

Subsequently she developed the following sensory impair¬
ments of her left side. The tactile sense was much impaired
all over the left half of the head, trunk, arm, and leg, fairly
accurately limited by the median line, the impairment being
greatest below the knee. The anaesthesia also involved the
mucous membrane of mouth and tongue. There was also
some impairment below the knee of the right leg. Left
hemianalgesia was present, pin-pricks producing no result below
the left knee, and little or no result elsewhere in the left side.
Her temperature sense was impaired all over the left half,
mostly below the left knee, a hot test-tube being unfelt. She
also had impairment of the senses of smell, sight, hearing, and
taste on the left side. I mention this instance of combined
absence of the tactile temperature and pain sense as I believe
it to be rare except in peripheral neuritis. Cocaine, ether,
chloroform, syringomyelia, locomotor ataxy, hysteria, are usually
attended by analgesia without impairment of the tactile and
temperature senses. Carbolic acid, acetic acid, hemianaesthesia,
some cases of locomotor ataxy, and some brain diseases have,
on the other hand, diminished tactile sense but unimpaired
pain and temperature sense. This case, however, is cited
mainly in illustration of the skin lesion which was feigned.

Among the sane, ulcers are frequently induced by the use of
epispastics, acetate of copper, quicklime, and many other drugs.
Frauds of this kind are also not infrequently performed by the
insane, especially by hypochondriacs who wish to “ get up a
case.” They rub a part until it becomes inflamed or ulcerated,
and keep up the irritation by thrusting piris through the
bandages. Maniacal patients will also sometimes rub their
skin with urine until there is an eruption of petechiae or
pustules. Jaundice has been imitated in France by taking
daily a small quantity of muriatic acid, and the deception has
been almost complete, even to the discoloration of the adnata
and of the urine. Paleness of the skin has also been caused
by burning sulphur, and by the use of digitalis, emetics, and
purgatives, but watchfulness and preventing their use check
the effects. The condition described in some books as erythema
gangrenosum , or patches of superficial gangrene, is usually to

Digitized by VjOOQle

1900.]

BY THEO. B. HYSLOP, M.D.

be seen in hysterical persons and under circumstances which
point to their having been self-inflicted. These self-inflicted
affections are usually arranged unsymmetrically on the left
side, and on parts easily accessible to the right hand. The
diseases most frequently simulated (according to Crocker) are
erythema, eczema, pemphigus, ulcerations, morbid growths or
discolorations, changes in the cutaneous secretions, etc., and
the same author points out that the eruption or lesion nearly
always differs from what may be called the natural eruption it
is supposed to represent, and is often unlike any known disease.
" Thus,” he says, “ if it is an erythema, it is probably sharply
defined and irregular in shape, and, with a clumsy operator,
may even be angular in outline. If it is gangrenous and
produced by a liquid caustic, in addition to the irregularity it
is common to find that some drops have been spilled away
from the main lesion, or that it has run down in a streak, or
that it has damaged the clothing or stained the fingers or
nails. Then the lesions are either single or few in number, at
least at each supposed outbreak, though when the deception
has lasted a long time the number of lesions in the aggregate
may be very large.”

The evolution and progress of skin affections in insanity,
and their relationship to it, are questions large enough to form
a separate paper. Here, however, it must suffice to say that
sometimes mental diseases alternate with skin diseases; re¬
current attacks of insanity may have recurrent eruptions;
frequently curable insane patients have curable skin affections,
while incurable insane patients have incurable skin affections—
the condition and progress of the one sometimes warranting a
prognosis as to the other. Or, as Dr. Savage says, “ if you
see the skin gradually clear up you will soon see mental
improvement too, but an obstinate skin means a tardy or
difficult cure.”

Discussion

At the Autumn Meeting of the South-eastern Division of the Medico-Psychological

.Association, 1899.

Dr. Fletcher Beach said that the only case he had the opportunity of seeing
was one to which Dr. Hyslop alluded—the case of butterfly affection. It occurred
about twenty vears ago, and he had to find a name for it himself. He was, how¬
ever, quite willing to fall in with the well-known name of adenoma sebaceum.

Dr. Selvatico Estense (Rome) said he was very pleased to be at a meeting of
the Division and to take part in the discussion, because he had seen many cases of

Digitized by

Google

72 RARER SKIN DISEASES AFFECTING THE INSANE. [Jan.,

pellagra, which was a malady of northern Italy. Generally speaking it occurred
in countries in which maize was the principal food. It occurred in the south of
France as well as in northern Italy. It had been said that when maize was not
perfectly dry, fermentation took place and developed some special poison, which
Lombroso called pellagra. In Italy there were about one hundred thousand cases
of pellegra, but they were not all cases of insanity. Patients lived many years
without developing mental trouble ; but in the later stages insanity developed, espe-
daily in the form of melancholia.

Dr. Savage said that if they took up Dr. Crocker’s book and referred to
almost any of the remedies suggested, they would find that each of them had
more or less power of producing rashes. Most of the cases he had seen showed
rashes of one kind or another, and it was absolutely necessary to stop all
drugs, in order to make sure how much might be due to the drugs and how much
to the disease. Drawings made by Mr. Lennox Marks, at Bethlem, showed a good
example of pigmented areas spreading over the face. The patient slowly improved,
and was discharged, only to return some time afterwards, when there was no trace
of the condition which had previously been so marked. It had always been a
matter of wonder to him that they got comparatively few cases of inflammatory
skin disease in general paralytics with a very feeble circulation. Sir James
Crichton-Browne had described many of these as cases of chilblain of the brain.
He (the speaker) thought that was an important point, for although he observed
extreme congestion of the extremities, yet in cases of mental stupor he very rarely
saw anything like severe chilblain of the skin. In dealing with hysterical girls
they had to remember that these patients suffered from a grave nervous disorder,
and in some cases but the early stage of much graver disease. Dr. Savage
mentioned the case of a girl who had caused a number of sloughs on different
parts of her body down into the muscles, by the use of very strong ammonia.
These sloughs she preserved in a bottle of spirits, which she seemed to be very
proud of showing. He told her that it was perfectly clear how these sloughs
had been caused, and threatened that if any more occurred her father should be
told. This seemed to have had the desired effect, for the patient recovered.

Dr. Stoddart said that generally every insane patient had a greasy, dirty skin,
while the growth of the beard in female dements was often rapid. He believed
there was some truth in the statement that the prognosis in the adolescent male
patient depended on the growth of the beard. If these patients improved simul¬
taneously with its growth, as a rule they went straight on to recovery ; but if the
beard remained downy it was a bad sign. He quite agreed with Dr. Savage’s
remarks about drugs. They all knew that both arsenic and potassium bromide had
a marked effect on the skin. In the relations between affections of the skin and
nervous diseases, both in the insane and in diseases of the lowest level, in connec¬
tion with peripheral neuritis, there were affections of the skin; although he was
not prepared to offer any explanation, it was a striking point.

Dr. Shuttleworth said that during the twenty-three years he was at the Albert
Asylum only four cases of adenoma-sebaceum came under his notice out of some
1600 patients. The disease was certainly rare and little known outside the specialty
of mental disease, and, he might add, outside the particular province of asylums.
The probability was that the affection was congenital; that was to say, of embryonic
origin, but of later development. The patients were ordinary epileptics. Similar
affections—he did not say identical affections—were known to dermatologists. Dr.
Brooke, of Manchester, had sent him portraits of patients which resembled those
described by Dr. Hyslop, except in the distribution. Dr. Brook had also sent him
one which he thought was a true case of adenoma sebaceum. It would be interest¬
ing to know what became of these skin affections after leaving the asylum. He
himself had never had the opportunity of watching the affection beyond the age
of twenty. There was no doubt there was a process of development—first, the
minute papules were almost colourless, and afterwards, generally towards the age of
puberty, they developed a deeper colour. It was not contagious, but embryonic. Dr.
Beach had named the disease, and had given his reasons; it would be only right to
ask the dermatologists to say why they called it adenoma sebaceum. Crocker
made use of words to this effect, that the era of the development in the shape of
congenital overgrowth in the skin shows thickening of the corium, increase also in
the number of the sweat glands, and a marked increase of connective tissue.

Digitized by tjOOQle

1900 .] EPILEPSY ASSOCIATED WITH INSANITY.

Dr. Helen Boyle, who exhibited three photographs of a case at Claybury
Asylum, said it began as small papules on the right side of the forehead; in the
next stage it looked like herpes; after that it developed rapidly, and began to ooze
with little points of pus. Opinions as to diagnosis varied between adenoma and
epithelioma. It spread over the body in several patches. In the course of a few
weeks the trouble had entirely disappeared under antiseptic dressings. It cleared
up, leaving a rather bad scar, which was contracting.

Dr. Richards said that it appeared to him that Dr. Hyslop had not clearly
proved that the mental disease had anything to do with the skin disease in these
cases. Among the large number of cases which had been under his care at Han-
well there were not more of skin disease than would be found among a like number
of sane.

Dr. Tuke and another member having referred to cases of skin pigmentation,

Dr. Hyslop said with regard to what Dr. Stoddart said about the growth of the
beard, he suggested that it might be due to the fact that razors were not accessible
in asylums, for it was within a few days after admission to the asylum that they
began to show hair on their faces.

Epilepsy associated with Insanity . By Ern est W. White,
M.B.Lond., M.R.C.P., City of London Asylum.

The object of this paper is to briefly consider the various
forms of insanity which are complicated by epilepsy, and for
convenience we shall discuss them as they occur during infancy,
puberty, adolescence, the climacteric, and the senile periods.

The so-called eclampsic convulsions of infancy from teething,
worms, and other reflex irritations are common enough, but
fortunately in but a small proportion of cases (probably only
about 15 per cent.) does idiocy result. Idiocy and imbecility
are frequently complicated by epilepsy, but these conditions do
not bear any relation of cause and effect, they march side by
side, and spring in most instances from a common origin—
some inherited taint of mental disease, from epilepsy, or allied
neuroses, or alcoholic intemperance on the part of the parents.
The idiot with frequent and early epileptic seizures is incapable
of improvement in habits or intellectual development. When
the fits do not occur early, and are not frequent and severe,
they may to some extent be controlled by drugs, and slight
mental amelioration may be effected.

We next come to epilepsy associated with insanity during
the period of puberty. When one remembers the great changes,

Digitized by

Google

EPILEPSY ASSOCIATED WITH INSANITY, [Jan.,

mental and physical, which occur normally in both male and
female during this period, one is not surprised if any inherited
tendency to mental disease or epilepsy then becomes evident.

Epilepsy is pathologically closely allied to the physiological
process of blushing so common in the sympathetic period under
discussion. I must own, however, that I have seen but few
cases of primary insanity of puberty. Nearly all have been
sequential to epilepsy or chorea.

Insanity associated with epilepsy during adolescence is very
common. The epilepsy has probably first appeared during the
period of puberty, the fits have recurred with ever-increasing
frequency; irritability, loss of self-restraint, fits of passion, and
failing memory have followed—then a maniacal outburst with
extreme violence necessitates certification. We are accustomed
to observe in the intervals between the attacks the facial ex¬
pression, or rather the want of it—“ the facies epileptica.” The
patient is mildly demented, and often has widely dilated pupils,
the speech is drawling, ideation being sluggish. They usually
have abundant hair, which is abnormally moist when the fits
occur. There is marked moral decadence, yet often religious
fervour. They are at one moment quoting texts, at another
swearing, obscene, and lying. They are most quarrelsome,
impulsive, and dangerous, and often come to blows. It is an
interesting fact that their injuries heal most readily. They are
thickset as a rule, with good muscular development, and are
coarse feeders, needing aperient medicine once or twice a week.
Frequently they have delusions of a religious nature, and of
persecution, with hallucinations of one or more of the special
senses of the familiar types. These delusions and want of self-
control often cause homicidal acts.

The series of epileptic fits may occur at fixed periods, and
are of similar duration. If one patient has a fit in a ward
another will quickly follow, and certain patients are similarly
affected by any loud noise or unexpected nervous shock, such
as the shutting of a door, the taking of a bath, or a sudden
change of temperature. Some patients are threatening and
violent before, the majority after, the fits. In some a maniacal
outburst takes the place of these fits—a form of “ ^pilepsie
larvee ” or “ masked epilepsy.” The “ aura ” is seldom present
in the epileptic insane, and the “ cry ” is rarely heard in adults.
Each patient falls in his accustomed way, either forwards, back-

Digitized by VjOOQle

1900.]

BY ERNEST W. WHITE, M.B.

wards, or sideways, and there is generally one point of impact.
Those who fall backwards often impinge on the occiput with
tremendous force, giving the impression that the skull must be
fractured. This, however, is a very rare accident, for in chronic
epilepsy the bones of the cranium are greatly hypertrophied.
The more frequent the seizures, and the more rapid the
sequence, the more prolonged is the clonic stage relatively to
the tonic—the M status epilepticus ” which is symptomatic of
nervous and muscular exhaustion, characterised by temperature
as high as io6° Fahr. There is a general cerebral congestion,
and our treatment must be appropriate. A certain proportion
of cases of epileptic insanity are attributed to falls on the head,
and on treatment of the exact site of the injury, eliminating
hereditary taint, good results from an operation may be antici¬
pated, provided that the disease be not of long standing.

When chronic epilepsy has induced insanity, or occurs con¬
currently with it, there is always evidence of impaired memory,
reasoning power, and change of moral character, involving the
feelings, affections, inclinations, temper, habits, and moral dis¬
positions. These patients are inveterate liars, and bring all
sorts of charges, based in most instances upon their hallucina¬
tions, against their fellow-patienfif or those in whose care they
are. The ultimate goal is dementia, therefore cases of epileptic
mania are incurable, except the epilepsy is controllable by
medicines, or is connected witji pregnancy. Too often these
last named become insane during pregnancy, recover after
parturition, and again become insane with the next pregnancy.

The incidence of one or more epileptic fits in cases of mania
and melancholia of some duration is, as a rule, a bad sign, as
it points to active disease affecting the motor tracts being
superadded to that of the intellectual centres. There are,
however, exceptions to this general rule, for I have had two
cases where epileptic seizures have marked a turning-point to¬
wards recovery. One was a severe case of protracted mania.
After doses of hydrobromate of hyoscine during a maniacal
period she had a severe fit, and immediately began to improve
mentally. After several months she was discharged, and has
for the last two years remained quite well. She had been
previously under treatment in several asylums for several years.
The other was a male patient, addicted to self-abuse, with a
tendency to phimosis. During an operation for the relief of

Digitized by VjOOQle

EPILEPSY ASSOCIATED WITH INSANITY, [Jan.,

that condition he had a severe epileptic fit, the first in his life¬
time, and from that day he made a good recovery and has
kept well. The occurrence of epilepsy in the earlier stages of
general paralysis in the insane is well recognised. A fit in a
person between thirty-five and fifty years of age, suffering from
mania or melancholia, who has never previously had one, often
clears up the diagnosis. It points to active changes affecting
the convolutions of the motor areas, and as the disease be¬
comes more advanced the tendency to these seizures increases.
The epilepsy of general paralysis is marked by the want of
tonicity in the fits, the shortness of the tonic stage relatively to
the clonic, the tendency of one fit to run into another, until the
seizure appears to be a series of clonic spasms with slight
intervals. It is completed with extreme exhaustion. Epilepsy,
during adolescence, in melancholic cases is rare, except in the
form associated with general paralysis. Climacteric insanity is
also seldom complicated by epilepsy, but in senility it is common
enough, associated with both mania and melancholia. The
form is often that of “ petit mal,” a mere transient unconscious¬
ness during excitement. In these cases the patient not in¬
frequently continues the conversation which had been inter¬
rupted by the fit, as if the function of the nerve-cells was
temporarily arrested by defective blood-supply. In most
instances the heart and blood-vessels have undoubtedly under¬
gone degenerative changes. “ Petit mal ” is therefore said to
induce early dementia, but in these cases both conditions
have a common cause—inadequate nutrition of the nerve-cells
owing to the defective blood-supply, or impurities in the supply.
Cases of senile mania and melancholia complicated by epilepsy
occurring for the first time late in life never recover, but soon
drift into dementia, and after a year or so, or even in a shorter
time, die.

We shall now consider the epileptic records of the City of
London Asylum for the past two years, to ascertain how the
incidence of fits in the chronic insane is influenced by various
conditions.

First as to the moon. It is generally noted in asylums that
the chronic insane are more troublesome, noisy, and destructive
at the full moon. One steward assured me that there is more
crockery broken then than at any other time of the month.

Digitized by

Google

1900.]

BY ERNEST W. WHITE, M.B.

But will not the light nights account for this to a large extent ?
Our returns, however, show that it is just after full moon that
fits are most prevalent in the epileptic insane of the female but
not of the male sex.

All female epileptics are more quarrelsome and troublesome
at menstrual periods, but a very large percentage are unaffected
in regard to epilepsy. As a rule, in my experience, menstrua¬
tion has no influence in inducing fits. A former superintendent
(Dr. Dyer) of the Metropolitan Asylums at Darenth assures
me that he has noted that a sudden change in the temperature
or atmospheric pressure increased the number and severity of
the fits, and rendered the patients more noisy, excited, and
troublesome.

Epileptic fits are undoubtedly more prevalent in winter and
spring-time. Our records show that most occur in January.
February, December, and April follow in order, while there are
fewest in the summer months, June, July, and August. I suggest
that exercise and the free action of the skin explain this fact, but
we have no statistics to show whether epilepsy is as common in
the tropical as in the temperate zone.

Our records show that fits in males are two and a half times
more numerous by night than by day, whereas in females they
are twice as numerous by day as by night. This may be
accounted for by the fact that the men are largely employed by
day, and the use of their muscles and free action of the skin
reduce the tendency. As indigestible food cannot be the cause,
I would suggest that the explanation of nocturnal fits is to be
found in insane dreams coupled with an abnormally hyperaemic
condition of the brain. We may definitely state that the more
indolent the epileptic the greater is the tendency to fits by day
or night.

The automatic actions of these patients after fits are note¬
worthy. A man will put his coat on back to front, or apparently
with the intent of walking forward will step backwards through a
window. Whatever their erratic behaviour may be, they remember
nothing of it when they come to themselves. I am one of those
who are of opinion that chronic epileptics should be deemed
irresponsible for homicidal acts, having seen many cases of
epilepsy marked by brutal violence associated with an absolute
mental blank as to all that had occurred.

Digitized by

Google

7 »

EPILEPSY ASSOCIATED WITH INSANITY, [Jan.,

Treatment .—The recognition of the controlling power of the
bromides in epilepsy has resulted in epileptic wards being
furnished like the others, bright and cheerful, with pictures,
birds, books, and flowers, while strong-rooms are seldom used.
Yet we have to guard against abuse of these drugs, recognising
the enfeeblement and destruction of the nerve-cells which
result from large doses of the bromides too long continued. In
recent cases, and in those where improvement seems possible, we
must carefully regulate their administration. They seem to
act by allaying reflex excitability, for in many acute cases,
where the action of the drug has been cumulative or the dose
excessive, the earliest symptom of danger has been loss of
power, of deglutition, and absence of reflex excitabilityon tickling
the fauces. In chronic cases excessive exhibition of the bromides
may keep them under. The fits may be controlled, but the
advent of dementia is hastened. There are a great many cases
in which the bromides do no good, for the number and severity
of the fits are not reduced, and in some cases are even
increased. Ergot is the only drug in which I have any con¬
fidence for these intractable cases; it may be given as liquid
extract of ergot, as ergotine, or as citrate of ergotinine sub¬
cutaneously. About sixteen years ago I first tried this drug,
and obtained excellent results. My statistics, then collected at
the East Kent Asylum, were unfortunately lost and publication
prevented. In the status epilepticus the bromides are worse
than useless, for it is a state of exhaustion. A quarter of a
century ago we were advised to administer croton oil and the
like. Well, these patients practically always died. When it
was recognised that the condition is a thorough exhaustion
requiring stimulation there was a change of treatment, and a
large proportion of the cases recovered. In the status epilepticus
there is an intense turgescence of the venous sinuses and stasis
of the blood-vessels of the brain generally. Depletion by blood¬
letting is of little service because of this stasis and lack of tone,
but we have in ergot a remedy which frequently acts like a
char i. We relieve the bowels by an enema, raise the head to
assist ^ return of venous blood by gravity, then give half-drachm
doses < "quid extract of ergot in a little brandy and water

between ..ts, or the citrate of ergotinine hypodermically in

tJtt to -fo of a grain in case of difficulty of deglutition. Nitrate

Digitized by VjOOQle

BY ERNEST W. WHITE, M.B.

1900.]

of amyl, digitalis, and chloral have been useless in my expe¬
rience.

It seems to me that there are two principal forms of
epilepsies, the one originating in the nerve-cells of the cerebral
cortex (cerebro-spinal), the other primarily in the vaso-motor
nerves (sympathetic). The former is that in which the primary
nerve storms occur, and the bromides by allaying the reflex
excitability prevent explosions. The latter is that in which
there is lack of tone in the vaso-motor nerves of the vessels of
the cortex, an instability of function in these nerves so to
speak, whereby the nerve-cell function is disordered, and it is in
these cases in which the bromides are absolutely useless that
ergot is of service. Epilepsy can certainly arise from either
anaemia or hyperaemia, and this strengthens the vaso-motor
theory of the origin of the latter form. The chronic alteration
of the brain circulation may also account for the mental
enfeeblement of chronic epilepsy. Ergot is undoubtedly a
vaso-motor nerve tonic which specially acts upon the vessels of
the brain, and should be given for congestive headaches, as well
as for epilepsy where the congestion primarily occurs in the
venous sinuses.

Discussion

At the Spring Meeting of the South-eastern Division of the Medico-Psychological

Association, 1899.

Dr. Fletcher Beach said that his experience was that a small proportion of
epileptics very much improved after careful treatment. In clinical teaching he
always pointed out to students that these epileptic patients might be divided into
three classes—those who entirely and speedily recovered, those who recovered after
a number of years, and those who drifted into dementia. A large number died,
but an appreciable proportion improved and were cured. Two years ago, in his
paper on “ Insanity in Children,” he had referred to clinical facts in this connec¬
tion. In the earlier stages, during infancy, they were often delirious, as might
naturally be expected. The number of cases of epilepsy increased with age. The
removal of portions of the cranium had been followed by wonderfully good results
in his hospital practice; but when the cranium was small, because the brain was
small, no benefit could ensue. Operative interference was, therefore, limited as a
curative measure. As far as his observations went, epilepsy generally begins at
night, the reason being that the amount of carbonic acid excreted is much in excess
of the oxygen absorbed by the blood. For the last six years he had given direc¬
tions that bromides must be taken for at least two years after the last fit. With
regard to ergotine, its value must depend upon its influence upon the cerebral calcu¬
lation, and not upon its action upon the heart. ,, ,

Dr. Bower, while agreeing with most of Dr. White’s remarks, held t vjr 1 his
experience epilepsy had generally begun just before puberty. WhjP r emale
epileptics under his care had luxuriant hair, all the males were .arly so.

He would supplement Dr. White’s paper with two remarks: first,* epileptics
should be treated in separate asylums; and second, that they should be kept in bed
after the fits. The first had been advocated by Dr. Ewart some years ago, and
carried out successfully on the whole; the secona had been Dr. Rayner's system at

Digitized by VjOOQle

80 ACUTE MANIA TREATED WITHOUT SEDATIVES, [Jan.,

Hanwell. It was disappointing to hear of the small success of operative measures.
He gave bromides sparingly, and was convinced that the constant use of these drugs
sent a good many cases into asylums. He had not used ergotine, but commended
the employment of Epsom salts as most potent and useful treatment. As to the
status epilepticus , a stimulant was very necessary. For a good many years he had
given injections of chloral with success, while in the control of ordinary seizures
chloral with bromides rendered them less frequent and less severe. He did not
think that dementia followed so surely on that combination as on bromides alone.

Mr. Maclean could not remember any good results from the use of ergot, but
believed that the best course was to give small doses of chloral combined with
bromides, thus diminishing the number of the fits in epileptic cases.

Dr. White, in replying to the discussion, agreed with the statement made by Dr.
Fletcher Beach to the effect that epileptic fits were referable in some degree to the
amount of carbonic acid circulating in the blood, as it went to support his opinion
and principle of treatment that fresh air and exercise reduce the number of the
seizures. His paper was founded on his personal experience and observations, and
was exclusive of children, who are not found in asylums as a rule. He regretted
that a long series of observations made by him in the Chartham Asylum some
fourteen years ago—records of five years’ work—had been destroyed, rendering it
necessary for him to begin afresh. His experience had differed from Dr. Bower’s.
He had found chloral of little use in the status epilepticus; and, although much
hair may fall off, he had not seen frequent baldness in male epileptics. He
could see that Dr. Rayner’s treatment might be very useful, but had not yet
adopted it.

Notes on 206 Consecutive Cases of Acute Mania treated
without Sedatives . By C. K. Hitchcock, M.D., M.A
Medical Superintendent, York Lunatic Hospital.

DURING the sixteen years I have been at York 206 cases
of acute mania have been admitted, inclusive of 29 relapsed
cases occurring in sixteen individuals. Of these 206 cases,
171 have recovered, 8 have died during the attack and because
of the mania, and 3 have died during the attack from inter¬
current bodily diseases, 12 have been discharged relieved to the
care of friends, 7 were transferred to other asylums, and 5
remain under care.

The average period under treatment was for males three and
a half months, and for females five months, with the addition,
in many cases, of one month at home on trial before discharge.
Seven cases recovered after one year, and 2 after three and five
years respectively.

The ratio of recoveries to the number of cases under treat¬
ment is 83 per cent., the ratio of deaths is 3*8 per cent.

The point to which I wish to call attention is that, excite-

Digitized by LjOOQle

1900.]

BY C. K. HITCHCOCK, M.D.

ment and sleeplessness being prominent symptoms in greater
or less degree in all these cases, I have not used sedatives in the
treatment of any one of them, and my firm belief is that I have
thereby secured a larger proportion of recoveries, a calmer
after-existence for those cases which have not recovered, and
perhaps a diminished death rate.

Before coming to York I had the advantage of becoming
intimately acquainted with the practice as to the use of sedatives
in six different asylums, and formed the opinion that sedative^
were largely and harmfully used both for recent and chroniq
cases; that no known sedative will cure or cut short acute^
mania ; that given in large enough doses to subdue maniacal
excitement there is a possibility of permanently harming a
patient ; that continued sleeplessness is not of itself a condition
incompatible with complete recovery. Having watched the
effect of chloral and other compounds of that group, hyoscya-
mine and the hydrobromate of its alkaloid, opium and its
alkaloids, cannabis indica, and other drugs, I resolved to use
none of them. Of course the speedy subdual of excitement
and the inducement of natural sleep are most important points
of treatment, but it always seemed to me that in preference to
straightway drugging an excited sleepless patient one must try
to ascertain in each individual case the cause leading to that
state and endeavour to remove the cause and so indirectly attack
the symptoms. The history of the case, with careful physical
examination, with temperature taking, and urine testing, will
sometimes give a clue to treatment. A purgative may work
wonders, particularly calomel, valuable not only for its thera¬
peutic action but also as it is tasteless and inodorous, and
mixes readily with cream or butter. Milk and eggs with some
farinaceous food in abundance will suit another case, and here
the old maxim comes in that if you intend to feed, feed early
and often.

Other types of patients, particularly those of post-puerperal
mania with tendency to exhaustion, after the bowels have been
well acted on and food has been taken, will most readily and
harmlessly be influenced by suggestion. In these cases I never
use or allow the use by nurses or others of the words mesmer¬
ism or hypnotism, but certainly the personal influence of the
physician will in some cases induce the patient to take food or
to sleep with the happiest results.

xlvi. 6

Digitized by VjOOQle

82 ACUTE MANIA TREATED WITHOUT SEDATIVES. [Jan.,

Occasionally I have resorted to the wet pack or hot bath
with or without cold affusion to the head, and sometimes use a
bath of i io° to 115 0 for ten minutes, the patient being after¬
wards wrapped in blankets only. Hot whiskey and water or a
glass of stout are also amongst simple remedies that may be
very helpful.

I do not incline to keeping cases in single rooms, and if they
are physically in fit condition to be in the open air they are out
of doors most of the day, although I do not go the length of
employment of forced and prolonged exercise combined with
enormous quantities of food. If a case tends to pass into
partial dementia I should add massage, shampooing the head,
shower-baths, to the indirect treatment of suitable social influ¬
ence and surroundings.

I have now solely considered the treatment of cases where
the mania is established and the patient is under care in an
asylum, exclusive of the prophylaxis of insanity or the treatment
of cases of threatening mania. Although nothing new has been
advanced, my relation of details of treatment is not intended to
be didactic, but is merely a statement of my own experience
in the treatment of a class of cases from which it is perhaps the
easiest to get favourable results.

Discussion

At the Autumn Meeting of the Northern and Midland Division of the Medico-
Psychological Association, 1899.

The Chairman. —I hardly agree with Dr. Hitchcock when he says that his is a
common experience, because very few of us can say that we have treated a similar
number of cases of recent acute insanity without hypnotics. I doubt if the death-
rate in his records was really diminished by withholding hypnotics; indeed, more
cases might have lived if these had been given.

Dr. Clapham. —My feeling is that the first and most necessary treatment is a

f ood purge, not only for cases of mania, but for all cases that come into asylums.

'here is great neglect in this matter, judging from the effect of its administration.
Feeding, of course, must be attended to in mania, where there is so much tissue
waste. As regards hypnotics, I certainly do not agree with Dr. Hitchcock.
Hvpnotics get a man to sleep to begin with, and have the effect of putting him in
a fair way of quietude and proper condition for receiving other necessary treat¬
ment. By using baths and other sedatives you may afterwards do without
hypnotics, but I think it is certainly necessary in the first instance to administer
them in many cases.

Dr. Miller. —There can be no doubt that even in comparatively recent times
hypnotics have been abused to an alarming extent, but I have never personally
known cases treated in the manner Dr. Hitchcock describes. Acute mania is more
noisy during the day and dementia during the night. Good feeding and warm
baths are extremely valuable, and go far further to quiet acute mania than the
use of drugs.

Dr. Kay.— It is best to avoid the use of hypnotics as far as possible, but in
asylums, to a certain extent, the interests of other patients must be safeguarded.

Digitized by VjOOQle

1900.] HYSTERIA AND ITS RELATION TO INSANITY. 83

In acute mania men do without sedatives better than women; the latter are much
more noisy, and sedatives are a great advantage to them.

Dr. Perceval. —If we give an hypnotic for the convenience of others we study
the good of the largest number; but if we give it as curative, ^1 heartily agree
with Dr. Hitchcock that it is quite unnecessary. The high number of his recovered
cases clearly shows that. I think the results of Dr. Hitchcock’s method would
have been more valuable if he had treated one half of his cases with hypnotics,
and the other half, or some of them, without , as test cases.

Dr. Hearder. —A great deal depends on the nursing staff. With a good
nursing staff—two or three nurses to each maniacal patient if necessary—seda¬
tives are not so much required; but with a comparatively small nursing staff they
are practically indispensable, owing to violence of conduct. I think it is better to
do without sedatives for these acute cases, and in the large majority I think we
do manage them without sedatives to a very great extent. It is the chronic
cases that are mostly treated by sedatives in asylum practice; and this is quite
right, because they are hopeless from a curative point of view, and must be kept
quiet to promote the chances of recovery in the acute insane. I do not think that
in asylum practice sedatives are too greatly used in acute cases, for it is generally
recognised that they do better without them.

Dr. Hitchcock. —What made me take up this subject was the fearful abuse of
sedatives at almost every asylum with which I was connected before I went to
York. 1 have seen two 16-ounce bottles made up for the males and females, each
1-ounce dose containing 30 grains of chloral, given night after night to be used at
discretion for patients who were noisy. I have seen this most detrimental treat¬
ment pushed until many patients have been at death’s door, and therefore resolved
to adopt other methods even with chronic noisy patients. I cannot blame myself
for any patient having failed to recover because no hypnotics had been given, even
if sleepless for six or seven nights; but the longer I have gone on the more I have
been satisfied of being right in continuing as described. I did not touch on
the use of sedatives for chronic noisy patients, yet it has been my practice not to
give them sedatives. I found at York certain old cases that had been accustomed
to hypnotics. These continued noisy and excited until they died. I have not now
any of those noisy, troublesome, violent cases, and believe that they are produced
very often by the treatment pursued in the earlier stages of their insanity.

Hysteria and its Relation to Insanity . By Geoffrey
Hungerford, L.R.C.P. and L.R.C.S.I.

The term hysteria among the ancient Greeks had reference
to a disease primarily due to some abnormal state of the female
generative organs. Even yet we assign a foremost place to the
sexual elements in hysteria, but more as a symptom than as a
cause of the disease. We find that the greater the number of
cases we investigate the more we shall be impressed by the
fact that a marked element of sexual perversion generally
exists, at times so dominating the reasoning powers of the
patient that he becomes firmly convinced that unless his sexual
desire is indulged the community will suffer in some inexpli¬
cable manner. In a recent case I found this symptom strongly

Digitized by VjOOQle

8 4 HYSTERIA AND ITS RELATION TO INSANITY, [Jan.,

marked in connection with the habit of masturbation. As a
rule the “ delusional errors ” of these patients are vague. They
generally can be brought to admit that their ideas are erroneous ;
and their ability or otherwise to do this should, I think, bear
much weight with regard to prognosis.

The history of the case mentioned is of considerable interest.
The patient has lived a very indolent life, had always plenty of
money to spend, and his main idea has been to “ kill time.”
Lately he has manifested an intense anxiety regarding his own
condition and a morbid fear that any food will disagree with
him. He stands before a glass examining his tongue and
asking whether he does not look very ill. At times he states
that his case is hopeless and that he is a broken-down wretch,
but if not noticed he laughs a moment afterwards and seems
rather ashamed of his remarks. At other times hard exercise
and drastic advice prevail, and he appears in a normal condition
quite different from the indolent, helpless being of a few hours
before.

The literature of hysteria is very plentiful and teems with
different theories and definitions, some of which are directly
contradictory to one another, so that much more time than is
at my disposal would be occupied in merely glancing at the
different and disputed views taken. Rather than enter on that
discussion let us realise the necessity of recognising the early
stage of this condition as one which often masks more serious
underlying symptoms, which, if neglected or wrongly treated,
may result in patients entering our hospitals and asylums who
need never have gone there if proper precautions had been
taken.

As a fundamental principle it may be laid down that the
condition of an hysterical patient is always abnormal and
occupying the ill-defined and shadowy borderland lying
between sanity and insanity. It is a state in which ideas
control the body and produce many and unlooked-for changes
in its functions. Of two predisposing causes—heredity and
education—I would particularly speak. The latter, if properly
directed, will gradually eliminate the former and cause it to
sink more and more into the background. The early training
and mode of life of a great number of hysterics have a direct
bearing upon their disordered state. Most of them have been
impressionable, emotional children, generally the offspring of

Digitized by VjOOQle

1900.]

BY GEOFFREY HUNGERFORD.

parents with a neurasthenic taint. Their parents, perhaps in
their very eagerness for their children's welfare, overshoot the
mark, turning over and rendering suitable the soil for those
seeds of disease which they are striving to eradicate. In the
majority the disease was pre-existent but ignored. It only
wanted an opportunity of breaking out. That opportunity is
the exciting cause in the individual, but it would, in all pro¬
bability, no more occasion an attack of hysteria in a healthy
person than the mere presence of the specific bacteriae of any
of the fevers would necessarily cause an outbreak of febrile
disease, unless a suitable soil had pre-existed together with an
inability of the tissues to resist the attack.

The healthy mind takes its colour more or less from its
surroundings ; the cases under discussion do so in an abnormal
degree. They are open to scientific “ suggestion ” more readily
than their neighbours. It is obvious that the greatest hope of
successful and preventative treatment presents itself during
childhood. At this period of life the ratio of hysterics to the
sexes is about equal ; after the age of twelve the paths of the
two sexes widely diverge, and the educational factor comes
into full force. The boy goes to school, has to fight his way
in his own schoolboy world, and has a spirit of healthy emula¬
tion awakened ; the girl, on the other hand, is more restricted,
and her surroundings, unless carefully adapted to her dis¬
position, tend to foster inherent seeds of disease, presupposing
that an hereditary taint exists.

Though the consensus of opinion in the English school of
medicine is that hysteria is far more common among women
than among men, yet Charcot and other French observers hold
a diametrically opposite opinion. The explanation suggests
itself. This is a racial defect due to the early training and
education of the French boy, which entirely differs from that
of the English boy. The French system is not calculated to
improve moral fibre, but rather panders to an already hysterical
temperament. #

Among hysterics the imitative faculty seems to be abnor¬
mally developed. They are highly impressionable. They
closely, though often secretly, observe those about them, seeking
for a kindred spirit to foster their deluded ideas and sympathise
with their imaginary woes. If they succeed their symptoms
will become more pronounced, their delusions will become

Digitized by VjOOQle

HYSTERIA AND ITS RELATION TO INSANITY. [Jan.,

fixed, and they can no longer be included in the category of
sane individuals.

The generally accepted view is that hysteria is an affection of
the layers of the cerebral centres immediately below the highest,
and therefore more or less under control. Insanity, on the
other hand, is a disorder of the functionally highest layers of
the cerebral centres, the activities of which are accompanied by
intellectual processes; thus control is impossible. It was a
common error to regard hysterical disorders as a deliberate sham,
and thus limit its sphere to the extent of rendering the subject
unintelligible. Leaving this obsolete view behind, it would seem
that most success can be looked for by following a course of
treatment having as its basis a discouragement of the “ ego ” in
all its departments, together with a strenuous opposition to the
indolence which lies at the root of the nature of every hysterical
person, and which affords countless opportunities for the growth
and manifestation of those very peculiarities which it is desired
to overcome. A “ watchful neglect,” to use a paradoxical ex¬
pression, coupled with a quiet but assured firmness, would
seem to be at the root of all successful treatment; for, as a
hysteric will quickly notice a want of confidence and self-reliance
in those about him, so conversely will his condition improve
when he can see nothing which will pander to his weaknesses,
or give countenance to his distorted fancies.

Discussion

At the Autumn Meeting of the South-western Division of the Medico-Psychological

Association.

Dr. Wood said he had treated a few cases by suggestion. Some he found very
easy and some very difficult to deal with.

Dr. Benham related a striking instance of difference of opinion as to the
mental condition of a case he had lately seen. He had lately visited a house
where a lady was keeping certain patients. One of these at the time of his visit
was lying in bed in a wretched bodily condition. He was informed that for three
days she had taken no food, and that she then was about to be forcibly fed for
the first time. She appeared from her past history to be in a condition of acute
melancholia, and a case for treatment in an asylum.

The legal case broke down, the fedy having pleaded guilty to keeping lunatics
without certificates ; but he was informed that there was an eminent gentleman in
court prepared to swear that it was simply a case of hysteria, in contradiction to
Dr. Benham’s evidence. It was most important that they should understand what
was meant by hysteria in such a case, where medical men came to absolutely
opposed conclusions. With regard to the treatment of these patients, he was in
complete accord with Dr. Hungerford.

Dr. Davis instanced a remarkable case of hysteria in a boy at Plymouth, who,
some time ago, gave his parents a great deal of trouble. He voluntarily came

Digitized by VjOOQle

1900.] THE EVOLUTION OF ASYLUM ARCHITECTURE. 87

into the asylum, where he remained for some time. He was very extraordinary
in his conduct on many occasions, and seemed to have some attraction for other
patients. He was rather effeminate in appearance and manner, and they had a
difficulty in keeping him separated from the others. He was discharged and
returned home. There he shaved, dressed himself as a woman, and met several
soldiers and sailors in Plymouth. Eventually it appeared that he and a soldier
were found together and apprehended. "He was not dealt with by the Criminal
Court, having said that he was insane, but was returned to the asylum. Dr. Davis
did not believe that he was insane; it was very difficult to draw the line in such a
case.

Dr. Deas said that when they had to form an opinion as to border-line cases
they always found that it was very difficult to say whether it was one of hysteria or
insanity. Was it worth while, therefore, to keep up this distinction between these
disorders. He claimed that the essentials of unsoundness of mind existed just as
much in hysteria as in insanity. For the purposes of discussion, the essentials of
insanity were want of self-control and the too great proneness of the nervous
system to respond to stimuli. These two essentials covered the ground of insanity
and hysteria. If this were the case, was it worth while to retain the term of
hysteria as a distinct disease ? It seemed to him that the so-called cases of
hysteria were really cases of moral depravity and mental impairment. In his
opinion it would contribute very much to the elucidation of early cases of insanity
if they could sweep away all idea of their being merely cases of hysteria. He did not
know that he had seen a case of hysteria in which he would not come to it with a
more open mind and be more able to get to the heart of the trouble by simply
viewing it as one of impairment of mental power. All the principles used in the
treatment of hysteria were exactly the same as those used in cases of insanity, and
he could not help thinking that it would be a distinct advance if they heard less of
hysteria and more of the early symptoms ending in and tending towards insanity.

Dr. MacDonald said that, while agreeing with much in Dr. Hungerford’s
paper, he was inclined to support Dr. Deas when he suggested that the term
hysteria might with advantage be dispensed with. He was inclined to agree with
Dr. Deas that it might be hysteria, but that it might be a great deal more.

Dr. Hungerford, in replying on the discussion, said the manifestations of
hysteria were so diverse, that it would be rather hard to classify all as insanity.

The Evolution of Asylum Architecture, and the Prin¬
ciples which ought to control Modern Construction.
By R. H. Steen, M.D.Lond., Senior Assistant Medical
Officer, West Sussex County Asylum, Chichester.

“ The recovery of the curable, the improvement of the incurable, the comfort
and happiness of all the patients, should steadily be kept in view by the architect
from the moment in which he commences his plan.”—-Con oily, Construction and
Government of Lunatic Asylums , p. i.

In the present day the great increase in the number of
certified lunatics has raised the question of asylum architecture
to one of primary importance. New asylums are being built
and planned in all parts of the country, and the managing
authorities are keen to provide the best possible accommodation
for the suffering ones under their care.

Digitized by CjOOQle

88 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

In these circumstances it is surprising to find how little
literature there exists dealing with the matter, and an authori¬
tative treatise on the subject is much to be desired, although it
must be admitted that never before has the treatment of the
insane by properly constructed buildings exercised greater
attention. New plans, new systems are being introduced and
are still on their trial, and several years will be necessary to
determine the correctness of the ideas of their respective
advocates.

In the following pages the writer does not claim to do
more than touch the fringe of this extensive subject : firstly,
by describing types of the earlier asylums, and pointing
out errors inherent in their designs ; secondly, by describing
briefly the different systems at present advocated in this and
other countries ; and lastly, by suggesting what appears to be
the most suitable form of structure for the treatment of the
insane in this country.

Historical\

The construction of asylums as a definite branch of the art
of architecture is one of very recent growth, and may be said
to date only from the commencement of the present century.

A short historical survey of the subject can be most con¬
veniently classified under four headings:

1. Period of complete neglect of the insane.

2. Period of transition from one of neglect to one of custody
of the insane.

3. Period of curative treatment as distinguished from mere
custody, but still hampered by the principles governing the
latter.

4. Modern period. One of scientific treatment with com¬
parative freedom.

1. Period of neglect .—The presence of insanity in the com¬
munity can be recognised in the most ancient writings. No
attempt seems however to have been made as regards the
segregation of the insane till the ninth century X.D., when we
find that a Morostan (madhouse) existed in Cairo.

Jn England up till the latter end of the eighteenth century
little care was taken in providing accommodation for the
mentally afflicted. Those who were dangerous to the com¬
munity were shut up in prisons or delivered to the care of

Digitized by

Google

1900 .]

BY R. H. STEEN, M.D.

7. Special ventilating arrangements are provided.

Other types on the corridor system exist and need only be
mentioned. These are the quadrilateral Q , H-shaped, radiating
^ , and double quadrilateral | | | , and in all the same disad¬
vantages are present, viz. the different parts of the asylum are
too crowded together, giving rise to an insufficient circulation of
air, cheerless aspect of the wards not looking south, and one
ward overlooks the other.

The corridor type not having satisfied all requirements,
architects proceeded to build institutions modified in various
ways from this plan. The plan of the Hereford City and
County Asylum, opened in 1872, may be compared with that
of Derby County Asylum and is an example of the progress
made.

1. The aspect of the entrance is placed op the side opposite
to that of the wards, thus preventing proximity of the main
approaches to the grounds used by the patients.

2. There is a corridor (covered way) distinct from and not
interfering with the lighting of the single rooms.

3. Sanitary annexes with cross-ventilated passages are
provided.

4. Day rooms with large bay windows and of fair size are
present.

5. Dormitories have been provided, and there is not an
excess of single room accommodation.

6. A capacious dining and recreation hall is provided.

7. The medical superintendent's house is placed at one
extremity of the building instead of being in the centre.

The defects in this plan are, in the main, those noted in
connection with Derby Asylum. It may be remarked, how¬
ever, that the aspect of the building is bad, and that there is no
attempt made to provide wards of special design for the dif¬
ferent classes of patients. The chapel is placed above the
recreation hall. This is a common plan in the older asylums,
and is even yet recommended by recognised authorities (*).

The flights of stairs leading to this structure must, however,
constitute a danger to the feeble and epileptic patients, and the
lower building of necessity be mean in appearance and inter¬
sected by supports for the upper part.

The plan of the Barony Asylum, Glasgow (for 600), opened

Digitized by VjOOQle

92 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

in 1875, gives evidence of a distinct advance in construction,
and should almost be included in the next period.

The main features are as follows:

1. Differentiation in plan for special use, e.g. infirmaries and
acute blocks.

2. Day rooms more like private dwellings and on the
ground, with sleeping accommodation on the first floor.

3. Southern aspect of blocks, with northern aspect of entrance
block.

4. Absence of walled “ airing courts.”

With regard to (2) it is hardly advisable to have feeble
patients such as would necessarily be in the infirmaries ascend¬
ing flights of stairs on going to bed. The dormitories above
these day rooms are not cross-ventilated. It will be noticed
also that a chapel, distinct from recreation hall, has been pro¬
vided, though the corridors leading thereto must have been
expensive. There are general bath-rooms.

While the plan of construction of asylums had been gradually
developing, the internal arrangements had been progressing
pari passu . Conolly had recommended tiled floors to single
rooms and inspection plates in the doors of all single rooms.
Single rooms were now floored, like the rest of the ward, in
pitch pine, and no extraordinary fittings were used. The
decoration of the interior had also changed from the time of
the same authority when he wrote “ much ornament or deco¬
ration, external or internal, is useless and rather offends
irritable patients than gives any satisfaction to the more
contented.”( 8 )

4. Modem period .—The new ideas introduced by architects
into designs for hospitals now began to exert their influence in
asylum construction. In 1866 St. Thomas's Hospital, London,
on the pavilion type, was commenced, and finished in 1871.

Edinburgh Infirmary design was published in the Builder in
1870, and since that time many new asylums in this country
have been designed on this plan.

It may be here pointed out, however, that the pavilion plan
had been known in asylum architecture long before its intro¬
duction for hospital use—as, for example, the plan of Kingston
Asylum, Jamaica (1847),—but had seemingly been forgotten by
English asylum architects.

In the pavilion plan a large corridor of one story only

Digitized by VjOOQle

BY R. H. STEEN, M.D.

1900.]

connects together the otherwise separate blocks. The benefits
thus obtained are:

1. The blocks can be of varied architectural form to suit
various classes of patients.

2. The blocks need not be crowded together, and thus there
is no interference with the proper air and sun supply to each
part of the building. Should a serious fire occur it can be
confined to the area of the outbreak.

3. The blocks can be so arranged as not to overlook or
disturb one another by noise, etc.

4. Each block, as now designed, is self-contained. It has
its own dormitory, day space, dining-room, bath-room, lavatories,
store-rooms, and cupboards, and the asylum is thus split up
into many units for administrative purposes.

5. In large asylums the depressing effect of crowds of
patients herded in one huge building is minimised.

There can be little doubt that this type of asylum is the
most suitable for patients in this country and is the one which
is being adopted in almost all the newer asylums. One of the
chief drawbacks to the system is that on which stress is laid by
Sir H. C. Burdett, namely, “ the difficulty, if not impossibility,
of efficient supervision by the superior officers of the asylum.”( 4 )
This drawback, however, does not appear to be seriously felt
except in those asylums which are of enormous size and in
which whatever plan were adopted the same difficulty would
remain.

Pavilion asylums are of many varieties :

1. Linear, in which the connecting corridor is in one straight
line. This is the form frequently met with in hospital plans.

2. H-shape, e.g. Leavesden Asylum.

3. Echelon plan (e.g. Claybury Asylum) and its modifica¬
tions.

1 and 2. The linear and H shapes may be considered
together, as the latter is only a double linear with administra¬
tive offices in the centre. Both of these have the disadvantage
that the blocks are too closely crowded together and interfere
with the proper circulation of air and supply of sunlight, while
the greater part of one ward necessarily overlooks another, and
there is increased liability to spread of fire.

3. The echelon plan has many modifications corresponding
with the different varieties in shape of the main corridor.

Digitized by VjOOQle

94 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,
The following are given as examples :

(a) The quadrilateral, e.g\ West Sussex, Hertford. This
seems to be the most popular form in smaller asylums.

ip) V-type, e.g. 2nd, Gloucester Asylum. This form has
the disadvantage that the wards at the extremities of the V are
at a great distance from the administrative portion.

(i c ) The crescentic, with corridors as sectors connecting dif¬
ferent segments of the crescent, seems best adapted to the
needs of very large asylums, allowing greater concentration of
the huge building, e.g. Bexley Heath Asylum.

A description of a pavilion asylum is given below.

Asylum Hospitals.

At the same time as the architecture of asylums in England
has been progressing on the lines just mentioned, authorities in
Scotland have been providing buildings allowing a still further
classification of their patients, Dr. Clouston, at Edinburgh
Royal Asylum, having converted the old “ separate ” buildings
into hospitals; and Dr. Urquhart, at Perth Royal Asylum,
having built two attached hospitals. Dr. Howden, at Montrose
Royal Asylum, led the way in building a detached hospital.
This building has been in use about ten years. This example
has been followed by many of the older asylums in North
Britain, and the newer Scottish asylums are specially designed
with this principle in view. For descriptive purposes that of
Gartloch Asylum is most suitable, being one of those the design
of which appears to be the best.

The entrance portion is made up of waiting-rooms, surgery,
and quarters for the matron and medical officer. The in¬
coming patient is taken to an examination room with bath-room
adjacent, and after being seen he is sent to the observation
ward, or if old and feeble to the sick and infirm ward. The
observation ward is planned for twenty-five, day rooms on
ground floor, and dormitory on first floor. Staff required is one
to six patients in this ward, and the patients are under con¬
tinual observation both day and night. The remainder of the
block is one story in height. A kitchen and dining-hall placed
centrally divide the male from the female side. The sick room
is for twenty-eight patients. The feeble and infirm use the

Digitized by VjOOQle

1900.]

BY R. H. STEEN, M.D.

day room adjacent to the dining-hall and the dormitory next
to it. A small day room with single rooms is provided for
noisy patients. A noticeable feature is the exercising corridor,
which is wide and* practically forms a gallery. A small block
separated by a cross-ventilated passage is provided for the
treatment of infectious cases. The hospital provides accommoda¬
tion for 150 patients.

The points in this plan that invite criticism are :

1. The observation wards and those for noisy patients face
almost due north.

2. The dormitories adjacent to the exercising corridor appear
to be faulty in ventilation, as there is neither cross nor longi¬
tudinal air circulation.

3. W. C/s and lavatories, as in all Scottish asylums, are not
separated from the day rooms by cross-ventilation.

The hospital is intended for those patients requiring con¬
stant medical attention, e.g\ suicidal patients, generally feeble,
wet or dirty patients, and those suffering from intercurrent
diseases. The number of these, according to Sir John Sibbald,( 6 )
is one third to one half of the total number of patients. The
advantages claimed for this system are :

1. More complete provision for the medical treatment of
those requiring it.

2. In a section of the institution where medical treatment is
the predominant aim, all concerned will be more zealous in
their work.

That the remainder of the asylum can be constructed and
administered more economically and effectively with due regard
to the needs of the chronic cases.

That this subject has not been neglected in England is seen
by the construction of a hospital block in connection with the
asylum at Whittingham. The authorities of Wakefield Asylum
are also at present engaged in the construction of a hospital block.
This is being built at a cost of ^68,944. There is accommo¬
dation for 100 patients of each sex, with a cottage home at the
back for another 100. A complete administrative portion con¬
tains laboratories for scientific work. This system cannot, how¬
ever, be said to have found favour with English architects. The
plans of the many new asylums recently constructed or in
course of construction do not show a special hospital.

This subject must not be confused with the scheme to found

Digitized by VjOOQle

g 6 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

a hospital for acute cases of mental disease suggested by a
committee of the London County Council sitting in 1889.
The Scotch Board lays stress on the fact that chronic, as well
as acute cases, should be under one control. #

The following seem to be disadvantages in this system :

1. A building constructed mainly of one story must prove
expensive, having regard to the accommodation provided.

2. Administration must also be expensive. The staff required
is large, owing to the breaking up of the building into compara¬
tively small rooms and the need for two kitchens in the institution.

3. The size of the hospitals appears to be too large. An
ordinary county asylum in England of 550 patients would with
difficulty find 170 of that number suitable for the “ hospital ”
treatment, yet these will be seen to be the respective numbers
at Gartloch Asylum.

4. Though Sir John Sibbald expressly states that many
curable cases will be in the asylum blocks, yet there appears to
be some danger that the two sections of the institution will be
used to separate the curable from the incurable. For example,
one writer describes this system as follows :—“ The hospital for
the reception of all cases and treatment of the sick and infirm,
and the asylum for the care and detention of the insane, the
majority of whom are incurable.”

In this connection the words of Conolly may be recalled : “I
believe the absolute separation of the curable from the incurable
to be neither practicable nor desirable ; and I know that the
incurable patients are generally better companions for the
curable than other curable patients are.” ( Ibid r ., p. 19.)

Dr. Greene, in a paper read in 1890, says, “ It is a common
observation that association with the quiet chronic lunatic has
a most beneficial effect on the acute case, more especially if
this association can be combined with steady employment of
some kind.”

5. When the main attention of the staff is concentrated on
the hospital block there is a liability that the chronic patient
may be neglected.

It is feared that there is an idea much too common among
medical officers that as chronic cases are rarely recoverable they
should be put into a large building, housed and fed comfortably,
and that then one's duty is at an end. The doctor in an
asylum ought, however, to find that some of his best work will

Digitized by VjOOQle

1900.]

BY R. H. STEEN, M.D.

be done among these cases. This work may not bring him
prominently before the public with a remarkable recovery rate,
but he will find his reward in the general appearance and tone
of the great mass of those under his care. The depraved idiot
and the demented epileptic, as examples of two of the most
hopeless varieties of mental disorder, are capable of being taught
at least good personal habits, and may be raised from a position
of helplessness to one of comparative usefulness. Very many
of the chronic cases, owing to their deep-seated delusions, are
hopeless as regards being discharged “ recovered,” but they none
the less feel the deprivation of their liberty, and, liable as they
are to periodical exacerbations, require as close attention medi¬
cally and generally as the acute cases just admitted.

In an older asylum which has been constructed with its
wards all of one pattern it is evident at once how great a help
a special building for the treatment of the newly admitted and
sick cases must be. But in a modem pavilion asylum it is not
understood why the blocks already provided for the different
classes of patients should not serve their purpose more usefully
and economically than a detached hospital.

The newly admitted patient will always attract attention and
be carefully treated in whatever ward he is, owing to the fresh¬
ness of his case. The feeble and infirm do not like to be shut
off from the general cheerfulness of the younger and chronic
patients, and many can attend an entertainment in the hall
when they have only a short distance to go who could not do
so were they confined to a detached building. The wet and
dirty cases with proper attention should be few in number, and
even were they many it seems undesirable to congregate them
in one part of the asylum.

It may be here noted that a small hospital for the reception
and temporary treatment of patients mentally afflicted has
recently been opened in connection with Lewisham Union
Infirmary. This building is designed with two wards, each
accommodating eight patients ; two padded rooms ; the neces¬
sary offices ; a small acute ward ; and separate entrances for
the sexes. The idea is an admirable one, as many quickly re¬
coverable cases—for example, those due to alcoholic poisoning—
can be sufficiently well treated here, and saved from the expense
of certification and the stigma often attached to asylum con¬
finement.

XLVI. 7

Digitized by VjOOQle

98 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

Several differences between Scottish and English asylums
may be now mentioned. In Scotland :

1. The sanitary arrangements often open directly off the
wards without the intervention of a cross-ventilated lobby.

2. Dormitories and day rooms, in many instances, are con¬
structed without regard to the cross-ventilation insisted upon
by the English commissioners.

3. The absence of chapel accommodation. The recreation hall
is frequently made use of for the purposes of religious services.

4. The absence of enclosed “ airing courts ” is a noticeable
advance in the principle of non-restraint, but the number of
patients escaping appears to be larger than would be tolerated
in a more densely populated country. The annual reports of
the General Board of Lunacy state that the proportion of
escapes to the number of patients is over 2 per cent, per annum
in the asylums of Scotland.

The Villa or Village Type .

It has been seen that the tendency of late years has been to
split up the asylum into two separate buildings, and at present
there appears to be a movement on foot to do away with the
connecting corridors, and have all the blocks of the institution
disconnected. That this idea is no new one is evident from the
following list of asylums in Germany and America. The dates
of opening and number of beds are given in some instances.

Berlin State Asylums: Herzberge (1893, 1050 beds);
Dalldorf (1881, 1300 beds) ; Biesdorf (1893, 750 beds).

State Asylum of Saxony: Alt-Sherbitz (commenced 1876,
completed 1891, 961 beds).

America : Kankakee ; Toledo (1883, 1220 beds) ; Dakota ;
Willard; St Lawrence State Hospital (commenced 1888,
1200 beds); McLean Hospital, Boston (private for 200).

Alt-Sherbitz .

Attention has of late bqen directed to Alt-Sherbitz, due to
the praise given to this institution by Sir John Sibbald, ( 6 ) and
the action of the Edinburgh Board of Lunacy in modelling
their new asylum on this plan. Want of space forbids a
lengthy description of this place. A detailed account is given

Digitized by

Google

BY R. H. STEEN, M.D.

I 900 .]

in the admirable report of a visit paid by a deputation of the
Edinburgh Board in 1897.

The asylum is divided into a hospital and a colony portion.
The hospital consists of separate blocks containing from 20
to 50 patients each, the colony of cottages holding from 26 to
42 patients each. The asylum has several disadvantages
apart from those of the system, e.g. want of separate accom¬
modation for staff; small proportion of staff to patients (1 to 10)
considering the small size and scattered arrangement of the
buildings ; absence of internal decoration and primitive sanitary
arrangements. One writer describes his visit asa“ disappoint¬
ment,” and he found “ ten patients locked in seclusion in the
only ten single rooms of the asylum.”

The advantages claimed for this system of separate buildings
as compared with connected asylums are :

1. The cost of construction and management is less.

2. The separate buildings are more home-like and less insti¬
tutional in character.

3. More extensive classification can be adopted.

With regard to these points :

1. The cost of corridor construction is certainly a drawback
to the connected pavilion plan, but might be minimised by
devising a less expensive type. In Scotland the corridors in
many places are made of lighter material than the usual heavy
brickwork, but these are found to be very cold in winter and
excessively hot in summer. It must be, however, remembered
that corridors, besides acting as means of communication, sub¬
serve the useful purpose by means of subways of carrying the
various heating, lighting, water-supply, and other plant neces¬
sary to a large building. The cost of Alt-Sherbitz is given as
.£142 per patient inclusive of site ; this latter must be taken
into consideration, as many buildings already on the estate have
been converted to the use of the asylum. But having regard
to the absence of proper heating, ventilating, and sanitary
arrangements, with the lesser price of German labour, this
amount cannot be considered specially moderate. St. Lawrence
State Hospital cost £351 per patient exclusive of site. As
regards management Alt-Sherbitz rate is quoted at less than
.£25 per annum per patient, but it is felt strongly that in an
asylum built on this principle and administered on English
lines the maintenance rate could not possibly be less, and

Digitized by VjOOQle

IOO THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

would probably be greater, than in a connected pavilion asylum.
The experience of the Edinburgh Board will be looked forward
to with great interest in this connection.

2. To a visitor such an asylum must very well appear less
institutional in character from an external standpoint, but it is
open to doubt whether the patients will share the same idea.
There is no reason why the pavilion ward holding forty patients
should appear less home-like than the detached building with
fifty.

3. It is doubtful if this is an advantage. The principle of
placing the melancholiacs, the acute, and the noisy, epileptics,
and senile cases in separate buildings for each variety is one
which is open to criticism. What can be more harmful than
the so-called “ refractory ” block, in which each patient feels he
is labelled with a bad name, and therefore tries to live down to
his reputation? Melancholiacs exert a baneful influence on
each other, and recover much better under the stimulus of the
more spirited patient.

The disadvantages of the system are mainly those of adminis¬
tration, and the difficulties connected with this may be shortly
summarised as follows :—1. Supervision. 2. Distribution. 3.
Association.

1. The control of the staff and the care for the general
welfare of the patients during the daytime must, as a rule, give
rise to a considerable expenditure of time and labour, and in
severe weather efficient supervision by the superior officers must
be almost impossible. In Alt-Sherbitz the attendants sleep in
the dormitories with the patients, but in this country this
principle is rightly thought objectionable, and due attention to
the needs of the patients at night could not be managed
otherwise without a very large staff, and even then the matter
is beset with difficulties.

2. Under this heading are included the distribution of food,
of the various classes of stores, medicines, etc., and the circula¬
tion of material to and from the laundry, needle-rooms, and
workshops. At Alt-Sherbitz the dinners are taken round in
specially constructed and heated vans. At St. Lawrence it is
found necessary to have five separate kitchens.

3. Weekly entertainments have now become essential in the
treatment of patients. How the patients are collected for these
entertainments in winter-time in a segregated asylum is difficult

Digitized by VjOOQle

1900.]

BY R. H. STEEN, M.D.

IOI

to understand. The same difficulties will attend the association
of the patients for religious services.

Many other points will occur to those accustomed to the
ways of a large asylum, but enough has been said to show that
it is questionable if the few doubtful advantages obtained from
the separation of the components of an asylum compensate for
the many disadvantages connected therewith.

It may be noted that none of the disadvantages mentioned
apply to an asylum of comparatively small numbers for
private patients, where the staff possibly exceeds in number
that of the patients. For such no better type of asylum could
be suggested. In this paper, however, attention has been con¬
fined to the needs of the pauper classes only.

In conclusion the points that attention should be directed
to in the construction of a new asylum may now be dealt with.

1. The site .—The site chosen should possess a subsoil of
porous nature, such as sand or gravel. It should be slightly
elevated, but not exposed in position, with slight slope towards
the south. It should be in a central position in the district,
easy of access, and near some large town. It is a mistake to
build on a high hill, and banished by distance from the haunts
of men, as seems to be so frequently done. The patients like
to see their friends, and the staff should be in a position to
enjoy outside associations when off duty. The asylum should
have its own water-supply and a sufficiency (at least forty
gallons per patient per day) should be assured before building
operations are commenced. If a well be the source of supply
the sides must be rendered proof against surface contamination.
The water from the well should be pumped into tanks placed
either in a water-tower or on a neighbouring eminence ; if
the water is taken from the chalk some softening apparatus
will be required. The well should have underground reservoirs
in which the water can collect in the intervals of pumping. A
complete system should provide for an adequate supply of the
whole asylum and detached buildings for the following pur¬
poses :—(1) Drinking. (2) Washing. (3) Hot water. (4)
Culinary purposes. (5) Cleansing. (6) Flushing. (7) Fire.
(8) Watering.

The fire arrangements should include—

External hydrants off the main to command each block, hall,

Digitized by VjOOQle

102 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan.,

kitchen, stores, shops, and detached buildings from at least two
sides.

Internal hydrants of a 2$-inch pipe to command all the
wards, administration blocks, and places occupied by patients.

Every asylum nowadays has its farm, and the size of the
estate should be liberal, to allow extensive farming. An estate
of 200 acres is ample for an asylum of 800 patients.

2. The plan .—The plan of the asylum will necessarily
require some modification to suit the peculiarities of the site.
It is assumed, however, that the site is a level and extensive
plateau, and that the size of the asylum is to be one for 800
patients.

Following the plan of the West Sussex Asylum, an entrance
block placed on the north side will have rooms on the ground-
floor for porter and telephonic exchange, medical superintendents
office, with clerk’s office adjoining or near at hand, committee
room and luncheon room, assistant medical officer’s office, and
lavatory accommodation. An admission room with weighing
machine and height measure, and a studio lighted from the north
should be provided. At the entrance a small waiting and
visiting room is sufficient, The main corridors are now in many
places (e.g. Bexley) being constructed with bays for use on the
regular visiting days. The recreation hall is often used for the
same purpose. The first floor should provide accommodation for
the assistant medical officers and the matron, two staircases and
a partition wall being constructed. A second floor would be
of advantage to provide accommodation for housemaids and night
nurses. Many of the newer asylums have their entrance block
on the north, and a small block on the south corridor for the
medical officers. The advantage of this is that the doctors are
near the wards, but in practice it will be found that the medical
officer will be so frequently required in his office, either to
attend to his case-books or interview the friends of the patients,
that it will prove a severe hardship if his rooms are, as in one
case, one sixth of a mile distant from the front entrance. The
entrance block is in many cases placed on the south in a central
position, and has the disadvantage that the main approaches are
in proximity to the wards. This defect can be largely minimised
by the generous planting of trees and shrubberies, but in the
early days of a new asylum it must give rise to serious incon¬
venience. There are, however, many advantages in this situation

Digitized by VjOOQle

1900.] BY R. H. STEEN, M.D. 103

1. The main approaches are of more striking appearance.

2. The medical officers’ quarters are near the principal
departments of their work, i. e. offices, surgery, and infirmary
wards.

3. The planning of the stores, workshops, engineering build¬
ings (which must be situated to the north), with their approaches,
will be simplified.

As an example of the southern entrance block that of
Cheddleton Asylum may be mentioned.

In an asylum of the type under consideration (pavilions
connected by corridors) it will be found that the main corridor
can be described as consisting of four portions corresponding
with the points of the compass. The central axis of the build¬
ing separating the male and female sides will be given up to
the stores, kitchen, recreation hall, and chapel (if attached).

The stores should be placed to the north of the north main
corridor to facilitate the delivery of goods. It will be found
useful to have a subway from the outside communicating with
a basement in the stores. Communication with the kitchen
court should be rendered easy. A covered unloading shed will
be valuable in damp weather. Two serving hatches opening
on the corridor will be necessary.

The kitchen, with its court and offices, and the recreation
hall, will be placed between the north and south corridors, and
bounded on each side by a connecting corridor. On these
connecting corridors will be placed on each side recreation,
mess, and bed rooms for the staff. The matron and head
attendants will also have their offices most suitably situated on
these corridors. Leading to the kitchen serving counters will
be two short corridors, one for each side. A serving counter,
for use on entertainment nights, ought to be provided between
the kitchen and the hall.

In many cases a central dining-hall is provided. The
advisability of this is a subject much discussed. The advan¬
tages claimed for a general dining-room are—

1. It helps to relieve the monotony of the daily life and
clears the wards for a time so that they can be ventilated.

2. The food is more easily distributed from the kitchen.

As regards this question, the patients who go to the dining
hall are those who can go out, either to work or to the gardens,
and there will thus be sufficient time to thoroughly ventilate

Digitized by VjOOQle

104 the evolution of asylum architecture, [Jan.,

the wards. The patients who most require change are those
who are unable to go to the general dining hall. The great
aim and object of modem asylum construction is to render the
life of the patients as little institutional as possible, and it is
most disastrous to the home feeling to have gangs of patients
from the different wards merging into one huge herd in the
dining hall. The patients do not like this system, and the
shock to the newly admitted one is such as to deprive him of
appetite till accustomed to the crowd. The full staff ought to
be present at meals, but this is impossible with the dining-hall
system, as many of the attendants have to remain in the wards
with those patients unable to attend. The question of facility
of distribution of food is not a great matter when the true
interests of the patients are at stake. It may be doubted,
however, whether it is easier to transport the patients to their
food than to transport the food to the patients. It is a very
simple matter to distribute the food in properly constructed
tins to the various blocks. The recreation hall, if made use of
as a dining hall, is lessened in efficiency for the purposes of
entertainment. To remedy this in the newer Scottish asylums
the recreation hall is built above the dining hall. This is
costly, and an upstairs hall will suffer from the disadvantages
above described in connection with an upstairs chapel, and in
the case of a panic from an alarm of fire it is to be feared that
the exits usually provided would not be sufficient.

The patients’ blocks will be next considered. These are
usually of four varieties: infirmary ; epileptic block ; that for
noisy patients; chronic class. To these should be added a
fifth, the hospital.

The infirmary ward is used for the aged and infirm. It
usually consists of two parallel wings connected by a gallery at
right angles to these. One wing is composed of a small
dormitory and adjoining day room, the other wing is a large
dormitory. Single rooms are placed on the north side of the
gallery. The large dormitory should be easily controlled from
the gallery, a glazed partition being used in place of the more
customary brick wall. A combined day room and dormitory
is frequently provided, but is hardly necessary except in very
large asylums. A verandah in connection with the infirmary
is a useful feature in many of the newer asylums.

The hospital .—The best position for this block is in the

Digitized by VjOOQle

1900.] BY R. H. STEEN, M.D. I OS

centre of the south corridor between the male and female sides.
A plan designed by the author for the purposes of this paper
is given. The block will be seen to be almost symmetrical on

H9SPITAI BLOCK

smu * ,* ■ r **n ii r,,t

each side. On the ground floor is a hospital ward for nine
patients with a sanitary annexe. A short gallery connects the
main corridor with the ward. Off this gallery are a small
convalescent day room, single rooms, padded room, stores,
scullery, and attendant’s room, and a bath-room is provided
at the entrance to the ward. In the space enclosed by the
ward and with doors on the main corridor are operating theatre,
room for ophthalmoscopic or other examination, surgery, and
drug store. On the first floor on both sides are isolation rooms,
sick attendants’ room, and a small dormitory. On the female

Digitized by VjOOQle

106 THE EVOLUTION OF ASYLUM ARCHITECTURE, [Jan,,

side there are added rooms for the assistant matron and a
lying-in room. The advantages of having a block such as this
may be stated as follows :

1. Its central position will enable the nursing arrangements
to be undertaken by female nurses. Should it, however, be
found necessary to employ male nurses on the male side, it
will be seen that the two sides can be made absolutely separate,

2. Night supervision of the ground-floor can be effected by
one nurse.

3. The surgery and operating room, besides being in close
proximity to the ward that most requires them, are centrally
placed as regards the rest of the asylum.

4. A case of infectious disease can be isolated speedily and
effectively without undue expense. The elaborate detached
isolation buildings could then be constructed on a much smaller
scale, and would rarely be required.

5. The block will form a valuable training school for the
junior nurses, and the assistant matron can effectively supervise
the work done.

Each newly admitted patient will be sent to this block,
placed in bed, and kept under observation as long as may be
thought necessary. A case of illness occurring in the wards
can be also sent to the hospital, and more carefully treated
than if remaining in the ordinary ward. A patient deemed
suitable for any special line of treatment will be under super¬
vision day and night. The sick members of the staff can be
treated in quietness, and separated from the noise and bustle
associated with their ordinary room. This hospital it is
suggested will supply all the requirements of the hospitals
connected with the Scottish asylums, and will not suffer from
the many disadvantages of detached buildings. The size of
the block will depend partly on the size of the asylum, and
partly on the liability to illness of the inmates ; one factor in
the latter being the climatic conditions of the district in which
the asylum is situated.

The epileptic block is best constructed with one large day
room with dormitory adjoining, and of such form that all parts
of the day room can be seen from any one portion. The com¬
munications between the day room and dormitory should be
by means of large glazed doors, so that the patients in bed
during the daytime can be under the observation of the nurses

Digitized by VjOOQle

1900.]

BY R. H. STEEN, M.D.

107

in the day room. With this, form of ward one sanitary annexe
can be made to serve its purposes both by day and night.
The plan of having the day room on one side and the dormitory
on the other side of the main corridor, as is so frequent, is open
to many objections.

Blocks for noisy cases are usually of the gallery type, with a
larger single room and smaller dormitory accommodation, as
compared with the rest of the asylum.

The chronic and workers' blocks usually consist of large
day rooms on the ground-floor with large dormitories on the
first floor ; a small proportion of single rooms being necessary
only for the few who are likely to be restless at night.

In the planning of any one of the blocks the following
details should be borne in mind :

1. Southern aspect of the block.

2. Thorough cross-ventilation of every dormitory.

3. Ventilating and heating arrangements for the single rooms,
and padded rooms.

4. Each dormitory to have one attendant’s room over¬
looking it.

5. Sculleries of ample size with larder provided for the staff.

6. Sufficient lavatory and bath-room accommodation, all
w.c.’s, slop-sinks, and dirty linen closets being separated from
the ward by cross-ventilated corridors.

7. Ward stores placed near the day room.

8. Clothes room placed adjacent to the dormitory. In the
epileptic blocks this can be connected with the sanitary annexe.

9. Boot rooms of good size placed near the entrance to
the patients’ garden.

10. Sufficiency of closets for brooms, pails, and coals.

11. Fireproof staircases, and at least two in each block.

12. Fire hydrants commanding the ward from within, and
on the outside from two standpoints.

The chapel, according to the wishes of the Commissioners in
Lunacy, is now frequently a separate structure. The advantages
usually claimed for a detached chapel are—

1. It is more pleasing to the patients, being in accordance
with their previous habits of “ going to church.”

2. It is desirable to separate worship, as far as possible, from
asylum associations.

1. As regards the first mentioned, it is undoubtedly pleasant

Digitized by

Google

108 THE EVOLUTION OF ASYLUM ARCHITECTURE. [Jan.,

in fine summer weather for the patients to have a short walk
before entering church, but in severe weather it is unpleasant,
and even dangerous, for them to remain in damp clothes
throughout a service, however short In dark winter evenings
it is a serious responsibility to keep under observation large
numbers of patients, many of whom are suicidal and others
epileptic. The feeble, deformed, and aged, who much enjoy the
services, will be unable to attend if the distance to be traversed
is great.

2. The presence of the asylum staff alone will militate against
forgetfulness of the asylum associations.

The chapel is often used for choir practice, sacred concerts,
organ recitals, morning prayers, and other purposes. If
detached it will be found that the recreation hall will have to
take its place on week days, and the chapel will therefore be
only for Sunday use.

The chapel usually contains two small retiring rooms for
epileptics. These are rarely used, and a spacious porch would
prove convenient for this purpose and be an ornamental addition
to the structure.

The house of the medical superintendent is in most cases
connected with the asylum. This is according to the rules of
the English Commissioners. The Scottish Board insist on this
house being detached. It seems to be only right that the
medical superintendent should be able at times to be completely
separated from his duties, and as he is frequently a married
man it is undesirable that young children should be exposed to
the sights and sounds inseparable from an asylum.

Engineering works.—Heating and ventilating .—Many dif¬
ferent systems have been introduced of late years, but it is
doubtful if any one of them surpasses in efficiency the old-
fashioned system of open fires.

Lighting .—Electric light has now established itself as the
most suitable means for this purpose.

Sewage disposal .—The best method of dealing with the
sewage of an asylum is a matter still under discussion.

The above subjects are of an extensive nature and much
beyond the scope of the present paper. Want of space also
forbids a description of laundry, workshops, mortuary, isolation
hospital, farm, and the detached buildings for the staff which
are essential to every asylum.

Digitized by

Google

1900.] CLINICAL NOTES AND CASES. 109

The following are the conclusions which have been arrived
at by the writer :

1. Plans upon the villa system and those consisting of
detached blocks placed at a distance from the main building
present disadvantages which outweigh the advantages claimed
for them ; and such systems are not likely to become popular
in this country and under the existing conditions as to manage¬
ment.

2. The division of an asylum into two portions—the acute
and the chronic—almost equal in size, is open to objection.

3. The most suitable plan for an asylum in this country is
one made up of distinct pavilions, each complete in its details,
connected together and with the administrative offices by
means of corridors.

( J ) Report of Metropolitan Commissioners in Lunacy , 1844.—(*) Hospitals
and Asylums of the World, Sir H. C. Burdett, p. 18.—( a ) The Construction and
Government of Lunatic Asylums, Conolly, p. 13.—( 4 ) Burdett, p. 99.—( 5 ) On the
Plans of Modem Asylums for the Insane Poor, Sir John Sibbald, p. 15 —( 6 ) Ibid.,

p. 20.

Clinical Notes and Cases.

Cases of Communicated Insanity . By E. W. Griffin, M.D.,
Assistant Medical Officer, District Asylum, Killarney.

The following cases are of interest as being of somewhat
rare occurrence. A careful, if incomplete investigation reveals
the fact that a sister’s son, after " sunstroke,” was treated to
recovery in an American asylum, and remains well. But, as
in so many similar instances here, nearly all the brothers and
sisters emigrated to America, and have been lost sight of.
However, Mrs. M— assured me that no case of insanity had
occurred among her progenitors as far back as her grandparents,
to her knowledge. Nor was there evidence of paralysis,
epilepsy, hysteria, alcoholism, or phthisis. The mother is
alive and well at the age of seventy. The father died a few

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

IIO

[Jan.,

years ago at a similar age. I have seen the children of Mrs.
M—, who are certainly not neurotic.

Case i. —Mrs. M—, married woman, aet. 50, farmer’s wife, educated,
was admitted into Killamey Asylum on 21st February, 1899. There
was no direct hereditary predisposition, and the cause of the attack was
attributed to anxiety about her sister’s illness.

On admission .—She was much excited, talked continuously and
incoherently. The friends informed the writer that they had expe¬
rienced great difficulty in bringing her to the asylum. Pulse 85, full
and bounding. Tongue furred, breath offensive.

Since admission .—Night nurse reported that patient walked about
single room during the night, shouting, singing, and talking. Refused
food. Is much exalted in manner and conversation, and cannot
localise herself in time and space. Says she came here from America to
attend her sister’s wedding, and that several of the guests came into
her room during the night. Is labouring under hallucinations of sight
and hearing. Her delusions are evidently of a pleasing kind, as she
danced, laughed, and sang continually whilst her case was being taken.

February 23rd.—Patient was fed with nasal tube last evening, and
given calomel gr. iv. Bowels were moved three times during the
night, and restlessness and excitement is not so marked this morning.

25th.—Still refuses food, and has to be fed twice daily. Gets grs. xx
sulphonal in evening meal. Reported as having slept four hours
during the night. Tongue cleaning. Pulse 80.

March 4th.—Patient has been taking her food for the past few days,
and is sleeping fairly well at night. She knows where she is, and says
she is sorry for the trouble she has given everybody. Has spent
several hours in airing-ground daily since the 1st of March.

nth.—Is quite free from delusions and hallucinations of the special
senses now, and she expresses herself as feeling quite well in mind.
Remembers the events that took place at her home prior to admission,
and says that she experienced a fulness and throbbing in her head for
some days before she became insane, and a feeling that something
dreadful was going to happen. Is sewing quietly in the ward, and takes
the greatest interest in her sister, who is suffering from an attack of
acute mania similar to her own.

18th.—Is quite coherent in her conversation, and rational in her
manner. She is a sober, steady woman, and is very anxious to do any¬
thing that will expedite her recovery. Has been taking syrup of the
hypophosphites (Fellows’) during the past week.

The patient was discharged recovered on the 20th April, 1899.

Case 2.—Mrs. T—, married woman, aet. 43, the mother of thirteen
children, educated, was admitted into the Killarney Asylum 25th
February, 1899. Had a mild attack about eighteen months ago, post-
puerperal The cause of the attack was the same as in the case of her
sister, viz. over-anxiety about her sister’s illness and want of sleep.

On admission .—The patient was noisy, violent, and impulsive in

Digitized by VjOOQle

1900.] CLINICAL NOTES AND CASES. Ill

disposition. Talked loudly and incoherently, and could not tell where
she came from. Pupils dilated, equal. Tongue furred, and lips
cracked. Pulse 90. Bruises on upper and lower extremities. In a
state of acute maniacal excitement, noisy, shouting, laughing, gesticu¬
lating. Pays no heed to any questions put to her; laughs and puts
out her tongue when addressed. Appears to have no memory, no self-
control ; is somewhat erotic. Fleeting delusions; talks about getting
a sight of hell, heaven, etc. Laughing and singing loudly when not
talking. Hallucinations of sight and hearing.

February 27th,—Had no food since admission, and did not sleep
during the night. Was fed this morning with nasal tube, and given
grs. iv of calomeL

28th.—Bowels were moved four times during the night, and the
patient was reported as having slept from 2 a.m. to 6 a.m. Took
20 grs. of sulphonal at bedtime. Is still very noisy and restless in
disposition. Took a fair amount of liquid nourishment to-day.

March 4th.—Is eating and sleeping fairly well since last noted, and
is now capable of answering simple questions. Knows where she is,
and was able to recognise her sister this morning.

nth.—Patient has improved in mind during the week, and is now
able to converse rationally and coherently; is still exalted in manner
and conversation. Slept without the aid of sulphonal for the past two
nights.

18th.—Is now quite calm and rational in her manner, and walks
about airing-ground with her sister, to whom she appears to be much
attached. Is free from delusions and hallucinations of sight and hearing.

25th.—Patient became excited in dormitory on the 19th inst., and
had to be removed to a single room. Since then she has been going
on well, and had no return of the excitement. Sews industriously in
the ward, and spends several hours every day in airing-ground. From
this time forward the patient’s progress was uninterrupted, and she was
discharged recovered on the 29th May, 1899.

History of cases .—The two sisters went to see a married sister,
Mrs. C—, on the 9th February, who was suffering from mental
aberration, attributed to worry of mind and loss of sleep induced by an
unsuccessful lawsuit prosecuted by her husband against a neighbour.
It appears they nursed their sister a whole week by day and night, and
had scarcely any sleep or rest during that time. They used to lie on
the affected sister’s bed at night trying to keep her quiet, as she was
very restless, and talked the greater part of each night. Mrs. M—
appeared to be all right when leaving on the 17th February, but
developed symptoms of insanity next day. Mrs. T— became men¬
tally affected on the 17 th, and had to be taken home by her husband.
They both attributed their attacks to want of sleep and rest. From
the description of Mrs. C—’s insanity given to the writer by her friends
and the two sisters in the asylum, it was somewhat similar to the cases
above described, but of a much milder form; There was great rest¬
lessness, pleasing delusions, and hallucinations of sight and hearing.
She recovered at her own house after a few weeks’ illness. These two

Digitized by VjOOQle

I 12

CLINICAL NOTES AND CASES.

[Jan.

cases may be described as examples of folie simullanee (M. Regis),
and are undoubtedly striking examples of persons becoming insane
from companionship, not in consequence of any direct transference of
morbid ideas, but from the shock arising out of the painful impressions
caused by witnessing the attack and the strain of nursing the patient.
The important facts about these cases are—(i) The exciting cause was
the same in both cases, viz. the illness of their sister, Mrs. C—, who may
be described as the active agent in the matter. (2) The form of in¬
sanity and mental condition were exactly similar. (3) Quiet and unin¬
terrupted recovery in both cases. (4) No direct hereditary predisposi¬
tion or any marked neurotic tendency. (5) Both sisters were intelligent
and well educated for persons of their class (farmers’ wives). The
sister who recovered and remains recovered at home suffered from
periodical headaches and gastric derangements. She had no children.
(6) All three sisters were devotedly attached to one another.

Major Operations on the Insane.—Notes of a Case of
Cataract . By Major J. H. Tull Walsh, I.M.S., Civil

Surgeon of Berhampur; and Superintendent, Berhampur
Lunatic Asylum.

I SEND the following notes in connection with Dr. J. H.
Sproat’s article on the same subject in the Journal of Mental
Science .

Nimai M—, aet 40 on admission to the asylum, 19th January,
1893. He committed rape on a woman in March, 1892, and appeared
sane at his trial before the magistrate, who sentenced him to three
years’ rigorous imprisonment. He was sent to the Bhagulpur Central
Jail, and was then in good health.

In his description roll it was stated that he had previously been insane,
and the cause assigned was failure in business and loss of money.
There is no reliable evidence that he was really insane, and no dates
are given.

Shortly after admission to the Bhagulpur Jail, Nimai showed signs of
insanity. He became quarrelsome, intractable, refused to work. He
laboured under the delusion that he was illegally detained in jail, being
sentenced to “one day’s imprisonment only.” He was certified as
insane, and sent to the Berhampur Asylum.

On admission he was noisy, voluble, and incoherent; refused to do
any work. He remained noisy and excited till July, 1893, when he
became quieter as the result of treatment with chloral and bromide of
potassium. He became worse again in 1894, and remained noisy and
excited. He would sit in one place and scream all day. There was
slight improvement in the beginning of 1898, but it did not last, and
when I first saw him, in July, 1898, he was incoherent except in regard to

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

1900.]

113

very simple matters, noisy, liable to outbreaks of excitement, and dirty in
habits. He had double cataract, and was almost totally blind ; he had
also a small right inguinal hernia. In October he improved somewhat,
and, though very noisy at times, was fairly rational. He varied some¬
what, but as I could generally make him understand me I decided to
operate on him for his cataract.

On February 17th, 1899, I removed the lens from the left eye, and
by keeping careful watch over him prevented any interference with the
dressings. He recovered with good sight, and the effect on his mental
condition was most marked; he became quiet, rational, and clean in
habits. He told us that he was a Christian, and as he had no friends
I wrote to the mission to see if employment could be found for him.
'Hie missionaries were not able to do anything for him.

In May I operated on the right eye, but he removed the dressings
the night after the operation, and the eye did badly, and could only
tell light from darkness. He remained sane, however, and appeared
very grateful for the restoration of sight. His sentence had expired in
1895, so that there was no difficulty about his release. He was brought
before the visitors in May, 1899, and by their order released. I have
not heard anything of him since.

Spurious Pregnancy . By G. Findlay, M.A., M.B., Brailes,

Warwickshire.

About three years ago I was called to see Mrs. B—, aet. 54, a
fairly stout, well-developed woman, mother of nine children, and the
wife of an agricultural labourer. Some time before, I had attended her
for climacteric disturbances, but her menstrual periods had previously
been regular.

She informed me that she believed herself to be pregnant, as she
had not menstruated for over three months. I told her that at her age
she was not likely to be in that condition, and that the cessation of her
periods was due to her time of life; but she persistently said that she
was convinced that she was with child, and refused to permit me to
make a proper examination, saying that as she had had nine children,
and the youngest fifteen years old, she knew perfectly what was the
matter. About two months afterwards she called to tell me that her
impressions were realised, as she had distinctly felt the child move,
and could feel it then; that she had first felt the movements about a
fortnight before, when she was at a concert in the village, and that she
was getting much stouter round the waist. I again told her that I
should like to examine her when she was in bed, but she refused, and
asked me to attend her when she was confined.

I did not hear anything more about her until about four months
after our last interview. Her husband then came to me at two o'clock
one morning, wishing me to attend at once, as his wife was in labour,

XLVI. 8

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

”4

[Jan.,

and as he had got a woman to look after her while he came for me.
On arriving at the cottage I found her in bed, rather excited, and
exclaiming that she was glad I had come as the pains were very
strong, but seemed to make no progress, although she had been bad
for two or three hours. I then made a vaginal examination, and found
that there was not even an enlargement of the uterus, although the
abdomen was distended. There was no evidence of any tumour. The
abdomen was soft on palpation, except where she said she had a pain
as I was examining her, where there was a distinct contraction of the
abdominal muscles. I repeated that she had made a mistake, that
there was no child and no labour ; but she would not believe me, so I
called her husband and told him in her presence that as there was
no child to be born I was going home. Next day Mrs. B— was up
and dressed, and could hardly even then believe that she had not been
pregnant, although the pains and the distension had disappeared.

I saw her recently, and she told me that she had never menstruated
again, that her impression of being pregnant was very real at the
time, although she now knows that she was mistaken. Since then she
has enjoyed good health, except for a slight attack of bronchitis last
spring, and has shown no symptom of mental aberration. There was
no hereditary predisposition to insanity.

Note on Mental Condition of a Girl who became a Mother at Fourteen
Years of Age .—She lived with a married “ aunt,” who was childless.
When visited before parturition she appeared unconcerned about her
condition, rather vacant. During labour she was wonderfully quiet,
taking everything as a matter of course.

After confinement she lay contentedly in bed at first, and did not take
much interest in anything, but wished much to get up in three or four
days. She took no notice whatever of the child, who was brought up
on the bottle by the aunt, who took entire charge of the infant. The
girl showed no maternal instincts at all, but was dull and indifferent.

There is no reason to doubt that conception occurred after criminal
assault, a few months after irregular menstruation had begun. Her
condition was not discovered until three months after the event.

An Attack of Epilepsy (Status Epilepticus) followed
within six weeks by an Attack of Chorea , occurring
in a Patient suffering from Acute Ptierperal Insanity .
By C. C. Easterbrook, M.A., M.B., Assistant Physician,
Royal Asylum, Edinburgh.

The following case is worthy of record on account of its
rarity, and of the interesting association of neuroses which were
manifested by the same patient within a comparatively short
period:

Digitized by

Google

1900.]

CLINICAL NOTES AND CASES.

11 5

R. B. B—, an unmarried shop-girl, aet. 22, was admitted into the
Edinburgh Royal Asylum on August 19th, 1895, suffering from acute
mania of the puerperium.

1. Family history .—Her parents were intelligent, respectable people
of the working class. The father had always enjoyed good health, but
a brother of his was melancholic, and committed suicide; another
brother died at twenty of “ heart disease,” and several of the father’s
cousins were “ consumptive.” The mother was a martyr to rheumatism,
and had suffered from a definite attack of rheumatic fever at twenty-one.
A sister of hers had always been “weak-minded” (imbecile), and her
father died of “paralysis.” Hence, from the patient’s point of view,
there were hereditary tendencies to—

(1) Insanity (paternal uncle and maternal aunt).

(2) Paralysis (maternal grandfather).

(3) Rheumatism (mother, and possibly the paternal uncle, who died
of “ heart disease ”).

The tendency to phthisis (paternal jhalf-cousins) was less obvious.
There was no history of epilepsy or of chorea in the family.

2. Fersotial history .—Patient had always been an excitable, highly
strung neurotic subject. She took no convulsions in infancy, but in her
seventh or eighth year she for a time was subject to “ dizzy turns*” the
precise nature of which it is now impossible to ascertain. She knew when
they were coming, and would cry out, but she is said never to have lost
consciousness or to have fallen during them. At fourteen she had a
mild attack of chorea, brought on by a “fright in the darkit lasted
between three and four months, and involved the face and limbs, and to
some extent the function of speech. There had been no history of
growing pains, and she never had (or has) been rheumatic.

Her psychical history since the onset of puberty at fifteen and during
adolescence has been extremely bad. There have been four distinct
attacks of insanity, for each of which she required to be sent to Morning-
side Asylum. There was mental disturbance at the first menstruation,
characterised by taciturnity and dulness; and this was the commence¬
ment of the first of her four previous attacks, which were as follows :

First, at fifteen. Stuporose melancholia of pubescence. —Lasted three
and a half months—from January to April, 1889. This attack is
described in the asylum records as “ a good case of melancholic
stupor.”

Second, at fifteen. Acute mania of pubescence .—Lasted four months
—from July to October, 1889,—and was characterised by great forward¬
ness and precocity, and a tendency to “ show off” before the other sex.

Third, at sixteen. Acute mania of adolescence .—Lasted eight months
—from December, 1889, to July, 1890. This attack was characterised
by several monthly exacerbations, and finally by two months of stupor
before recovery occurred.

Fourth, at nineteen. Acute mania of adolescence. —Lasted fourteen
months—from July, 1892, to September, 1893. This attack was
characterised by an initial five months of continuous mania, and then
by a period of quiescence, and next by a relapse before final recovery.
It is interesting to note that on the occasion of this, her fourth admis¬
sion into the asylum, she is recorded for the first time to have a “ systolic

Digitized by VjOOQle

I l6 CLINICAL NOTES AND CASES. [Jan.,

mitral bruit.” There had been no rheumatic, or choreic, or cardiac
symptoms complained of since her previous admission.

3. Present illness (August, 1895).—The patient during the previous
two years had become loose and unsteady in her habits, and on August
8th, 1895, she gave birth to an illegitimate male child. The labour was
difficult; instruments were used, and much blood was lost both at and
after the birth, and during the succeeding week she fainted on three or
four occasions when sitting up in bed in order to attend to the calls of
nature. The lochia were profuse but “ sweet.” She nursed the baby
for two days, but had to give this up on account of soreness of the
nipples. On the eighth day of the puerperium—/. e. August 16th—
morbid mental symptoms supervened. She became elated, excited,
and restless, decorated her hair, smashed her watch, would not stay in
bed or take food or gc to sleep, and in three days was so much worse
that it became necessary once more to send her to the asylum (on
August 19th).

On admission she presented the typical appearances of puerperal
acute mania, being hilarious, laughing, singing, whistling, chattering,
full of flitting fancies, cheeky, blasphemous, obscene, tricky, mis¬
chievous, very restless, confused, incoherent, spitting right and left,
destructive, and inattentive to the calls of nature. Bodily she was
anaemic and feverish, the temperature being ioi° F., and the pulse
144. The pupils were large and sluggish. There was a mitral systolic
bruit sufficiently rough in character to make one suspect more than a
mere functional origin, but its direction of propagation could not be
ascertained at the time, owing to the patient's restlessness. The
mammae were full of milk, and were hard and lumpy. There was
no pelvic tenderness, and, as normally happens by the eleventh day
after labour, the uterus could not be felt above the pubes. The
lochia were “sweet,” though now somewhat scanty. The nurse was
unable to obtain a specimen of urine for examination. The treatment
adopted was confinement to bed till the feverishness passed off; a pre¬
liminary half-ounce dose of magnesium sulphate ; free nourishment,
mainly by milk and egg custards; vaginal douching once daily with
1 to 60 carbolic lotion; belladonna plasters, applied to the breasts
after they had been massaged and softened; and sulphonal as required
to control the insomnia and restlessness.

The mania continued unabated in severity for nearly a week after
admission ; then for two days the violent motor restlessness diminished
somewhat, and this was followed next morning, on the nineteenth day
of the puerperium—/. e. August 27th—by the sudden occurrence of a
severe epileptic convulsion. I was sent for at once, as the patient was
not known to be subject to fits. The fit by this time had ceased, but
she was deeply unconscious and in a state of general muscular relaxa¬
tion, and the conjunctival and pupil reflexes were absent. The sleeve
of her strong cloth dress (with which she had been robed on account
of her destructive tendencies) was found to have been pulled up over
the right biceps, the arm being tightly constricted at the point, and
below this red and oedematous. During the rest of the day the patient
did not properly regain consciousness, owing to the recurrence of a
severe epileptic fit every three or four hours. Since the onset of the

Digitized by VjOOQle

1900.] CLINICAL NOTES AND CASES. 117

first fit the mania had been entirely in abeyance, and had been replaced
by the condition of status epilepticus . The convulsions were typically
epileptic in character, the patient becoming at each fit suddenly and
deeply unconscious, the eyes being turned strongly upwards, and the
characteristic state of general tonic spasm being followed by clonic
convulsions, which started at the lips and spread rapidly to the limbs
and body generally. During the fit there was no wild talking or quasi-
purposive throwing about of the limbs, as in hysterical convulsions.
The only other condition which could reasonably be suspected to
be present was puerperal eclampsia; but an examination of the urine,
which was being passed copiously, and which it was now possible to
obtain, proved such a diagnosis to be untenable. The urine had a specific
gravity of 1023, was amber in colour, acid in reaction, and contained a
healthy percentage of urea, and no albumen, blood, or sugar. Eclampsia
gravidarum was thus not present, and this was all the more unlikely
when we remember that, as a complication of child-bearing, eclampsia (*)
sets in in more than half the cases during actual parturition, and in the
remaining cases during the last two months of pregnancy or during the
first two days of the puerperium, rarely, if ever, as late as the nine¬
teenth day of the puerperium. Subsequent events confirmed the
diagnosis of epilepsy, for, whereas a patient with eclampsia seldom
survives more than twenty-five fits, this patient remained for eight days
in the condition of status epilepticus , during which she had about
a hundred severe fits and many lesser ones. On an average there were
twelve severe convulsions in the twenty-four hours, and many slighter
ones in addition. During the eight days of status epilepticus —August
27th to September 3rd inclusive—the patient remained comatose,
feverish (temperature usually about 102° F.), and exhausted. Feeding
was accomplished with great difficulty. At first sips of custard could
be trickled down the throat between the paroxysms, but finally nutrient
enemata had to be resorted to; and it was by means of medicinal
enemata, each containing chloral hydrate 45 grains and potassium
bromide 60 grains, that the condition was finally controlled. On
the eighth day (September 3rd) of the status epilepticus three such
enemata were given—/. 135 grains chloral and 180 grains bromide ;
but notwithstanding these large doses, there were twelve severe con¬
vulsions and many slighter ones. On the next day two similar
enemata were administered, and no convulsions occurred, the patient
gradually returning to consciousness. During the following week she
regained strength, and the condition of post-epileptic mental con¬
fusion wore off, the mania now returning, but in a milder form than at
first, with much less motor disturbance, the condition being essentially
one of subdued mental exaltation and excitement, characterised by
hilarity, constant chattering of nonsense, and playful tricky ways.
This condition of mania continued, becoming gradually milder, during
September and October, when another neurosis made its appearance.
It was difficult to say, owing to the playful movements and mannerisms
of the patient, when the chorea precisely began, but on October 14th
—that is within six weeks of the cessation of the status epilepticus —
distinct choreic movements were present, affecting the face and upper
limbs. She made faces and grimaces, and moved about her head,

Digitized by VjOOQle

118

CLINICAL NOTES AND CASES.

[Jan.,

shoulders, and hands in the short, jerky, involuntary, irregular manner
characteristic of the disease. The mitral systolic bruit, which could
now be listened to under more favourable circumstances, was distinctly
propagated towards the axilla, indicating organic mitral disease. The
chorea was mild in type, and disappeared under arsenic treatment in a
fortnight. Meanwhile the mania was gradually subsiding, and by the
middle of November she was regarded as convalescent, and was dis¬
charged recovered on January nth, 1896.

[4. Note on the subsequent history of patient '.—Patient again became
pregnant, was married in April, 1897, and confined two months later.
This time the labour was natural, and she nursed the child for four
months, when melancholia set in, which in three weeks was succeeded
by mania. She was readmitted into Momingside Asylum in Novem¬
ber, 1897, suffering from lactational acute mania, was treated with
mammary gland tissue, which had no apparent effect on the course of
the disease, and, after passing through a melancholic phase during con¬
valescence, was discharged recovered in June, 1898.

At the time of writing (November, 1899) I hear from her parents that
she had her third baby in May, 1899, that she nursed it, but again “ took
the trouble,” and was admitted into Middlesbrough Asylum, Yorks, at
the beginning of the present month. Dr. Pope, of Middlesbrough,
kindly writes to me that Mrs. R. B. B. M— is suffering from lactational
subacute mania, with features strongly suggestive of hysteria, so that yet
another neurosis must be added to this strange history.]

Pages of theory might be written on the strength of the
above case as to the nature of insanity, epilepsy, and chorea,
their pathogenetic relationships to one another, and their par¬
ticular localisations in the common dwelling-house of the
nervous system.

The following considerations, however, show the necessity of
great caution in generalising from such a case.

1. Child-bearing is one of the commonest causes of insanity in
women y accounting for 10 per cent, of all the cases, puerperal
insanity claiming 5 per cent., lactational insanity 4 per cent.,
and gestational insanity 1 per cent.(*)

2. Child-bearing is an occasional cause of epilepsy , but the
epilepsy usually begins during pregnancy, and this form is apt
to recur in successive pregnancies and in time to become
chronic.( s ) Puerperal epilepsy is much less common and is less
apt to recur. Puerperal status epilepticus , as the sole manifes¬
tation of epilepsy, must be considered as distinctly rare, for the
“epileptic state” itself, according to Sir William Gowers,( 8 ) is
“ very rare ” in comparison to the frequency of the disease
epilepsy.

When epilepsy and insanity are associated, the epilepsy, as

Digitized by VjOOQle

1900.] CLINICAL NOTES AND CASES. I 19

is well known, is generally the forerunner of the insanity.
This is epileptic insanity, which accounts perhaps for 9 per
cent of the total insanity in Britain,( 4 ) being somewhat less
common in women than in men. Epilepsy consecutive to
insanity is rare,(*) although epileptiform convulsions are not
uncommon in the course of insanity, both chronic and acute;
witness especially the convulsions seen in the recent alcoholic
insane.

3. Child-bearing is an occasional cause of chorea , but chorea
gravidarum nearly always occurs during pregnancy, this form
of chorea being usually very severe, apt to be complicated with
delirium and mania, and often fatal.( 5 ) Chorea arising during
the puerperium is rare.( 6 ) In the above case distinct symptoms
of chorea appeared during the ninth week after labour, so that
if the puerperium is limited to the period of six weeks following
parturition the chorea in this case could hardly be called
puerperal. However, the puerperium is stated by various
authorities to last from one to two or even to three months
after parturition, and whether the chorea in this case was to be
regarded as a puerperal manifestation or not, the fact remains
that the chorea was consecutive to puerperal insanity. Now
when chorea and insanity are associated the insanity is nearly
always consecutive to the chorea.^) This is choreic insanity,
and it forms a very small percentage of the insanities. Rarely is
chorea consecutive to insanity, although choreiform movements
are not uncommon in the insane. When chorea occurs in the
course of insanity the insanity usually disappears, the chorea
remaining and becoming chronic.( 7 ) In the above case the
mania was subsiding as the chorea appeared, and the chorea
itself only lasted about two weeks.

Applying these considerations to the case of the patient in
question, we recognise—

1. That she suffered from puerperal insanity, a common
form of mental disease in women.

2. That during her illness she developed first epilepsy and
then chorea, both of them rare conditions to arise during the
puerperium and also (especially the chorea) as consecutive to
insanity.

3. That the epilepsy was in the comparatively rare form of
status epilepticusy and that the chorea was peculiar in not
becoming chronic.

Digitized by VjOOQle

120 CLINICAL NOTES AND CASES. [Jan.,

Hence it would seem unjustifiable, in consideration of the
rare developments of the illness, to form generalisations as to
the nature and affinities of the above neuroses.

However, looking at the whole facts of the case, one may
conclude—

1. That the patient had a bad family history.

2. That she herself was a very neurotic subject. This, in
the present state of our knowledge, probably means a marked
chemical instability in the nerve centres.

3. That the occurrence of acute mania or of epilepsy or of
chorea in such a subject was not to be wondered at.

4. That the occurrence of the three diseases in succession
within a short period in the same patient favours the view that
the three diseases have a common site, namely, in the “ highest
level ”( 8 ) of the cortex. If one carefully analyses the symptoms
of acute mania, epilepsy, and chorea, it seems to me that the
functions of the nervous system essentially at fault in these
diseases are the mental and the motor. This favours the view
that the three neuroses have their site in the pre-Rolandic
portion of the “ higher ” cortex, rather than in the post-Rolandic
cortex, which is more essentially mental and sensory in
function.( 9 )

5. That in the absence of a definite pathology, the fact of
the curability of the three diseases shows them to be essentially
functional neuroses, dependent upon morbid molecular activity
of the nerve centres and not upon gross nutritional or structural
changes.

6. That in the absence of a definite proof of any autotoxic,
toxic, or microbic agency, the ultimate cause of the three
neuroses is an inherent chemical instability of the nerve centres,
and a consequent tendency on their part to morbid chemical
activity and functioning when they are brought under the
influence of any “ irritant ” in the wide sense, the “ irritant ”
merely acting as spark to powder. I do not agree with
those ( l0 ) who hold the essential cause of chorea and epilepsy to
consist in a microbic or toxic agency in the blood. The great
incidence of these neuroses and of the insanities during the
developmental period of life, especially during the period of
maturation of the nervous functions, is strongly in favour of
the view that the forts et origo of these disorders is in the
cerebral cortex. It is the metabolism of the nerve centres, not

Digitized by VjOOQle

1900.]

CLINICAL NOTES AND CASES.

I 2 I

the metabolism of the blood, which is the root of the evil of the
“ developmental ” neuroses, and there is reason to believe that
the toxines which have been found are an expression, not the
cause, of the morbid chemical activity of the higher neurons.

(*) Hermanen, “ Puerperal Eclampsia/’ Clifford Allbutt’s System of Medicine,
vol. vii, 1899.—( a ) Clouston, Mental Diseases , 5th edit., 1898.—(*) Gowers,
** Epilepsy,” in Clifford Allbutt’s System of Medicine, vol. vii, 1899.—( 4 ) Savage,
" Epilepsy and Insanity,” in Hack Tuke’s Diet .of Psycholog. Medicine, vol. i, 1892.
—( 5 ) Osier, Principles and Practice of Medicine , 3rd edit., 1898.—(®) Risien
Russell, 11 Chorea,” in Clifford Allbutt’s System of Medicine, vol. vii, 1899.—( 7 )
Ludwig Meyer, “Chorea and Insanity,” in Hack Tuke’s Diet, of Psych. Med.,
vol. i, 1892.—(•) Hughlings Jackson, Evolution and Dissolution of the Nervous
System, 1888.—-(•) Ferrier, " Regional Diagnosis of Cerebral Disease,” in Clifford
Allbutt’s System of Medicine, vol. vii, 1899.—(*°) Macpherson, Mental Affections
1899.

Discussion

At Autumn Meeting of the Scottish Division of the Medico-Psychological

Association.

Dr. Ireland hoped that, in the future, inquiry would be made as to the children
born of this unhappy person, whose neurotic tendencies were so marked. He was
puzzled to distinguish between epileptic and epileptiform convulsions, and between
chorea, reported as being rare in insanity, and choreiform motions which are not
uncommon. How were these terms to be used and understood ?

Dr. Bruce thought that Dr. Easterbrook would have general support in stating
that epilepsy and chorea are very closely connected. He remembered two cases,
one starting with chorea and the other with epileptic seizure. Both ended in
death. The first was a lad of about seventeen years of age. He became gradually
weaker from loss of power, and choreic movements began in the right hand,
extending to the arm, and later to the side of the body. Following upon these
choreic movements a severe epileptic fit occurred, which seemed to clear the
mental atmosphere. On the following day the movements began to affect the
whole of the right side, and the patient had another fit, from which he never
recovered. The other case was one of general paralysis. The chorea came on
gradually, and afterwards became rapidly general. In three days a severe con¬
gestive seizure ended in death. He thought that there was still a great deal to be
said in favour of the view that certain congestive states were due to poison in the
blood, which, he believed, could, by inoculation of the blood, produce a condition
of toxine poisoning in another person.

Dr. G. M. Robertson said he would refer to the treatment of status epilepticus.
He thought that in chloroform they had got a means of actually stopping the
convulsions in all these cases, and he felt certain that if chloroform had been used
by Dr. Easterbrook long before the expiry of seven or eight days the convulsions
would have ceased. In Jacksonian epilepsy there was a gradual march of the
spasm. It started, say in the thumb, and gradually spread up the arm and
shoulder, affecting the side of the head ; then spread to the leg. In true epilepsy,
on the other hand, the convulsions were supposed to be sudden and universal,
perhaps more in one side than the other, but practically simultaneous. In one of
the cases of status epilepticus which he had treated the patient was kept under
chloroform only sufficiently deeply to prevent the convulsions being very severe.
The convulsions then, instead of being sudden and universal, had a march exactly
the same as the march of the convulsions in Jacksonian epilepsy. In true
epilepsy the amount of discharge was greater and more sudden, and therefore they
were not able to follow the march of the spasm, except in the manner referred to.
This point had never been confirmed. It would therefore be very interesting to
have further observations in similar cases treated by chloroform.

Digitized by VjOOQle

122

CLINICAL NOTES AND CASES.

[Jan.,

Dr. Keay said that he had tried venesection in the treatment of status epilepticus t
as recommended by the late Dr. Wallis. He had bled two patients, and both had
died very soon afterwards.

Dr. Urquhart said he had precisely the same experience. The bleeding
certainly stopped the fits, but the fatal event followed within a few hours.

Dr. Campbell Clark said he had a case of status epilepticus, and the patient
was bled about eighteen months ago, but was still alive. He had been interested
in puerperal insanity for a very long time, and he had made very careful notes of
all his cases; and he had been struck by the point which had been raised as to
whether they had to deal with nerve-cell metabolism or with some other condition.
Dr. Easterbrook thought there was no evidence of septicaemia. He was of opinion,
however, that septicaemia was present much more often than they supposed.
There was evidence of it in many cases in the shape of small boils or pustules
scattered over the body, and especially over the buttocks. The poisoning of the
blood in the great majority of these cases did not necessarily show itself by the
appearance of abscesses which they could not always detect in the lungs or other
internal organs. It might show itself externally and in other ways. In the case
under discussion he would be inclined to think that there might be not only the
nervous instability due to irregular metabolism, but also due to changes in the
blood. The fact that cases of puerperal insanity with bad neurotic histories
did not always develop epilepsy showed that there was some further explanation
than had been given. It was most important that they should consider these two
points in the possible explanation of chorea and epilepsy.

The President said that he had a case of post-puerperal insanity giving rise to
trouble and anxiety. The week after insanity occurred serious epileptic fits super¬
vened. These passed away, and having remained conscious for forty-eight hour9
she then lapsed into a stuporose condition. Was there a chance of her recovery P
He had read Dr. Clark’s series of papers with very great interest, and as they did
not draw special attention to this point he took it that it was a very uncommon
occurrence.

Dr. Easterbrook, in reply, said that he had recently seen the child, now a boy
of four, who was bom just before the illness described, and who so far had enjoyed
good health. He thought that the terms “ epileptiform ” and “ choreiform ”
should have a descriptive value only, without reference to the nature of the
morbid processes described, otherwise confusion might arise. Thus ** epilepti¬
form ” was generally applied to the convulsions characteristically seen in Jack¬
sonian epilepsy. These were usually attended at first by consciousness, but in
time often by unconsciousness, and then the cases were indistinguishable from
true epilepsy. Sir William Gowers said the cases were then "not practically
separable,” the specific explosive brain habit being present in both. Epileptiform
convulsions, however, might occur in other conditions than epilepsy. Similarly
choreiform movements occurred in other conditions than true chorea, to which,
however, they were probably allied. The prognosis in puerperal epilepsy was said
to be not unfavourable. It was certain that products capable of producing convul¬
sions had been obtained from the blood of epileptics, but it was possible that these
poisons were formed in the diseased nerve centres, and that in status epilepticus a
vicious toxic circle was established comparable to that which is said to exist in
the congestive seizures of general paralysis. He had no experience of bleeding or
of chloroform as remedies for the epileptic state. In reply to Dr. Campbell Clark
he would say that there was no local evidence of sepsis in this case, and the
temperature was only ioi° F. He quite agreed with Dr. Clark that puerperal
insanity often had the appearance of a poisoning, but he was not inclined to say
that the majority of the cases were due to septic poisons. Most of the cases he
had seen presented no signs of sepsis locally or constitutionally, and he therefore
thought that the rapid involution of the uterus during the early puerperium
(when puerperal insanity was most common) supplied a toxine which poisoned the
unstable higher nervous centres. It was, however, good practice to use an anti¬
septic douche in cases of puerperal insanity to begin with.

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

123

Occasional Notes.

Tuberculosis in Asylums .

It is well that the appeal of our President has not fallen on
deaf ears. The Association have considered it advisable to form
a small Committee to co-operate in the National Movement,
which was inaugurated so nobly by His Royal Highness the
Prince of Wales, and to enforce by every legitimate means the
advantages of the modem treatment of tuberculosis. We have
much pleasure in congratulating our General Secretary on the
results of his arrangements, which have placed the important
question of phthisis in asylums in a position of prominence, with
the prospect of authoritative solution.

Our readers will doubtless carefully consider the relevant and
cogent facts which have been presented to them in this and the
last number of the JOURNAL. Dr. Crookshank’s prize essay is
not only an honour to himself, but also an honour to the
Association which elicited it. Dr. France, following up the work
published by him in 1897, opened the discussion of the 9th
November with a paper which met with sincere and hearty
approbation. Although there may be some slight difference of
opinion between them as to the value and interpretation of
difficult statistical inquiries, the outstanding facts are beyond
dispute. Phthisis has been shown to be largely one of the
preventable diseases. The condition of affairs in the asylums
of this country is not in accordance with the demands of recent
scientific developments. Our common humanity insists that
the requirements of modem sanitation should be met, however
hardly these may bear on the ratepayers of the country. It is
a part of the White Man's Burden; but, lightened by the assurance
that it is a compassionate, a beneficent, a patriotic duty, it will
be borne without a grudge. The tendency of public opinion is
assuredly towards the alleviation of the evil fortune of the
insane in their cloistered lives; and, when it is clearly shown
how alleviation may be secured with scientific precision, we
may count upon active co-operation in dealing with difficulties
as they arise.

Digitized by VjOOQle

124

OCCASIONAL NOTES.

[Jan.,

Sir James Crichton-Browne in his eloquent speech reminds
us that he first attacked the problem of tuberculosis in asylums
in 1883. In the intervening years much knowledge has accu¬
mulated, and the scientific position has been fortified till it is
now impregnable. It is not sufficient for us, however, to hold
that position. The country is astir with hopes of relief from
the intolerable assaults of a wide-spread and deadly foe. Now
is the time to range ourselves with those who have already
entered on a vigorous campaign, with the augury of a successful
issue.

Pensions .

We are informed that the Parliamentary Committee has
followed up the ideas expressed at the Annual Meeting, in the
discussion of the report it then brought up. A communication
has been sent to the County Councils Association, and is
receiving attention at the hands of that important body. We
know that the Lord Chancellor is in favour of a pension scheme,
and if a satisfactory one can be arranged with the County
Councils Association, we may look forward to the time when
asylum authorities can go into the employment market with
offers of pecuniary conditions equal to those now made by
other services. We cannot too urgently ask each superintendent
to furnish any information required for the guidance and
assistance of the Parliamentary Committee.

The Sale of Intoxicating Liquors\

The final Report of the Commission appointed to inquire into
the operation and administration of the laws relating to the sale
of intoxicating liquors is now published, and contains much
that is of interest to the members of our specialty, who pro¬
bably see more of the extreme evils of intemperance than any
other class of the medical profession. We can, however, allude
only to a few of the more important of the many far-reaching
suggestions contained in the Report

“ Simple drunkenness,” apart from disorder, the Commission
proposes “ should be liable to arrest.” Their recommendation,

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

125

by making this condition practically a crime, will probably do
more for the cause of temperance than all the other suggested
legislation. Our people are so law-abiding that this view of
drunkenness, it may be predicted, will soon be generally adopted,
with satisfactory results. It is well to recall that not so long
ago it was regarded as the “ duty ” of a gentleman to get drunk
after dinner; but now that “ society ” regards intoxication
as disgraceful the habit is abandoned. In the lower classes of
the present day drunkenness is widely regarded as rather a fine
thing, certainly not as a matter to be ashamed of. If they can
be brought to view it as criminal and disgraceful, a similar
change of habit will doubtlessly follow.

The “particeps criminis ” must logically be held responsible
for his share in the offence, and the Report is consistent in
recommending that “licence-holders” should be called upon
to show that they did not know of a drunken person “ being
upon ” or “ leaving their premises.” This, again, is an important
step in the right direction.

“ Habitual drunkards,” it is further recommended, should be
placed on a black list, and the licence-holders of the district
in which such drunkards reside should be warned by the police
not to serve such persons under penalty ; also, that the persons
prohibited should be liable to penalties for attempting to evade
the prohibition. Although there are obvious difficulties in
carrying out this proposal, it would, without doubt, have bene¬
ficial results, even with limitations.

“ Habitual drunkenness,” the Report recommends, should be
treated as “ persistent cruelty,” entitling the wife or husband to
separation and protection for herself, or himself, and children.
This, if it becomes law, will save an immense amount of un¬
merited suffering, from which at present there is no legal
escape.

The initiation of investigation in regard to habitual drunken¬
ness before a magistrate, on the action of a member of the
drunkard's family, which is also proposed, though open to abuse,
could probably be made a useful and workable provision.

The Habitual Drunkards Act, at present badly halting in its
progress, by the aid of these and many similar recommendations
would be greatly helped in its beneficial results.

Incipient habitual drunkards would by these provisions be
brought under the operation of the Act at a stage when the hope

Digitized by VjOOQle

OCCASIONAL NOTES.

126

[Jan.,

of cure would be greatest, and the time required for treatment
at its lowest limit.

The “ van system,” in connection with “ grocers* licences ”
in Scotland, appears to be the most pernicious custom in the sale
of intoxicating liquors. The van may be briefly described as a
perambulating drink-shop, combined with the worst evils of the
tally-shop. The system is a most pernicious and insidious
incitement—not only to drink, but to debt.

The Commission recommends that these vans should be liable
to search ; that the drivers must produce when called on signed
orders from customers, must carry no liquor beyond that in
supply of such orders, and that each order should bear the name
and address of the sender. These regulations it is to be feared
are too easy of evasion, nor do they touch the worst feature of
the system—the debt. We would suggest that all transactions
under van system should be for cash, and that there should be
no recovery for debt thus contracted.

The Report concludes by urging that licensed houses should
be greatly reduced in number, and by asserting that, “ while no
claim to compensation can be urged by those who lose their
licences, some allowance might be made as a matter of grace,
which, however, should be raised, not from public rates or taxes,
but from the trade itself.**

Statistics of great value and importance in regard to the
consumption of liquor in this and other countries (especially in
Norway and Sweden), of cases of drunkenness, of deaths from
alcoholic causes, etc., are given in an appended memorandum by
Mr. Whittaker.

The Report, indeed, contains a large amount of information
on the drink question, and should be studied by all interested.

The Medico-Psychological Association as a body, moreover,
should note the fact that the Commission does not seem to have
troubled itself with statistics in regard to the share of intoxicants
in the production of mental disease.

London Lunacy .

The tenth annual Report of the Asylums Committee of the
London County Council has now attained very closely to the

Digitized by VjOOQle

OCCASIONAL NOTES.

1900.]

127

bulk of the blue-book of the Lunacy Commission, and contains
information of scarcely less interest.

The total number of pauper lunatics of the county of
London is now upwards of 21,000, being rather more than a
fifth of the whole lunacy of England and Wales. This vast
number, moreover, is increasing by an annual addition of
upwards of 600 ; it is not, therefore, a matter for surprise to
find that, in despite of all efforts, the provision of asylum
accommodation has not yet overtaken the demand, although
by the completion of the asylums now in hand (including a
working colony for 300 epileptics) the total number of beds on
January 1st, 1901, will be 16,500, giving a surplus of 600 at
that date, which will about meet the estimated increase for that
year.

Receiving-houses seem to be in a fair way to become
accomplished facts, since the statement is made that their
establishment has been recommended by a special sub-com¬
mittee, and by a conference of guardians representing the
metropolitan unions and parishes. The Commissioners in
Lunacy also are said to favour their institution.

This matter has been so often and so long advocated in this
JOURNAL, that the carrying out of this system of early treat¬
ment is welcomed with great satisfaction, and its influence on
the admission rate to the asylums will be watched with much
interest.

The examination of attendants by the Medico-Psychological
Association is spoken of very favourably, and this no doubt
will lead to a considerable increase in the number of candidates
from the London asylums.

The statistics of relapse receive special consideration in two
tables. The first shows that the relapsed cases readmitted into
the asylums from which they were discharged up to the 31st
March, 1899, amounted to 20*53 P er cent. °f those discharged
recovered during the four years ending December 31st, 1898.
A second table shows that 13*49 per cent, of these relapses
occurred within twelve months of their discharge.

The readmissions into the same asylum in England and
Wales, as stated in the Report of the Commissioners in Lunacy,
varied from 14*3 in 1894 to 16*1 in 1897, but these relapses
relate to patients discharged at any date, and not, as in the
London County Council Report, within the four years ending

Digitized by VjOOQle

128 OCCASIONAL notes. [Jan.,

31st December, 1898. Hence the excess of relapses is probably
greater than that which is shown by the figures 20*53 per cent.,
as compared with a mean of about 1 5 per cent, for the whole
country.

Accurate records and other circumstances may account for
some of this apparent excessive relapse rate, but not for all ;
and it would be of interest to arrive at any facts that might
throw light on the question. Is there, for instance, any relation
between the period under treatment and relapse ? Do early
discharges produce early relapses ? What proportion of relapses
is due to intemperance ? Many other questions of importance
might be asked.

The prevention of relapse is one of the most important
subjects with which we have to deal in arresting the accumula¬
tion of lunatics, and it involves the recognition of the fact that
legal mental recovery is not the same as medical recovery ;
that a person who is no longer certifiable may still be in such
a physical state that discharge from the asylum is certain to
be followed by relapse.

Convalescent care, in or out of the asylum, is needed for such
cases—in asylums as voluntary patients, or out in suitable
homes. Recovered inebriates should be sent to inebriate homes
when the Habitual Drunkards Act comes into full action.

The report is replete with evidence of the vigorous activity
of the London County Council, as, for example, in the publica¬
tion of the Pathological Archives , edited by Dr. Mott, which are
the most brilliant evidence of the dawn of a new era in the
treatment of London lunacy.

The Treatment of the Poor .

There can be no doubt that legislature is tending towards
methods of treatment of the poor which are indicative of the
total downfall of Bumbledom. In that large class with which
we are more immediately concerned, there are unfortunately all
sorts and conditions of men. As Mr. T. W. L. Spence showed
so clearly in a recent pamphlet, the great majority of “ pauper ”
lunatics are gathered from strata of society which would never
have touched the depths of pauperism except by reason of

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

129

mental disorder. We gladly note that the Cottage Homes
Bill, reported without amendment by the Select Committee to
the House of Commons last August, has reference to the aged
and deserving poor, and their separation from those whose
character or habits are bad or disagreeable.

With regard to imbeciles and epileptics the Committee
report that “ they are of opinion that all pauper imbeciles and
epileptics should be provided for outside the workhouse. Not
only would the removal of this class of pauper leave further
room for a better system of classification, but it would obviate
what would appear to be a great source of discomfort to the
aged poor in many of the smaller workhouses.

“ In London, pauper imbeciles are removed from the work-
houses, special institutions having been provided for their accom¬
modation by the Metropolitan Asylums Board. Your Com¬
mittee think that the principle should be extended to the rest
of England and Wales, and that throughout the country pauper
imbeciles should be provided for in institutions separate from
the workhouses. They think that pauper epileptics should also
be maintained in separate institutions, and not in workhouses.
If this were done, the suffering would be diminished which is
now endured by many who resist entering a workhouse at the
time when in their own interest indoor relief should be sought,
owing to the feeling of repulsion entertained at the idea of
living with such associates.

“Your Committee consider that these separate institutions
should be provided by the councils of counties and county
boroughs. These councils now are charged with the provision
of asylums at which pauper lunatics are maintained, the guar¬
dians paying the cost of maintenance. Your Committee do not
suggest that pauper imbeciles and epileptics should be admitted
to the lunatic asylums, but that separate institutions should be
provided expressly for their accommodation. Such institutions
need not be so costly as lunatic asylums, as the inmates would
not require the elaborate accommodation and attention which
is essential for lunatics.”

The physicians of our asylums have long been urgent in their
efforts to classify the cases under their care, and much has been
done in this direction. We feel that the recommendations of
the Select Committee will command general support, and that
they are of special importance to those whose proper work is

XLVI. 9

Digitized by

Google

OCCASIONAL NOTES.

130

[Jan.,

psychological. Appended is the summary, which will be read
with interest.

“ I. That it is desirable so to classify the inmates of work-
houses, that the aged and respectable poor shall not be forced
to mix with those whose character or habits are bad or dis¬
agreeable.

“ II. That, in order to make room for proper classification, all
children, other than infants, be provided for outside, and apart
from the workhouse premises.

“III. That it should be the duty of the county councils to
provide suitable accommodation in separate institutions for the
proper treatment of all pauper imbeciles and epileptics.

“ IV. That the aged and deserving poor, so far as it is possible,
should receive adequate outdoor relief, and that where they are
in the workhouse they should constitute a special class and
receive special treatment and privileges.

“ V. That guardians should provide special cottage homes
within the unions, or other suitable accommodation for married
couples and respectable old persons whose poverty is not their
own fault, but the result of misfortune.”

Masturbation in Schools .

A well-known and very successful Irish schoolmaster, now
retired from business, Maurice C. Hime, LL.D., is one of the
last contributors to this difficult subject. Dr. Hime’s little
pamphlet ( Schoolboys' Special Immorality ) seems to assume that
there is generally too much reticence on this topic, and that a
little more plain speaking might do good. If good is to come
of it, we will not object to any plainness of speech.

It is perhaps natural that a schoolmaster should get into the
habit of thinking that argument and precept are the chief
guides of human life, and therefore we are not surprised to find
that Dr. Hime holds that boys should be particularly warned
against self-abuse. He also advocates a much closer surveillance
over schoolboys than is at all usual in English schools. Some
of his proposals strike us as being flatly absurd, such as that
schoolboys’ trousers should be made without pockets; and his
parenthetic denunciation of tobacco seems almost comic ; but the

Digitized by VjOOQle

1900.] OCCASIONAL NOTES. 131

general issues which he raises, first, whether boys ought to be
more closely watched to prevent their indulgence in masturbation,
and secondly, whether they ought to be warned against it, are
suitable enough subjects for discussion. It does not appear
to us that Dr. Hime quite appreciates the dangers of the course
he advocates. He truly grasps the advantages of work and
organised play, and the ill effects of idleness and slipshod
habits. He also lets us see that one of his great aims as a
teacher was to produce a manly and self-reliant habit of mind
among his pupils. In our judgment the latter ought to be the
chief end of education at school, but we do not think this can
be well achieved by increased surveillance. Such a habit of
mind among the majority of boys in a school, and the healthy
public opinion which is associated with it, are the best safe¬
guards against this, as against all other boyish vices. It is, we
apprehend, a mistake to suppose that boys are generally ignorant
of the wrongfulness of masturbation ; quite the reverse is the
fact. Curiosity and the excitement of puberty tempt them, and
they give way to vice because their minds are not sufficiently
virile to enable them to resist; but they know that they are
doing wrong. The sense of sin and shame is so closely asso¬
ciated with the sexual feelings that very little instruction on this
point is required. At all events, to argue with vice, to demon¬
strate by the closest reasoning to the vicious that their courses
are illogical and unnatural, has never proved of the smallest
efficacy in dealing with adults. What reason have we to
suppose that the puerile intellect will prove more amenable ?

It may become—no doubt from time to time it does become
—the duty of the schoolmaster to address corrective remarks to a
boy or to boys on sexual subjects, but to his personal influence
infinitely more than to his arguments will be due the result.
Such remarks, when required, should be brief, dry, and manly.
Tom Brown’s father in Hughes’ famous book, after much heart¬
searching, comes to the conclusion that an oldster cannot talk
on certain subjects to a boy, and dismisses his son with the
simple advice to do and say nothing which his mother and
sisters would be ashamed to hear of. Dr. Hime’s own method
shows that he recognises that reserve is desirable, for he tells us
of an address to his boys on the subject, and says, “ The guilty
ones quickly understood what I was speaking about—none of
the others did. They only knew that I was speaking about

Digitized by VjOOQle

132

OCCASIONAL NOTES.

[Jan.,

something awful, and that the less was thought or spoken about
it the better.” Can anybody with the least knowledge of
human nature, whether shown in boys, men, or Bluebeard’s wife,
believe the latter part of this sentence ? or fail to see that the
boys both spoke and thought of the incident ? The narrator,
indeed, goes on with apparent satisfaction—“ The boys listened
to my address with breathless attention.” Sexual topics even
among grown-up people, nay, even among elderly scientists are
sure of attention, often of more attention than they deserve, and
always command “ breathless attention ” among the young ; but
we take it that this just shows the danger of such subjects.

There are other considerations which most physicians of
experience will endorse. Tissot and his school undoubtedly
exaggerated the evils of masturbation. It is, of course, both a
filthy and “ unnatural ” vice, but it is not credible that a habit
which is so common among boys that some have held it to be
universal can be solely responsible for all the ills which have
been laid to its charge. One of the worst things it does is to
produce sexual hypochondria, and the tendency to that unfor¬
tunate affection is certainly increased by mysterious references
to the terrible consequences of “ this dread vice,” and so forth,
as the spermatorrhoea quacks, to whom it is the chief stock-in-
trade, have found out long ago.

The influence of school life, by associating boys together in
large numbers, may increase the tendency to self-abuse, but it
is idle to suppose that the vice does not occur in boys who are
brought up at home, or that it is not frequently self-taught.
Dr. Hime seems to think that a more constant association
of boys with masters than is usual will check the habit. He
does not notice the proposal, which has found some favour
on the other side of the Atlantic, to educate boys and girls
together. We can imagine this plan having disadvantages
sufficient to counterbalance its supposed gain. Every indi¬
vidual, boy or girl, who lives so long, must pass through the
trying organic change which constitutes puberty, and must
battle through the mental struggle which accompanies that
change. The best preparations for the fight are a sound mind
in a sound body, and with these victory is pretty sure. Occu¬
pations and enthusiasms for higher things help much; admoni¬
tions, we fear, little. The child, agitated by curiosity, inexperience,
and a tempest of new and half-understood passions, wholly fails

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

135

to grasp the arguments or appreciate the standpoint of the
old, and much which one reads upon this subject seems to
show the old have, in some marvellous way, forgotten the time
of trial which they passed through in youth. Happily, per¬
chance, there is another side to Elia’s touching exclamation,
“ From what have I not fallen, if the child I remember
having been was indeed myself! ” But, on the other hand, the
ordinary adult has indeed fallen profoundly, if he was ever in a
state in which a few guarded words on the wickedness of sin
would confer on him an immunity against committing any sin
to which his age and physical condition strongly tempted him.

Dr. Hime believes that he succeeded in stamping out self¬
abuse entirely in his school. If he did we heartily congratulate
him, but we believe that the enforced example of his own
enthusiasm, high-mindedness, and hard work did more than any
dehortations from vice to bring about this most desirable
consummation.

Varieties of Mental Disease in their Relation to Crime .

In the Report of the Prison Commissioners for the year
ending March, 1899, we note that the Medical Inspector, Dr.
Herbert Smalley, has continued the admirable modifications
which he introduced the previous year in the statistical tables
dealing with the insanity of convicted prisoners.

The variety of mental disease is now specified in accordance
with a modernised system of classification ; and a table of
peculiar interest is appended, showing the forms of criminal
conduct related to the various types of alienation.

Seeing that, in the overwhelming majority of these cases, as
Dr. Smalley has pointed out in previous reports, the mental
state is obviously unsound on reception into prison, and
symptoms become sufficiently definite to allow certification in
the very early stages of imprisonment, we may safely regard
the developing insanity as the cause of the criminal act. These
records should, therefore, in a few years offer excellent material
for a study of crime as a part of the semeiology of mental disease.

During the last two years 287 convicted prisoners (216
males and 71 females) were certified in the local prisons of
England and Wales. This number is, of course, too small to

Digitized by VjOOQle

REVIEWS.

134

[Jan.,

afford a basis for generalisations; but it suggests, nevertheless,
some interesting points.

The forms of mental disease which bulk most largely in the
tables are the insanities characterised by systematised delusion,
acute mania, and general paralysis. The delusional insanities
account for nearly 37 per cent, of the whole ; they play the
most important r 61 e in crimes of violence against the person,
and are also the main factor in crimes against property.
General paralysis, sufficiently pronounced for diagnosis, is noted
in 28 cases (24 men and 4 women). As is usual in what
Legrand du Saulle has termed the medico-legal period of this
disease, the illegal acts committed with most frequency in these
cases were petty crimes of acquisitiveness. Sexual offences
appeared to be mainly related to states of dementia and con¬
genital imbecility. Epileptic insanity was extremely rare, only
three cases figuring in the statistics.

We trust that this interesting table will be a permanent feature
in the Prison Blue Book.

Part II.—Reviews.

The Fifty-third Report of the Commissioners in Lunacy , England .

London, 1899. Pp. 476. Price 2 s. 4 d.

The Commissioners in Lunacy in their annual report to the Lord
Chancellor for the year 1898 startle us by recording an increase to the
total number of known lunatics in England and Wales of 3114. This
is the largest annual increase yet recorded, and exceeds the annual
increase for the preceding year by 507. Undoubtedly these figures
add weight to the remarks we made in reviewing the report for 1897.
On that occasion we drew attention to the fact that the number of
active Commissioners was too small for the work which is expected
from them, and suggested as a possibility that the Lord Chancellor
might, after some years, perceive the necessity of revising the con¬
stitution of the Board of Commissioners. When such a change occurs,
we hope some statistical reformer may be added to the Commission—
some one who may recognise the unrivalled opportunities which such a
position holds out for the increase of our general knowledge of insanity,
and its comprehensive scientific investigation—to inaugurate new pro¬
cedure for the care of the insane, improved methods of treatment and
suggestions for the prevention of insanity.

The increase in the total number of reported insane of 3114 includes
231 private patients, 2868 pauper and 15 criminal. The chief increase

Digitized by VjOOQle

Summary of Insane Patients, ist January , 18pp.

1900.]

REVIEWS.

Total.

•O — to w) \0 nO

©* ON 0^00 NOOC-NO

^ 00 w no ^ on

" ▼ « - - Ui

r* m

“•I

« nO to - »0 *>.0 0n>0

00 ON ^ I no »- ON '(TO

to M | M 0 « *0

£ -* « « NO to

•

to to r* ■<+ so " ft 00 NO

»0 0 O V T « <OOC 0 ON

't « - *>. « * ~ 00 - to

« « - U)N R

r«.

Criminal.

% " 1 - 1 * 1 111
m NO

t>»

8 ~ II 1 | 1 i 1 1

- ' 1-15 1 1 1 1

*■ T

“tO *t to to . . ON . 0

ft 00 - ON NO 00 1 NO

« ^ ON no 1 1 ON 1 ON

O «- *0 «o

t>. —

«o

£-3

0 NO U) t>NO NO

- - Ml I I - ON 1 NO

10 - *0 to 1 1 to 6^ 1 »o

00* NO to \

»o

ON NO NO O ft 00 'Nf

5 O ON ^ I 1 <000 I ON

to to ft 1 1 - 00 I to

n <o« n

Private.

- T n w on vo | | to |

«S O 00 00 -r 1 1 1 - 1

0 *>« ci *+

H | - eo - ~

t>.

'G m

a.|

t 1 'S.s 1 1 1 1 ? 1

00 00 00 0 «

•

•5 % t ? * 1 MSI

so 00 *- *0 ft —

r«.

Where maintained on 1st January, 1899.

In County and Borough Asylums .

In Registered Hospitals.

In Licensed Houses:

Metropolitan.

Provincial.

In Naval and Military Hospitals

In Criminal Lunatic Asylum (Broadmoor)

In Workhouses:

Ordinary Workhouses . . . .

Metropolitan District Asylums .

Private Single Patients

Outdoor Paupers.

Total.

Digitized by

Google

135

1 Forty-eight of these patients were boarded out from Prestwich Asylum in Rochdale Union Workhouse, and from Suffolk Asylum in
Mildenhall Workhouse, under the provisions of the Lunacy Act, 1890, s. 26. See Appendix B, Table VIII.

136

REVIEWS.

[Jan.,

in the number of pauper patients has been in county and borough
asylums, where the stationary death rate and also the diminishing
recovery rate account for much of the increase.

We regret to see once more the table showing the ratio (per io,ooo)
of total insane to the population, and that showing the ratio (per 10,000)
of the insane admitted during the year 1898 to the whole population.
The conclusion the Commissioners arrive at is that, whereas there was
1 lunatic in every 337 persons in 1889, there is now 1 in every 302.
We would draw a distinction between tables which are useless, and
tables which are misleading. We think fables II and III fall under
the latter heading. The Table IV, showing the ratio (per cent.) of
pauper insane to paupers of all classes on the first of each year, gives
us an approximate estimate of the fluctuations of insanity, since the
ratio of the sane paupers to the population is nearly constant The
ratio of pauper insane to all paupers on January 1st 1898, is 11*64,
which shows an increase of o’56 per cent., or an increase slightly
greater than any yearly increase since 1889.

The number of patients resident in asylums, hospitals, and licensed
houses on January 1st, 1898, was 78,932. The appended table gives
the variations in increase and decrease in the different institutions.

County and

Borough

Asylums.

Registered

Hospitals.

Metropolitan

Licensed

Houses.

Provincial

Licensed

Houses.

Naval and

Military

Hospitals.

Criminal

Asylum,

Broadmoor.

Private

single

patients.

Idiot Estab¬
lishments.

Total.

Increase. . . 2418

—

| *5 6 <>

Decrease . . —

—

Total increase

•

2509

The number of admissions into asylums, etc., during 1898, exclusive
of transfers and readmissions due to lapsed orders, shows an increase of
488 on the number for 1897.

County and

Borough

Asylums.

Registered

Hospitals.

Metropolitan

Licensed

Houses.

Provincial

Licensed

Houses.

Naval and

Military

Hospitals.

Criminal

Asylum,

Broadmoor.

Private

single

patients.

Idiot Estab¬
lishments.

Total.

Increase. . .

Decrease . .

= 1

, 4 I

i — ! 23 22

• 1

— 8 — —

518

i 3°

Total increase .... 488

Digitized by tjOOQle

1900.] REVIEWS. 137

We see by this table that there is once more an increase in the
number of certified patients.

The portion of Table V which deals with transfers is given as usual.
The readmissions on fresh reception orders, rendered necessary by
previous reception orders having expired, have diminished from 103 in

1897, to 92 in 1898.

The recoveries during the year 1898 numbered 7121, a decrease on
the total of 1897 of 109. The decrease occurred in county and
borough asylums (21), in registered hospitals (8), in metropolitan
licensed houses (11), in provincial licensed houses (63), in naval and
military hospitals (14), in criminal asylum (3), in idiot establish¬
ments (1); while among private single patients there was an increase
of 12.

The percentage of recoveries to the total number of admissions
showed a falling off from 38*35 per cent, in 1897, to 36*87 per cent, in

1898, or 1*94 per cent, below the average rate for the ten years 1889-
98 ; while the total recoveries in 1898 bore a ratio of 9*06 per cent, to
the average daily number of patients as compared with 9*31 in 1897.
This gradually diminishing recovery rate we believe to be due to the
increased influx into asylums of the chronic senile insane.

j" Year.

Percentage ratios of recoveries
to admissions.

Percentage ratios of recoveries
to average daily number
resident.

l8?q

40*S0]

10*96'

IS80

4029

10-77

■ 881

39*72

- Average 39 68

10-51

- Average 10*54

1882

39'4i

10*22

1883

3850J

IO*28j

1884

40-33']

10*30]

188;

41*99

9-89

1886

4116

^ Average 40* 15

9*73

Average 9*77

1887

38-56

9*41

1888

38-71J

9*54^

1889

38-811

9*44]

1 I89O

38-59

9*87

. Average 9’98

| 189:

41-04 1

• Average 3916

10*58

1 JSQJ

38-94

10*08 I

««93

38-45;

9*95 J

1894

40-31]

10*13]

189s

38-18

9*78

■ Average 9*56

1896

38-53

- Average 38*44

9*54

I«97

38-35

9*31

I898

3687J

906 J

That the percentage of ratios of recoveries to admissions does not
correspond to the percentage of ratios of recoveries to average daily
number resident is evident from this table, and we continue to regard
the latter as the more accurate method of estimating the recovery rate.

Digitized by VjOOQle

138

REVIEWS.

[Jan.

c cc

€2.

II II

II It

« p t^oo «n «*.>« 't o «*,c p« o - o « - p -t ovoo

Q O V» PO vo Vc - b>00 V V N ‘*t io «ft o —

\d 10 X ■KW'.NCtfJ'tNN'fl

• « li N

25 fcl 55 fe! S & S 35 &u S &u S c&* S &u S biS b 25 i S bl

mi - ^ o - o m; -t « o - mix ^ o -r -r *n o

IT, ir 4 V Ml O io b *- b % « t> O S* ifl iflyb O ^ N

^^U)U)IOU)WStotf)0 Ml — ir, n l> ^ - »r ~l O

- « - - x r « «j «5

StuSCsISCsIStuS&hSSEfaSbJSCxiSCziSCbSCxlSCzJ

•o

C )

»o

- 1 - 73-0
QC cu

I * *
£ «§•

Digitized by VjOOQle

REVIEWS.

139

1900.]

The deaths during 1898 numbered 7602—an increase over that of
1897 of 270. The ratio of deaths to the average daHy number resident
was 9*45 per cent.—an increase on last yearis ratio of *02, but *21
below the average rate for the ten years 1889-98.

This table gives the comparative death-rates deduced from the Com¬
missioners* Table XIV. It shows how the death rate of the general
population and the death-rate of the insane tend to approximate as age
advances. An inspection of this table shows the diminishing death-
rate among women with advancing age when compared with the rate
for the general population. It throws some light on the accumulation
of the senile female insane in all asylums. We add columns which
show the ratios of the death-rate among the insane for each age-period
to the death-rate among the whole population for the same age-
periods.

Table XV gives the causes of death of all the insane who died in
1898, and the number of cases in which the cause of death was
ascertained by post-mortem examination. This is an interesting table,
and much information may be obtained from it. We hope the Com¬
missioners will not allow it to degenerate. We trust they will insist on
accurate returns as to the causes of death, and avoid in future such
vague terms as “apoplexy,” “congestion of the brain,” “softening of
the brain/* “ cerebro-spinal disease,** “ spinal sclerosis,** “ non-malignant
disease of the stomach,** “atrophy,** “disease of the spleen.” In classi¬
fying the diseases why place abdominal aneurysm in the division set
apart for thoracic diseases? The classification of causes should, we
think, advance pari passu with the general progress of medical know¬
ledge, and should be prevented from becoming a chronicle of the
fanciful notifications of some medical officers of asylums.

Post-mortem examinations were made in 5699 deaths out of the total
deaths, 7578. This represents 75 per cent. Since so many causes of
death are verified by an autopsy, we think a table giving a classification
of the causes of death ascertained by post-mortem examination would
be much more accurate than Table XV; inaccuracies would be fewer,
and vague “ portmanteau ** or actually faulty diagnoses would have less
weight.

We append a table (p. 140) showing the percentages of the principal
causes of death to the total number of deaths for the last four years.

Table XVI again gives the admissions with daily averages for the
several months of 1897. In January, May, June, and July the daily
average was highest. The forms of insanity, which are also given in
this table, are of a most antiquated type. Year after year we have
asked for a more scientific classification, yet “ ordinary dementia ** still
holds a position of prominence.

The Table XVII, setting forth the ratios per 10,000 of the yearly
average of the number of the insane in the five years 1893 to 1897 to
the whole population at the time of the census (1891), each classified
according to their occupations or professions, is most untrustworthy;
for the number of the insane are only the number of the officially
known insane, and the population of England and Wales has not
remained stationary since 1891. Then as regards the occupations and

Digitized by VjOOQle

140

REVIEWS.

[Jan.,

Cause* of death.

1895.

1896.

1897.

1898.

General paralysis.

2000

20*41

i8 *9"

>744

Phthisis pulmonalis.

1+88

13*88

* 4*57

14'.I 8

Senile decay.

7*71

8*69

9 ‘ 3 i

9*10

Pneumonia.

701

6*36

. 613

6*96

Cardiac valvular disease.

4/8

573

1 6*02

6+5

Epilepsy.

.S'16

4*89

! 4*66

5*23

Exhaustion from mania and melancholia

3«7

3*62

3*65 !

3’37

Organic disease of brain.

260

3‘50

3+6

1 3 '»S

Apoplexy.

3 *i 6

3 '**

3 ' *3

2 * 9 °

Chronic Bright’s disease.

2 ’ 9 »

2*56

1 a 72

296

Cancer..

201

2\s6

, 2*13

2*11

Bronchitis.

289

2*46

209

! 2*58

Accident.

•40

•42

'45

•47

Suicide ..

■*.S

*«4

I *28

•29

Other maladies . . . .

2236

2 i *57

22*43

22*5!

professions in this table, we hold that any attempt to group them is
almost certain to end in absurd failure. What can we gain by putting
professors and governesses in the same category ? What is a professor ?
Then why couple authors and reporters ? Why should shepherds have
to throw in their lot with rat-catchers, and cheesemongers with choco¬
late-makers, while “ hatters and hat-makers (not straw) ” have a ratio of
their own ?

Table XIX gives the yearly average of the number of patients
admitted during the five years 1893 to 1897 (inclusive), with their ages
and condition as to marriage. It also shows that 3 + 2 = 4 and
6+2 = 7.

In Table XXI we find the yearly average occurrence of the classical
forms of mental affection for the five years 1893 to 1897. 48^2 per

cent, are reported as suffering from mania, 28*2 per cent, from melan¬
cholia, 11‘i per cent, from ordinary dementia, 4*9 per cent, from senile
dementia, 4*6 per cent, from congenital insanity, and 3'o per cent, from
other forms of insanity. Of the yearly average, 70*8 per cent, were first
attacks, 77 per cent, were epileptics, 7*8 per cent, general paralytics,
and 24*3 per cent, suicidal cases (females to males as 27 to 21 ’5). In
Table XXI, as well as in Table XIX, we find several small arithmetical
errors.

When we compare Table XXIII with the similar table in the previous
reports we see that general paralysis is apparently making no increase
in the proportion of those admitted to asylums. We see, too, by this
table that among private patients there is only 1 female general paralytic
to every 15*4 male general paralytics; whereas among the pauper
insane the proportion is 1 to 4. (In making this small calculation we
do not feel confident about our data, for we find that 139 males + 9
females = a total of 149.)

The Commissioners in the preamble to their Report attempt to
disarm all criticism of Table XXV by stating that the information on
which it is based was obtained from “ friends of patients or relieving

Digitized by VjOOQle

1900.] REVIEWS. 141

officers,” and therefore not “altogether trustworthy;” while on page
136 they assure us in a foot-note that the causes mentioned in the table
“ have been verified by the medical officers of the asylums.” It appears
to us that the causes enumerated in this table are insufficient. The
^ moral causes do not exclude one another, and symptoms of insanity are
classified as causes. “ Venereal disease ” is too indefinite a term. The
table is really more a gauge of the opinion of the man in the street on
the causation of insanity than a scientific attempt to investigate the
aetiology of disease. Intemperance in drink appears as the cause of
insanity in 22*0 per cent, of male insane and in 9*1 per cent, of the
female insane; while “venereal” disease is stated to account for 2*1
per cent, of the male and *5 per cent, of the female insane. Hereditary
influence was ascertained in 204 per cent, male and 25*9 female.
Mental anxiety, worry, and over-work appear to exercise a much more
injurious effect among private patients than among pauper; whereas
intemperance in drink has a slightly greater causative influence among
paupers.

There is quite a multitude of causes of general paralysis to be found
in Table XXVII, and the percentages resemble the percentages of the
causes of insanity as a whole. Who would believe for a moment that
“ love affairs (including seduction) ” could account for even *2 per cent,
of male general paralytics? Further, we cannot but think a table
misleading which makes hereditary influence the most important causa¬
tive agent of general paralysis in women. “ Venereal ” disease is given
as a cause of general paralysis in 7*6 per cent, of male and in 3*0 of
female general paralytics. Every year the Commissioners lose a golden
opportunity of collecting valuable information concerning the aetio-
logical connection of syphilis and general paralysis.

The number of voluntary boarders on 1st January, 1898, was 142;
84 in registered hospitals, 24 in metropolitan licensed houses, and 34
in provincial licensed houses. One hundred and seventy-one boarders
were admitted into registered hospitals during the year; while 52 ceased
to be voluntary boarders, and were certified as patients.

The admissions into the county and borough asylums during 1898
numbered 19,234, which exceeds that for 1897 by 331, and the average
of the ten preceding years by 2183. Of the total admissions for the
year, 19*9 per cent, had been previously discharged from institutions
for the insane. The Commissioners, commenting on the annual increase
in the percentage of readmissions to all admissions, state that it “ possibly
bears some relation to the pressure for asylum accommodation, and
• the difficulty of being able to retain patients sufficiently long to con¬
solidate their recovery.” The recoveries came to 6168, and the deaths
to 6908. Post-mortem examinations were made in 78 per cent, of the
deaths, which is a falling off from the percentages for the two years
1897 and 1896. The suicides in county and borough asylums amounted
during the year to 14, which exceeds the number for the previous year
by 3. Three of these suicides were by strangulation, 3 by cut throat,
2 by hanging, 1 by precipitation from a height, 1 by a patient placing
himself in front of a train, 1 by a patient throwing himself under a
waggon, 1 by the drinking of thymo-creosol, 1 “ by gouging out both

Digitized by VjOOQle

142

REVIEWS.

[Jan.,

eyes,” and i caused by a table-spoon which a female patient “ pushed
down her throat” Though in many cases the details are given, the
Commissioners refrain from entering on the particulars in the last-
mentioned case. We may assume that it is the same incident as was
recorded in this Journal for April last Four deaths occurred from *
suffocation during epileptic fits. This exceeds by two the number of
deaths from this cause which occurred in 1897.

Insanitary conditions have existed in fourteen asylums, and serious
overcrowding has prevailed in several other asylums.

Table XIII, Appendix B, gives statistics connected with the care and
treatment of the patients in county and borough asylums. From it we
gather that Wakefield and Sussex East Asylums possess the highest
percentage of general paralytics—6* 1 and 6'o respectively. The
percentages of bedsores found at death vary between wide limits, and
this may not so much depend upon differences in the efficiency of
nursing as in differences in the accuracy of the returns.

The number of single patients on the 1st January, 1899, was 415,
which shows a decrease of 21 patients during the year.

We congratulate the Commissioners on their attempt to prevent the
examination at police courts for the purposes of certification, of all
patients who are not accused of crime. We agree with them that a
visit to the police court is a very injurious preliminary to the treatment
of many cases of insanity.

In conclusion, we desire to express our regret at the retirement of
Dr. Southey from the Commission, of which body he has been a
member for fifteen years.

Forty-first Annual Report of the General Board of Commissioners in

Lunacy for Scotland, Edinburgh, 1899, pp. 154. Price is. $d.

While this, the latest report of the Commissioners in Lunacy for
Scotland, bears the usual ample evidence of their zealous and un¬
remitting care for the welfare of the insane of all classes coming under
their jurisdiction, it also reveals the melancholy fact of the ceaseless
accumulation of mental wreckage, and the ever-increasing proportion of
people whose mental organisation proves unequal to the strain that it is
subjected to.

The population of Scotland increases at the rate of 77 per cent, in
ten years. In the past ten years its total number of lunatics has
increased 28*8 per cent., and the percentage increase in the number of
those appearing for the first time on the Lunacy Register in 1898, as
compared with 1888, is no less than 34*9 per cent. Taking the figures
of Table III of Appendix A, it is found that the total increase in ten
years of 57 per 100,000 of population is made up of 7 for private
patients and 50 for pauper patients; and, excepting in the case of
private patients, the record for 1898 when compared with 1897 is still
more unfavourable. The increase in 1898 of the total number of
lunatics in proportion to population amounts to 8 per 100,000, and the

Digitized by Google

REVIEWS.

143

1900.]

increase in the number appearing for the first time is 3‘6. These
figures indicate for the whole country increasing accumulation of lunacy,
and disproportionate increase of occurring insanity. The amount of
this increase, however, varies very considerably in different districts, and
the condition of affairs in the case of two solitary counties does some¬
thing even towards redeeming the situation. The proportion per 100,000
of population of pauper lunatics annually placed on the Register in the ten
years 1879—1888 for the whole of Scotland was 56, whereas in the suc¬
ceeding ten years it was 62. In the first period there were 19 counties
in which the rate was below the average for the country generally,
while in the second this number is reduced by 2. With the exception
of these two, the same counties which in 1879-88 had a low rate of
insanity figure under the same category in 1889-98. In only two
counties, Peebles and Linlithgow, is there an actual diminution in the
proportion of pauper lunatics annually placed on the Register in the
second period of ten years as compared with the first. In Elgin, on the
other hand, the corresponding increase is four times that of the country
generally, while in seven other counties the increase is more than twice
the average.

With but few exceptions it is those parts where the total lunacy rate
is high, and where poverty most prevails, that are marked by a relatively
high proportion of annual registrations. This disproportionate lunacy
and poverty seem likewise to go along with a standard of education
below that prevailing in other parts. According to the report of the
Registrar-General for 1897, five of the six counties where education, as
judged by the numbers unable to sign their names by writing on
marriage, is low, are among those where the lunacy rate is high. In
connection with this variation in the proportion of lunacy there is a
further curious fact worth passing mention. While the rate for the
whole of Scotland of illegitimate to total births in 1897 is 7 per cent.,
that for the seventeen counties in which the proportion of insanity is
below the average is 8 J, and that for the remaining sixteen counties is
6£. Various deductions might be drawn from this, and the question
might be raised as to whether a high rate of illegitimacy or a high rate
of lunacy is the more to be reprobated.

Compared with 1897, 241 more patients were placed on the Register
in 1898,167 more were removed by recovery or otherwise, and 7 less by
death, and the result is an addition over the year of 81. The recovery
rate in all classes of establishments shows a marked improvement over
last year, and the death-rate is little removed from the average except
in private asylums, where it is greater by 1*2 per cent, of the average
number resident. The number of escapes in 1898 is greater by 40 than
that in 1897; and while the total recorded accidents are 2 less, and
those which were fatal 3 less, the deaths by suicide are 5 more.
Though the total fatal accidents are stated to be 14, only 13 appear
under that head in Tables X and XXII of Appendix A. The death-rate
from suicide is 8’i per 10,000 of the average number resident in
asylums, while that for England is only 2*8; but there is no indication
that this difference is any way due to the larger amount of liberty
which is generally supposed to be granted to the patients under the

Digitized by

Google

144

REVIEWS.

[Jan.,

open door system. Of the 5 suicidal deaths to which reference is made
in the Commissioners’ entries in the patients’ books of the asylums, 2
probably occurred during the night, and inadequate supervision may
have been responsible. This question of night supervision was
prominently brought forward at the last Annual Meeting of our
Association, and in the Journal for October the matter is referred to
in the “ Occasional Notes.” The necessity for it in the case of suicidal
patients is recognised, but in this report the Commissioners urge that
its use may be largely and profitably extended, and the use of the single
room be proportionately discontinued. There is always the risk that
such a method as is here advocated may be carried too far, and the
result be detrimental to the best interests of the patients. For some
cases the single room constitutes the best mode of treatment; others
are more suitably treated in a dormitory under night supervision, and
the proper method to adopt in this as in other matters of treatment is
that which is best for each particular patient.

Although the death-rate from phthisis in Scotch asylums is, as was
pointed out by Dr. Crookshank in his prize essay published in the
October number of the Journal, a decreasing one, it is felt that much
more may be done in the way of prevention of this disease, and the
subject is specially dealt with in this report; but it is of course a hopeless
business to attempt to institute preventive measures so long as that
most potent factor in the causation of the disease, overcrowding, exists
to such an extent in nearly every asylum in the country.

With regard to the system of boarding out of patients in private
dwellings, there is little to be said beyond the fact that the same steady
decline in the proportion of those so accommodated continues un¬
checked. During the past ten years the percentage of those boarded
out has fallen 17, and this decline is distributed in varying amount over
no fewer than 26 out of the 33 counties. While the expenditure by
local authorities on account of pauper lunatics in establishments has
increased 32 per cent, in ten years, that for patients in private dwellings
has increased only 26 per cent.; and comparing the year under review
with the preceding one, the expenditure for establishments represents an
increase of 5 7 per cent., while that for private dwellings represents a
decrease of 1*4. The increasing stringency of the Commissioners’
requirements may partly explain this falling off in the number of pauper
patients in private dwellings, for if licences are granted only to those
“ people who are willing to regard them as their social equals, and to
share with them a common sitting-room and a common table ”—which
represents the ideal of the Commissioners—the supply of accommoda¬
tion will naturally be more limited.

Four circulars are appended to this report, relating to the registration
of attendants, transfer of patients from one asylum to another, the con¬
veyance of pauper lunatics by sea, and precautions against accident from
machinery. The last was issued to asylum superintendents in conse¬
quence of accidents occurring to patients in connection with the use of
mangles driven by steam power; and if “ there are simple means,” as
the circular says, “ by which the risk of such accidents from mangles
driven by steam or other mechanical power may be almost, if not

Digitized by

Google

REVIEWS.

145

1900.]

entirely removed,” we know that there are not a few readers of this
Journal who are unaware of any such means of protection against
accidents from mangle rollers, and who would be only too glad to be
enlightened on the point.

Number of Lunatics on January 1st, 1899.

Mode of Distribution.

In Royal Asylums
In District Asylums
In Private Asylums
In Parochial Asylums, i. e.*\
Lunatic Wards of poor- I
houses with unrestricted [

1 licences . . . J

In Lunatic Wards of poor-"l
houses with restricted V
licences . . . J

In Private Dwellings .

In Lunatic Department of 1
General Prison. . j

In Training Schools

Male.

Female.

_• |

H 1

1,888

2,229

4 ,H 7

3» x 33

3,190

6,323

136

3 i 3

355

668

447

463

910

1,129

1,696

2,825!

[6,959 8,020

14,979

1 48

232

140

372

7,233

8,166

' 5.399

Totals

Private.

Pauper.

Total.

835

924

L759

1.053

1,305

2,358

162

3,0643,097

6,161

136

—

313

355

668

—

447

463

910

123

1,089

1,613

1 2,702

993

1,187

2,1805,966

6,833

12,799

165

•39

1 “

207

1,086

'.259

2,345 6,105

6,901

13,006

Forty-eighth Report of the Inspectors of Lu?iatics y Ireland , for the year

1898.

There is but little of interest to note in this Report as far as regards
the statistical information supplied within its pages. We confess to a
feeling of impatience at the conservatism which can rest contented with
the antiquated and imperfect form in which the statistical tables are
still cast. In order to estimate the increase, and more particularly the
rate of increase, of insanity, whether as regards the number of insane
under detention or the number of admissions, tables giving ratios to
population of these numbers are absolutely essential; but these are
conspicuous by their absence. No doubt for the years between any two
consecutive census-takings the figures can only be regarded as approxi¬
mate, still they are probably not very far wrong, and ten years is rather
too long a period to wait for each new basis of calculation. A table,
however, which could be given with a close approach to accuracy would
be a similar one to Table IV of the English tables, showing the propor¬
tion of pauper insane to paupers of all classes. We have commented
before in these columns on the necessity for more comprehensive tables
XLVI. 10

Digitized by VjOOQle

146

REVIEWS.

[Jan.,

giving the figures for a series of years, and ratios for the same, as in so
many of the English tables ; but, so far, any suggestion of this kind has
been merely a vox clamantis. It is to be regretted that statistical tables
of this kind should be deficient in just those characters which would
make them of some practical value. It is probably a fact that the
Lunacy Office in Ireland is wholly undermanned, but a strong repre¬
sentation on this head, persisted in if necessary, ought eventually to
obtain a favourable response even from an ultra-economical Government.
The question of lunacy has now attained to such vast and far-reaching
dimensions, affecting every class in the social polity, that the public
have a right not only to information, but to the very fullest information
that is available on this important subject. More time and labour
should be spent on the analysis of the figures at the disposal of the
Lunacy Office, and if the present staff is inadequate for this purpose a
firm demand should be made for the requisite help, and on the ground
not of convenience but of necessity, and in the public interest.

The usual summary is given, showing the number and distribution of
the insane in establishments in the year 1898 and in the previous year
for comparison:

On ist January, 1898.

On ist January, 1899.

Males.

Fe¬

males.

Total.

Malcs * males.

Total.

In district asylums .

7.945

6.653

14,59 s

8,3 2 3| 6,966

15.289

In Central Asylum, Dundrum .

150

170

1481 21

169

In private asylums .

325

366

69I

327 387

714

In workhouses.

1.657

2,373

4,030

1,674! 2,365

4,039

In prisons.

2 \ -

Single Chancery patients in unlicensed
houses

4 s 43

( ^

Total.

10,127

9.463

19,590; 10,522 9,782

1 >

1 20,304

There is still a progressive increase in the number of patients under
detention, the figures for the three years ending 31st December, 1896,
1897, 1898, being 609, 624, and 714 respectively ; the increase in 1898
being ninety over that of the previous year, and 270 over the average of
the preceding ten years—a rather disquieting fact. However, this
increase is quite likely to continue yet for some years to come, and
until all unregistered lunatics are absorbed into the ranks of the regis¬
tered. If this consummation were once reached, certain opinions as
regards the “ increase of insanity ” would possibly become less alarm-
ing.

As usual the main increase has been in the population of district
asylums. The proportion per cent, in these institutions of the total
number under care in 1898 was 75 ; 20 per cent, being in workhouses,
and the remaining 5 per cent, in all other institutions. In the eighteen
years from 1880 to 1898 there was a rise of 8 per cent, in the propor.
tion in district asylums, and a fall of 7 per cent, in that of workhouses >

Digitized by VjOOQle

REVIEWS.

147

1900.]

so that there is but little doubt that the former have been reinforced at
the expense of the latter. This is made still more apparent if we
study the percentage of transfers from workhouses for some years past.
These have increased steadily from a percentage of 1279 t0 the total
number of admissions in 1890 to one of 18*28 in 1898, being a rise of
43 per cent. (We welcome the additional column of percentages in
this workhouse table.)

If, as authorised by the recent Irish Local Government Act, the
several counties or groups of counties were to provide auxiliary asylums
for the reception of harmless imbeciles, and, as the next step, if the
workhouses were to be emptied of all their idiot and lunatic inmates,
there would be a huge and sudden increment of some 4000 to the class
of registered insane, but probably after that the increase would be
small, as we have above indicated. The question is already being
agitated in some of the county councils, and it is to be hoped that they
will be able to arrive at some satisfactory decision as to the future of
these unfortunates.

The total number of admissions into district asylums was 3469, of
which 2676 were first admissions and 793 were recurrent cases. These
figures show an advance on those of the previous year of 184 in the
total admissions and 125 in the first admissions. A useful table giving
the admissions and readmissions for each year from 1880 up to 1898 is
introduced on p. 8 of the Report. There does not seem any reason
why this table and the subsequent ones which are inserted in the body
of the Report should not be placed in the appendix along with the
other statistical tables for greater convenience of reference. The
arrangement is calculated to cause confusion, as there are two of each
of Tables I, II, and III, one set immediately at the end of the Report,
the other in the appendix, while a third set are not numbered at all,
and do not appear in the index. The tables could be consulted with
more ease were a better method adopted in their arrangement.

The recoveries show a percentage of 36*9 on the admissions—an
advance over that of 1897 (36*3).

Eleven hundred and five patients died during the year, giving a per¬
centage of 7*4 on the daily average. The death rate in Irish asylums
remains very constant; for if we compare the last two quinquenniums, we
find that the average percentage death rates were 7*98 and 7*52 respec¬
tively. Consumption is the most fatal disease in Irish asylums, the death
roll from this cause last year numbering 2553 patients, a percentage of
30*7 on the total mortality. This proportion is more than double that of
English asylums, a fact which certainly demands explanation. Forty-
one deaths were assigned to general paralysis, or 3*7 per cent, of the
whole; and epilepsy accounted for forty-nine. Five deaths from
suicide occurred, and four from misadventure. In four of the suicidal
cases hanging was the method selected, and one patient was drowned.
Very costly appliances, patent gas fittings, etc., have of late years been
employed extensively in asylums in order to remove every possible
opportunity of injuring themselves from suicidal patients. The deaths
which occurred in this way last year point grimly to the futility of
trusting to such contrivances. A determined patient, if not closely and

Digitized by VjOOQle

148

REVIEWS.

[Jan.,

continuously watched, will carry out his self-destructive instincts despite
the most perfect mechanical devices. The unceasing vigilance of intel¬
ligent trained attendants is imperatively required. Besides, it is a
question whether extreme precautionary measures of this mechanical
kind do not tend to encourage carelessness and over-confidence on the
part of the attendants by inducing a false sense of security. One of
these patients was found dead hanging from a window shutter ; another
was found dead with a strip tom from her shawl round her neck; and
a third was found hanging by a string used as a boot-lace which she had
tied to the handle of a brush, the brush being laid across the partitions of
a water-closet '.

In a special section of their Report the Inspectors draw attention to
the very unsatisfactory sanitary condition of several asylums, as evi¬
denced by outbreaks of erysipelas, typhoid, dysentery, and diphtheritic
sore throat. Overcrowding would appear to be one determining cause
of these outbreaks, Ballinasloe and Richmond Asylum specially suffer¬
ing in this respect. At Letterkenny the diphtheritic epidemic was
attributable to an infected milk supply. In Sligo, however, where
thirteen cases of typhoid occurred with nve deaths, the sanitary accom¬
modation is described as “ antiquated and defective.”

Post-mortem examinations w ere held in 298 cases, or about 27 per
cent, of all the deaths. This is a very distinct advance upon the
number in the previous year, 255.

As to causation, as given in fable XIII, we have nothing further to
add to what was said in last year’s Review. The table would be better
omitted than published in its present fossilised shape. It is not true to
facts, and therefore not merely useless but mischievous. According to
certain of the highest authorities, from 16 to 20 per cent, at least of all
cases of insanity are due to intemperance. According to this Table
scarcely 9 per cent, are attributable to this cause. Hereditary influ¬
ences, again, are stated to have existed in only 859 out of a total of
3469 cases admitted, a proportion of only 247 per cent. Returns of
this kind are absolutely valueless.

The daily average, which was 14,340 in 1897, increased to 15,019 in
1898. A table is given on page n from which it appears that the
daily average has all but doubled since the year 1875. In latter years
the rate of increase has been much more rapid than previously, for if
we compare the figures for the last two decades we find that during the
period 1878 to 1888 the daily average rose 247 per cent., while in the
following ten years the proportional increase was 40*4 per cent.

The changes brought about in the government and management of
district asylums by the passing of the Local Government (Ireland) Act,
1898, are summarised by the Inspectors, and are briefly as follow's :

Abolition of the Board of Control.

Management of asylums to be in the hands of a Committee of the
County Council, instead of a Board of Governors, as formerly, half of
whom were appointed by the Lord Lieutenant, and the remainder
selected by him from a list of names sent up by the contributing bodies
to the maintenance of the asylum.

All appointments to be made in future by the Committee, those of

Digitized by VjOOQle

REVIEWS.

1900.]

149

the medical officers alone requiring the approval of the Lord Lieu¬
tenant.

Financial administration to be wholly in the hands of the Committee.
This includes the power to provide for the accommodation and treat¬
ment of private patients, and for the maintenance of chronic and harm¬
less lunatics in auxiliary asylums; and the granting of superannuation
will be vested solely in the local authorities.

The Privy Council rules, which up till now formed an uniform code
for the management of all asylums, now cease to operate; and each
Committee has power to make its own rules, which must, however,
receive the approval of the Lord Lieutenant.

The capitation rate in aid, formerly made by the Treasury out of
money voted annually by Parliament, will in future be paid out of the
Local Taxation Account, with the important proviso that the county
councils must satisfy the Lord Lieutenant that they have fulfilled their
duties as regards asylums.

It does not seem an altogether wise enactment that each asylum
authority should frame its own rules of management. Lunacy is now a
thoroughly organised system, a highly specialised department, just as
our poor-law and prison systems are. It would therefore seem very
desirable that its administration should be based upon an uniform code
of rules and regulations, applicable to all asylums ; each being, of course,
at liberty to make bye-laws suitable for local requirements. This would
give unity and solidarity to the department, the advantage of which few
will probably be prepared to dispute.

As regards the provision of increased accommodation, we learn that
in twenty out of the twenty-two district asylums extensive structural
additions and alterations have been, or still are being, effected. Besides
these the new County Antrim Asylum has been practically completed,
and is at present partially occupied by a number of patients from
Belfast Asylum. Another contingent of patients from the same asylum
has been transferred to the auxiliary asylum at Purdysbum ; this deple¬
tion of the parent asylum has greatly relieved the chronic congestion
from which it has so long been suffering. Portrane Asylum is still in
the hands of the contractors, but some 400 patients out of the over¬
grown population of the Richmond Asylum are comfortably lodged in
temporary buildings on the estate, pending the completion of the
permanent buildings. In connection with the Londonderry Asylum an
auxiliary block to accommodate sixty-five patients has been erected on
the Gransha estate, but beyond the drafting of plans and bills of
quantities no further steps have been taken with reference to the pro¬
posed new asylum for the county.

In private asylums there was an increase of twenty-three patients over
the previous year. The number of first admissions increased by twelve,
while the readmissions were fewer by seventeen, making a decrease of
five in the total number of admissions. During the past eighteen years
there has been an increase of only ninety-two patients, with respect to
which the Inspectors remark that, “ having regard to the low death rate,
such an increase cannot be considered any proof of the growth of
insanity amongst the opulent.”

Digitized by CjOOQle

REVIEWS.

[Jan.,

150

Three superintendents in this department of lunacy have been
removed by death during the year: Dr. Pirn, who was for so many
years superintendent of the Stewart Institution; Dr. Thomas Fitzpatrick,
the founder and patron of St. Vincent’s Asylum, to whose memory the
Inspectors pay a kindly tribute ; and Dr. John Eustace, of the Hamp¬
stead and Highfield Asylums, whose genial presence is missed at the
Dublin meetings of our Association.

The Universal Illusion of Free Will and Criminal Responsibility . By
A. Hamon, Lecturer in the New University of Brussels, etc.
London and Watford: The University Press, Ltd., 1899. Royal
8vo, pp. 138. Price 35.

Dr. Hamon sets himself to solve once for all the great question that
has puzzled philosophers and agitated theologians since first philosophy
and theology began to be. From Sptncer and Huxley to Hobbes and
Locke, from Hobbes and Locke to Luther and Calvin, from Luther
and Calvin to Aquinas and Erigena, from Aquinas and Erigena to
Augustine and Pelagius, from Augustine and Pelagius to the Sadducees
and Pharisees, we can trace the controversy in uninterrupted continuity
and in unmitigated acerbity; and if we fail to trace it further we may
be sure it is from lack of records, and not because we have reached or
approached its origin. Doubtless it enlivened those convivial meetings
of the man of Uz with his four argumentative friends, some account of
which has come down to us. Doubtless it was a subject of frequent
speculation under the stars of Chaldea. Doubtless the family of Noah
discussed on their tedious voyage the respective views of Mahalaleel
and Jared on the question. Indeed, there is great reason to suppose
that the first theological controversy of which we have any account was
concerned with this subject, and that Adam’s eldest son, who was, no
doubt, a determinist, initiated that method of closing the controversy
which determinists have since shown such readiness to imitate.

The problem which has employed for so many ages the best efforts
of so many master-minds, and on which so many libraries of books have
been written without any definite result, is now finally solved by Dr.
Hamon in 138 pages of double-leaded print. It is an achievement of
whose success an onlooker might entertain a doubt, were it not that Dr.
Hamon himself has none; when it is asserted over and over again, with
a certainty amounting to cock-sureness, that free will is an illusion, and
responsibility a dream, we have no alternative but to submit our own
judgment to that of one who evidently knows.

Considering the vigour with which Dr. Hamon enforces his conclu¬
sions, it is surprising that he does not carry them a little further. If
free will is an illusion, if the human being is an automaton, if all his
acts and thoughts are determinate, it is difficult to understand how Dr.
Hamon can hope to alter these determinate opinions by his assertions.
It is doubtful whether even argument would have any result. On

Digitized by VjOOQle

REVIEWS.

1900.]

ISI

second thoughts we perceive that this is a superficial view. Of course,
Dr. Hamon’s action in writing the book was predetermined, and in
doing so he was acting merely as an automaton. It must be admitted
that the whole tenor of his book lends countenance to this view. It
should be added that the translation is very badly done; but for this, of
course, the translator is not responsive. He was merely an automaton,
and could not help himself. If free will were not an illusion we should
recommend Dr. Hamon to employ a different translator for his next
book; but, as his translator was predetermined while the earth was still
a boiling gas, the advice would be futile.

Report of the Chairman of the Commissioners of Prisons upon the
Treatment of Crime in the United States .

In recent years the extension of the methods of positive science to
the study of social phenomena has largely modified our conception of
the social organism, not only in its normal but also in its morbid
activities.

Notably there has been a readjustment of our ideas regarding the
nature and genesis of crime, and, as a corollary thereto, regarding its
treatment. It has been recognised that, in a large proportion of
instances, crime is the natural reaction of a nervously unstable subject
under the influence of more or less malign conditions in the milieu ,
and that it is therefore irrelevant to apply to such cases a rigid system
of retribution which assumes the existence in the offender of average
normal capacity of conduct. Such a system, operating on the degene¬
rate with incipient criminal dispositions, can only aggravate his con¬
dition and further his development into the habitual criminal, while
methods directed rather to his physical and mental culture might
conceivably render him eventually a useful member of the community.

Efforts have accordingly been made to modify in this direction the
classic penal systems by the substitution, to some extent, of reformatory
for purely punitive agencies; and in this quest American penologists
have been specially prominent.

The principles and results of their experiments have been, both in
America and in this country, the theme of much discussion, which,
however, from the frequently extreme and partisan attitude of the
critics, has hardly led to complete illumination.

It has, therefore, been eminently desirable that we should have a
further estimate of the value of these novel systems from a competent
observer, familiar with the working of penitentiary methods in England.
This desideratum has been supplied in the Report to the Home
Secretary on the treatment of crime in the United States, by the
Chairman of the Prison Commission, Mr. Ruggles-Brise, to whose
enlightened administration are owing so many recent reforms in English
prisons.

The Report embodies the result of a personal study of the penal
institutions in five of the most progressive States of the Union, viz.

Digitized by VjOOQle

REVIEWS.

IS*

[Jan.,

New York, Massachusetts, Illinois, Ohio, and Pennsylvania. The
obvious bearing which many of the methods discussed have on several
pressing penological problems at home invests this important document
with an added interest of actuality.

In his preliminary remarks Mr. Ruggles-Brise indicates as an impor¬
tant feature of the American system that in the United States crime
and its treatment are a matter of local and not of federal concern; each
State has its own code of criminal law and its own penal system.
The main lines of the latter are, however, similar in all the States:
petty offenders and prisoners awaiting trial are under the care and
control of the local authority representing the counties and the cities;
persons convicted of serious crime are under the control of the State.
The former are detained in workhouses and gaols, the latter in State
prisons, and in some of the States in State reformatories. The two
classes of institution correspond roughly, as regards their inmates, to
local and convict prisons in England, with the difference, however, that
a far larger proportion of American prisoners—considerably over half—
are confined in the State prisons, which are to be regarded as consti¬
tuting the penal system of the country.

After briefly adverting to the fact that the workhouses and gaols are
admittedly the dark side of the system, and are in crying need of reform,
Mr. Ruggles-Brise proceeds to deal with the State institutions.

With regard to the internal administration of the State prisons he
notes these characteristics: there is no progressive stage system as in
England, though there is a somewhat rudimentary system of “ grades,”
and prisoners can also earn a “ good time ” remission; in spite of the
Labour Laws the prisons are run as vast factories, and thus contribute
materially to their own maintenance; after working hours discipline is
considerably relaxed, prisoners being allowed to chew tobacco, read the
papers, etc.; the warden has practically a free hand in the management
of his prison, being controlled only by a Board of Governors. The
“ spoils system ” unfortunately extends to prison ad ministration, the Board
of Governors, and in most instances the warden, going in and out with
the political party to which they belong. It is further noted that
the structural principles adopted in these prisons are most excellent.

The part of the Report which will prove most interesting from our
point of view is that dealing with the State reformatory system for
juvenile adult criminals, of which the well-known institutions of Elmira
and Concord are the most typical examples.

Mr. Ruggles-Brise prefaces his discussion of this system by pointing
out the extent to which American penologists have been influenced by
the ideas of the doctrinaires of the French revolutionary period
touching the responsibility of society for the genesis of the criminal,
and the mode of reaction towards him which that responsibility should
entail: “ it is held that a youthful offender, or rather a juvenile adult
(the age is fifteen to thirty at Elmira, fifteen to thirty-five at Concord),
however serious his crime, is more sinned against than sinning. His
crime is due to inherited defect, mental or physical, to vicious environ¬
ment, to his not having had a chance.” Hence the duty of society is
his regeneration, and not his punishment.

Digitized by VjOOQle

1900.]

REVIEWS.

153

The system pursued Mr. Ruggles-Brise describes thus:—“Themethods
of reform employed at Concord and Elmira, though differing in detail,
are in principle the same. They are, shortly, physical development, by
gymnastic and military exercise; intellectual training, i. e. from the
grammar school of the illiterates to advanced lectures on political,
ethical, and economic subjects; manual training, from the elementary
Sloyd process to advanced technological study, e.g. engraving, etching,
carving; industrial training in the ordinary outside trades—masonry,
carpentering, etc.

“The classification is by a system of grades kept with mathematical
exactness, showing the advance or relapse of each inmate in each
department of letters, art, industry, and general conduct. The inmate
is first put into an intermediate or probationary grade for six months.
For bad conduct he may be at any time reduced to the lowest grade.
After good conduct for six consecutive months he is advanced to the
highest grade. The basis of the whole system is the indeterminate
sentence, by which parole can be earned in twelve months, but the
average time for parole is about twenty-two months. No inmate is
paroled until he has a situation provided for him, and from that time
he is under surveillance for six months, during which time he may be
at any time returned to the reformatory for breach of parole. It is a
mistake to suppose that the discipline is lax, or that these places are
hotels where the prisoners go to enjoy themselves and have an easy
time. The contrary is nearer the truth. At both institutions it is a
common thing for the inmates to express a preference for the State
prison. . . .

“ A distinctive trait of the Elmira Reformatory is its reliance on the
so-called physical method as an instrument of reform. The principle
of it is that physical degeneracy lies at the bottom of the criminal
character. I saw a batch of inmates at Elmira going through a course
of Turkish baths, fitted in a most costly and elaborate manner. Thence
they are taken to a shower-bath and given a cold douche, and then put
through a course of gymnastic exercise, the purpose being to repair and
fit the organism for its normal and healthful functions, increasing the
amount of nervous energy, and by this means strengthening character.”

In criticising this system Mr. Ruggles-Brise observes that too much
stress must not be laid on statistics of probable reform : firstly, because
the large proportion of the prisoners are first offenders, who are or¬
dinarily less liable to relapse; and secondly, because the surveillance
after release is too short to show whether the cure is permanent.
“ But,” he adds, “I lay great stress on the general character and object
of these institutions, as evidencing an effort deliberately made, ingeni¬
ously contrived, and systematically executed, to deal with the great
criminal problem of adult-juvenile criminality.”

As regards the application of similar principles to this country, Mr.
Ruggles-Brise recalls the fact that two recent committees, viz. the
Committee on English Prisons and the Committee on Reformatories,
in their reports expressed a strong opinion in favour of a differential
treatment of young and first offenders as an alternative to ordinaiy
prison methods, and in the light of these reports he considers that it is

Digitized by VjOOQle

154

REVIEWS.

[Jan.,

not impossible that public opinion in England would encourage an
experiment having for its object the treatment of adult-juvenile offenders
between sixteen and twenty-one on methods specially directed to their
physical and moral reform, adequate length of treatment being secured
by the adoption of the principle of the indeterminate sentence.

Naturally the reformatory system as it is worked in America is an
expensive affair: thus the net cost per head is a shade over 133 dollars
at Elmira, and 183 dollars at Concord; at the State prison of Sing
Sing, on the other hand, it only comes to 71 dollars, and at Joliet to
20*6 dollars.

While Mr. Ruggles-Brise is thus favourably impressed with American
reformatory methods as applied to first offenders and juvenile-adults,
he is by no means prepared to endorse their extension to confirmed
criminals. Of recent years a tendency in this direction has appeared,
and several State legislatures have introduced for ordinary convicts the
parole system based on the indeterminate sentence. This in effect
gives to boards of elective managers the power to discharge from
prison, possibly after some twelve months’ imprisonment, any criminal
who succeeds in making them believe that he is not likely again to
violate the law. Mr. Ruggles-Brise criticises this system adversely, as
being opposed to the fundamental aim of the Criminal Code—the
protection of the community; the reasons which support this mode of
treatment for individuals with incipient criminal tendencies are not
valid in the case of recidivists.

Another detail of penological method dealt with in the Report is the
probation system in use in the State of Massachusetts. Under this
system the courts appoint special probation officers whose duty is to
inquire into the character and antecedents of persons before trial and
to report to the judge, and after trial to take charge of persons whom
the judge shall place on probation and commit to their care. The
system appears to be mainly applied to cases of drunkenness. It is
stated by a public commission, which inquired into it in 1896, to have
“ worked with admirable results.”

In an appendix Mr. Ruggles-Brise discusses the movement of crime
in America and the relative criminality of America and England. He
points out that the absence of accurate statistics in the United States
renders investigation difficult, the only method available being the
comparison of the prison population at given dates. The following
table shows the proportion to total population of the prisoners in the
two classes of prisons in the years 1880 and 1890:

State .
Local .

All prisoners

1880.

1 in 1395
1 in 2214
1 in 855

1890.

1 in 1358
1 in 1721
1 in 759

—which shows a very slight increase in serious crime and a considerable
increase in petty crime in the ten years 1880-90.

Still greater difficulty attends the comparison of the amount of crime
in England and in America. Calculating roughly from the latest
available statistics for the two countries, one finds that in England

Digitized by VjOOQle

1900.]

REVIEWS.

155

there is i prisoner in every 1764 inhabitants, in America 1 in every
759 Incidentally Mr. Ruggles-Brise demolishes the theory that the
prevalence of crime in America is due to the foreign immigrants; he
shows that this conclusion is arrived at by comparing the total native-
born population with the total immigrant population, overlooking the
fact that the young children who furnish hardly any criminals belong
nearly all to the former category. When the populations compared are
the males of voting age, it is found that there is an actual excess on
ratio of native over foreign-bom prisoners of 50 per cent.

Judicial Statistics, England and Wales , 1897. Parti.—Criminal
Statistics . London, 1899.

This volume of the Criminal Statistics is the fifth of the new series
inaugurated in 1892.

The improvements in the amount of matter and in its method of
presentation, which were made in accordance with the recommendations
of the Departmental Committee of that year, have enormously increased
the value of these returns, and have done much to remove from our
statistics the stigma of inferiority to those of other European govern¬
ments. With some further modifications and additions they would
come up to the level of the best Continental models.

Their most notable defect is still in information concerning what may
be termed the criminal individuality; on such points, for instance, as
domicile, civil state, economic condition, religion, they are entirely
silent. And in the case of those individual factors which are dealt
with, such as age, sex, nationality, the information furnished might be
more extensive. At present, for instance, in these tables account is
only taken of convicted prisoners. This is of course in most cases
natural and sufficient, but in a few instances it involves a sacrifice of
interesting results. To cite a striking case, attempting to commit
suicide is an offence of great and growing frequency ; as it is, however,
usually viewed with leniency, only a very small proportion of persons
charged therewith are eventually sent for trial; hence the statistical
information regarding this very interesting phenomenon is available in
only about 8 per cent, of the cases. In special circumstances of this
kind supplementary details might be given for accused as distinguished
from convicted prisoners. Such information is in fact furnished at
present for all forms of indictable crime in the police reports of many of
the larger boroughs.

In a few other matters dealt with in the tables more minute details
might also be given. For instance, it should be possible, as is done to
some extent in the new Scottish tables, to indicate in charges of homi¬
cide, wounding, etc., the number of cases in which the victims were
relatives of the offenders. In sexual crimes, again, the value of the
statistics would be enhanced by distinguishing cases of rape and in¬
decent assault on adults from cases of such offences committed on

Digitized by

Google

REVIEWS.

156

[Jan.,

children; the psychological import of these two varieties of sexual
crime is probably very different.

The information given in the coroners* tables might also be amplified,
especially as regards the statistics of suicides ; details, for instance, of
age, etc., might be included, and the age groups might be assimilated
to those used in the other tables, to facilitate comparison with the
different categories of crime, and with suicidal attempts.

Apart from such slight defects as we have indicated, the present
volume is excellently prepared; the comparative tables and diagrams in
particular are of the same admirable lucidity to which the editing of
Mr. Troup and Mr. Simpson has accustomed us.

In his introduction the present editor indicates, as the chief inference
deducible from the year’s figures, the further evidence they afford of
the tendency to decrease in serious crime which has been observable in
this country during the last twenty years. The progressive character of
that decrease, apart from merely fortuitous oscillations, is clearly shown
in tables and diagrams presenting for each year from 1875 to 1895, not
the actual number of indictable crimes in that year, but the annual
average estimated on five years’ figures, viz. the year in question, the
two years preceding, and the two years following that year.

If we now regard the different categories of indictable crime sepa¬
rately, we find that the decrease in the total is due almost entirely to a
falling off in the class of offences against property without violence. In
malicious injuries to property and in coinage offences the decrease is
less regular. In offences against property with violence there is rather
a tendency to increase, due most probably to the short sentence system
allowing a larger number of professional burglars to be at large. Crimes
against the person have also tended to be more numerous. The class
of miscellaneous offences shows a large increase, due entirely to the
steady rise in the number of attempts to commit suicide.

Viewed in relation to the estimated growth in population the diminu¬
tion in the figures is of course more marked; for indictable crime as a
whole the decrease from the quinquennial period 1878-82 to the quin¬
quennial period 1893-7, estimated on the ratio of the number of cases
reported to the population, amounts to 27*6 per cent. Amongst the
categories of crime showing an increase in the absolute figures, it is
found that the increase has been in excess of population only in the
cases of sexual crimes and attempts to commit suicide; the latter
offence has increased during the period mentioned by over 58 per cent.

The statistics of sentences awarded show a continuance of the recent
tendency to more lenient treatment of indictable crime. For example,
in 1897 of persons convicted on indictment of burglary and house¬
breaking only 13 per cent, were sent to penal servitude, as against 21
per cent, in 1877.

The figures relating to summary proceedings show the usual rise,
corresponding to the growing complexity of the collective life, with the
resulting multiplication of social sins of omission.

The comparative tables this year include an interesting return regard¬
ing coroners’ inquests for the last twenty years. It is curious to note
that the annual number of verdicts of death from excessive drinking has

Digitized by VjOOQle

1900 .]

REVIEWS.

157

in that period just doubled. The coroners’ returns also show the
increasing rarity of the verdict of felo de se . As an interesting point in
the psychology of the jury, it may be observed that the survival of this
verdict appears to be related not to social or economic conditions in the
localities where it persists, but solely to the personal views of the
coroners; that is to say, it tends to recur in the jurisdictions of indi¬
vidual coroners, while in the adjoining districts within the same towns
or counties the juries return the usual euphemistic verdict of “suicide
in unsound mind.” Oddly enough, of recent years verdicts of felo de se
have been relatively much more frequent in the case of female suicides.

A table of much medico-legal interest is that dealing with the offences
of criminal lunatics. The figures here show, as in previous years, that
inquiries into the mental state of offenders are practically confined, at
all events outside the large centres, to grave homicidal cases. Thus in
the year 1897, of forty-three lunatics who had committed offences of ihis
character, the mental state of the prisoner was recognised at or before
the trial in thirty-eight cases, leaving only five cases (ii*6 per cent.) in
which insanity either did not develop, or at least was not certified until
after sentence. On the other hand, amongst ninety-five criminal
lunatics who had committed other forms of indictable offence, the pro¬
portion not certified until after trial amounted to no less than 76*8 per
cent.

/ /

Contribution h FEtude du Prognostic de rEpilepsie chez les Enfants. Par
le Dr. E. Le Duigov. (Contribution to the Study of the Prognosis
of Epilepsy in Children.) Paris : aux Bureaux du Progrbs Medical,
and Felix Alcan, pp. 56.

In this brochure an attempt is made, upon the strength of ten clinical
observations of patients at Bicetre, to appraise the curability of epilepsy
occurring in childhood. The conclusions arrived at by the author are
that—

1. Epilepsy termed idiopathic may be cured in a certain number of
cases.

2. Epilepsy which commences with convulsions, appearing for the
first time at the age of two years or later, is more curable than that in
which they manifest themselves in the first year.

3. Though aggravating in a general way the prognosis of epilepsy,
heredity, whether direct or indirect, does not fatally compromise the
cure.

4. Intellectual enfeeblement, moral perversions, onanism, etc., involve
a more unfavourable prognosis.

5. Epilepsy associated with infantile hemiplegia disappears much
more frequently than that termed idiopathic.

It is to be regretted that the author has been obliged to found his
generalisations upon so small a number of cases, and it would be very
satisfactory if he were able (as it seems he originally intended) to follow
up the statistics of all the cases of epilepsy under treatment at BicStre.

Digitized by VjOOQle

I 5 »

REVIEWS.

[Jan.,

Such a study would be of much interest, and its value would at the
present time be specially appreciated in England in view of the various
arrangements now pending for the treatment and education of epileptic
children.

Recherches clitiiques et therapcutiqucs sur PEpilepsie , rHysterie, et
PIdiotic, Par Bourneville, avec la collaboration de MM.
Cestan, Chapotin, Katz, Noir (J.), Philippe, Sebilleau, et Boyer
(J.). Vol. xix. (Clinical and Therapeutical Researches on
Epilepsy, Hysteria, and Idiocy. Bourneville, etc.) Paris: aux
Bureaux du Progrbs Medical, and F£lix Alcan. Pp. 236, 13
plates, 13 illustrations in text, large 8vo. Price 5 fr.

This annual volume consists, as usual, of two portions : the first being
a report of the arrangements for defective and epileptic children at the
Bic6tre and at the Fondation Valine, with remarks on the desirability
of establishing special instruction classes in Paris; and the second
being devoted to clinical and pathological observations. At the Bic£tre
there were on the nth of January, 1898, 459 children, of whom 435
were idiots, imbeciles, or epileptics of unsound mfnd, and 24 classed as
non-insane epileptics. The last named were placed in the Bicfctre at
the charge of the municipality, and not like the others at the charge
of the department, so that the problem of dealing from public funds
with epileptic children not insane seems to stand much on the same
footing in France as in England. On the 31st of December, 1898, of 462
children in the Bic€tre, not less than 45 were classed as non-insane
epileptics. During the year 74 patients were admitted, 19 patients
died, and 54 were discharged. Of the deaths, 8 were due to epilepsy,
3 to pulmonary tubercle, 1 to tuberculous enteritis, and 5 to typhoid or
its sequelae.

It would appear that at the Bic&tre the proportion of deaths from
tubercle is this year less than the average in English institutions. At the
Fondation Valtee there were on 31st December, 1898,189 imbecile, epi¬
leptic, and hysterical girls, the admissions having been 62, the deaths
13, the discharges 20, and the transfers 24. (There is an error in the
headings of the table on p. 54.) Tubercular disease seems to have been
a factor in 7 out of the 13 deaths. A powerful appeal for the creation of
special classes for feeble-minded children in connection with the primary
schools of Paris closes this portion of the volume, and this appeal is
strengthened by a recital of satisfactory results obtained from such
classes in Switzerland, England, and Belgium.

We may perhaps say that the more interesting sections are those
which relate to the observation of cases. The use of bromide of camphor
in chorea forms the subject of an exhaustive article by Bourneville and
Katz, and is very favourably reported on. A case of double athetosis
with imbecility is carefully described, and Bourneville records his
opinion that children of this type are susceptible of much amelioration
if subjected to proper treatment at an early age (two or three years),

Digitized by VjOOQle

REVIEWS.

I 900 .]

1 59

after which their chances diminish. So far as mental improvement is
concerned, apart from control of muscular movement, we have seen
good results from education even at twelve or fourteen years of age, and
we have seen excellent macrara^ work and even wood-carving done by
children of this type, whose training was not commenced in early
infancy. A graphic account is given of a case of adolescent mania with
nymphomania, in which the starting-point seemed to have been a
sermon on death! Cure is recorded after seven months’ treatment at
BicStre. Another terrible example of juvenile depravity is given under
the heading of “infantile alcoholism, mental instability, and moral
imbecility,” the patient being a boy of thirteen who drank, smoked, and
attempted suicide, but whose condition speedily improved under treat¬
ment at Dr. Boumeville’s “ Institut m^dico-pedagogique.”

As usual the report contains some excellent plates, one of a case of
imbecility with athetosis at various ages, another of meningitic idiocy;
and there are large-sized illustrations of the brains of these and other
cases, such as hydrocephalic and sclerotic idiocy.

Lemons sur les maladies nerveuses. Deuxieme sdrie (H6pital Saint-
Antoine). Par E. Brissaud. Recueillies et publics par Henry
Meige. Paris: Masson et Cie., Editeurs, 1899, pp. 560, 165 figs.
Price 18 fr.

In this second volume of twenty-seven clinical lectures on nervous
diseases, some of which have been already published in scattered
periodicals (Presse mtdicale , Bulletin mkdical\ Progrte medical\ etc.),
Prof. Brissaud has given us a collection of most interesting and care¬
fully made observations accompanied with valuable remarks and com¬
ments, forming an important contribution to neurology.

After a chapter devoted to the general pathology of the neuron,
some of the reactions of which he compares with the phenomenon of
polarity in static electricity, in accordance with which he refers to the
axion as the positive and the dendrite the negative end of the cell,
and to the questions of chromatolysis, Prof. Brissaud discusses the dis¬
tribution of herpes zoster, especially in its relation to spinal localisation.
It is not so long ago that most clinical teachers seemed to close their
eyes to the fact that the eruption of herpes zoster on the chest rather
crosses obliquely the tracts of the intercostal nerves than follows their
course; but since the work of Head, Starr, and others we have been
taught to look for a central lesion to explain this. The distribution of
zoster as well as that of the thermo-anaesthesia of syringomyelia points to
a problematical persistence of the embryonic metameric disposition along
the whole length of the neural axis in the adult. “ Each primitive
segment,” as Brissaud says, “ of which we are formed in embryonic
life indefinitely preserves the material imprint of its initial differentia¬
tion.” While the study of herpes zoster on the trunk and the limbs
leads to the conclusion that it is often of central origin, there are of
course cases of peripheral origin (alcoholism, beri-beri, etc.).

Digitized by VjOOQle

REVIEWS.

160

[Jan.,

In connection with the question of metamerism it is important not
to confound radicular metamerism (/. e. of spinal nerve-roots) with true
spinal metamerism ; there is nothing in common between the peri¬
pheral distribution of radicular fibres and the peripheral representation
of spinal metamers.

In this relation the study of the distribution of anaesthesia in bands
and in sections (e.g. in the direction of the axis, and at right angles to
the axis, of a limb) in certain diseases is very interesting. In the case
of the cervical and lumbar enlargements of the cord Brissaud holds that
a secondary metamerism of the spinal enlargements corresponding to
the limbs is demonstrated.

The sixth lecture deals with ophthalmic herpes, and attention is
drawn incidentally to the importance of a guarded prognosis in these
cases on account of its frequent association with crossed hemiplegia.

In three of the following lectures Brissaud dilates on the support
which dermatology gives to the thesis of spinal metamerism; for
example, in the study of the distribution of the eruption in lichen,
pigmentary scleroderma, etc. If the diagnosis of radicular localisation
has been made possible by the convincing works of Ross, Allen Starr,
and Head, everything leads one to hope that that of spinal localisation
will soon not be insurmountable; in other words, if we owe it to these
authors that we can localise disorders of the radicular zones or rhi¬
zomes, the day seems near when we shall be able to localise the
disorders of the spinal zones or myelomers.

In the discussion of transverse myelitis Brissaud especially dwells on
the question of flaccid paralysis, which may occur early, or may be
secondary to spasmodic paraplegia after an interval of time. He rejects
the view of Marinesco, who holds that no single case has been observed
(with post-mortem confirmation) of complete transverse myelitis with
presence of knee-jerks. The secondary flaccid paralysis is believed to
be due to generalised peripheral neuritis. Every case of degeneration
of the lateral tract, either on one side or on both sides together,
exhibits as an inevitable consequence permanent contracture or spasm
whenever the sclerosis is not complicated with an accessory destructive
lesion of the grey substance of the roots, or the nerves, or the mus-
cles.

In Lecture XI is the description of a very interesting case of para¬
lysis of the roots of the brachial plexus, which could not be diagnosed
from syringomyelia.

The subject of syphilis of the spinal cord affords the author an
opportunity of discussing the syndroma of Brown-Sdquard (hemi-
paraplegia with crossed hemianaesthesia), in which the anaesthesia
habitually exhibits the dissociation so characteristic of syringomyelia;
the question of the tracts for heat, pain, and sensation in the cord is
also touched upon.

Lecture XIV is devoted to cases in which is observed the late reap¬
pearance of atrophic and paralytic disorders in the subjects of early
infantile poliomyelitis, due generally to a subacute adult poliomyelitis,
and no doubt arising from an original imperfection of the body of the
motor cell of the myoneuron.

Digitized by VjOOQle

1900.]

REVIEWS.

161

Lecture XV deals with the fascia lata reflex. After a superficial
plantar excitation the first contraction noticed is that of the tensor
vaginae femoris, and it is important to note the early atrophy of this
muscle in certain paralyses of central origin.

In Lectures XVI and XVII we find a very good account of bulbar
paralysis and pseudo-bulbar paralysis, with an analysis of the lesions
which produce them. In pseudo-bulbar paralysis the paralysis is
frequently a spasmodic one, hence the laughing and crying crises, etc. ;
and on account of the facial appearance and other manifestations it is
important not to diagnose incipient dementia in these cases.

Lectures XVIII and XIX are devoted to the slow pulse of cerebral
origin. Many authors refer cases of more or less frequent and more or
less permanent attacks of “ slow pulse ” to some cardiac cause. Bris-
saud shows that it is frequently associated with attacks of syncope,
occasionally with facial paralysis, and is most commonly a bulbar
symptom. In one interesting case which he details at length it was
probably due to the pressure of a tuberculous growth on the pons.

Among the subjects considered in the concluding ones of these
fascinating lectures we note especially “infantilism,” which Brissaud
shows to be a much too comprehensive term. The “ infantilism ”
related to cardiac, arterial, tubercular, etc., disorders should be clearly
differentiated, he shows, from myxcedematous infantilism (dysthy-
roidean), a condition which is itself different from true myxcedema,
although it is also markedly benefited by the administration of thyroid
extract. Some reason for the difference just referred to may possibly
be found in the distinction which Brissaud draws (see Lecture XXV)
between thyroidean myxcedema and parathyroidean myxcedema, the
former condition not being accompanied with intellectual apathy, and
the latter (due to a total alteration in the thyroid glandular apparatus)
exhibiting cretinoid idiocy or dementia.

This collection of clinical lectures is another testimony to the great
ability and activity of Charcot’s pupils and successors in the field of
neurology, and forms a worthy sequel to the works of the master.

Genlse et Nature de F Hysteric. Par le Dr. Vaul Sollier. 2 vols.
Paris: Ancienne Librairie Germer, Baillifere et Cie.; F^lix Alcan,
£diteur. Vol. i, pp. 526 ; vol. ii, pp. 333.

Dr. Paul Sollier, in the course of his researches into the mechanism
of hysterical manifestations, and into the nature of the disease, became
irresistibly led, without any preconceived notions, he is anxious to inform
us, to a new conception of hysteria, and these two bulky volumes are
the result. In the second volume are copious notes of observations and
experiments on twenty marked cases of hysteria, an analysis of which
has led him to the deductions and conclusions concerning the pathogeny
of hysteria which he brings forward in his first volume.

While the tendency is to consider hysteria as a mental or purely
psychical affection, Dr. Sollier is convinced “ that it is a physical one,
although simply functional.”

XLVI. 11

Digitized by Google

162

REVIEWS.

[Jan.,

Early on, struck by the amnesia and insomnia noticed in confirmed
hysterics, he discovers that hysteria is in reality a condition of patho¬
logical sleep or “ vigt/ambu/ism ”practically resembling somnambulism,
with this difference, “that in somnambulism patients have their eyes
closed or appear to be walking in their sleep, while in the case of
hysterical patients they appear, even to observers who are careful , to be
awake.”

Hysteria is, therefore, a disorder of sensation arising from numbness
or sleep of the cerebral centres, and it suffices to awaken the patients
and they are cured.

The next step forward in his theory was taken with the discovery that
awakening in hysteria is only complete when sensation is normal, and
that anaesthesia, which by its intensity and extent reveals the degree of
somnambulism, is the cause of hysterical symptoms or attacks. As a
corollary, make your patient feel and you cure him.

Since telling the patients to wake up did not always succeed in
causing the anaesthesia of hysteria to disappear, it became necessary to
facilitate the return of sensation by other means. Therefore Dr. Sollier
tried the effect of telling his patients, while in a state of hypnotic sleep,
to feel their arms, their legs, their stomach, their heart, etc., in succession,
and pages upon pages of his observations tell us of the wonderful sen¬
sations experienced by the patients during this process, “ supervening in
a definite order which appears to be subject to physiological laws.”

Hypnotism, while ntcessary in a certain number of cases, is not
always required to awaken sensation; other means are at our
disposal—simple fixation of attention upon the • anaesthetic parts,
mechanical means (hydrotherapy, electricity, etc.), and isolation.

When dealing with the viscera which cannot be influenced by
electricity and passive movements, their normal function must be
excited by the most powerful of their habitual stimulants (feeding in
the case of the stomach, etc.), and sensation reappears.

The general conception underlying these methods of procedure is
“awakening the cerebral centres.”

At first sight, says Sollier, this all seems to be suggestion , but nothing
is further from the truth : “ I have taken the greatest care to eliminate
the element of suggestion, which, deplorable from a therapeutical point
of view, is the most detestable of procedures in experimental psy¬
chology.”

That suggestion is not involved is, he says, proved by the fact that
when once started the return of sensation takes place in a certain definite
unchangeable order, that it is propagated to other organs than those to
which the patient's attention is drawn, and that the centre presiding
over the organs in which sensation reappears is the seat of special
sensations—painful hyperaesthesia. This may seem convincing to the
author, but it is difficult in wading through the accounts of the
numerous experiments (stances which must have lasted hours, one
would surmise) made upon “grandes hyst^riques,” most suggestible
among suggestible patients, and not infrequently “ grandes actrices ” as
well, and reading long accounts of their subjective symptoms, not to
conclude that all the results appear to fit in wonderfully well with what

Digitized by VjOOQle

REVIEWS.

1900.]

163

Dr. Sollier would expect; and one may well be excused for asking for
more proof of the existence of stomach, bowel, heart, etc., anaesthesia
in these cases—more proof of the existence of those cerebral centres
which are supposed to preside over the various viscera to which the
author draws marked attention. A patient is hypnotised, for example,
and asked whether she feels her heart “No,” is the answer, “ 1 have
none.” The observation is then made that over the precordial area
there is a large zone of anaesthesia and analgesia. “ Feel your heart
and chest,” she is then told. Thereupon a number of subjective
symptoms are described by the patient; she says she feels her heart
beat, etc., and lo and behold! the anaesthesia and analgesia have
disappeared ; ergo they were related to anaesthesia of the heart. When
on page 119, vol. ii, we are told concerning ‘Yvonne 1 that, “although
her pulse is regular, she feels her heart beat irregularly,” it is obvious
that the hysterical patient’s account of her sensations is not an unfailing
guide to the condition of her organs, and we fear that Dr. Sollier has
attached too much importance to these subjective phenomena. Not
only the heart, but the brain, it appears, has its sensation proper; “ it
can perceive what takes place within it as well as without it, ... .
and .... can act on itself.” Mirabilt dictu 1 And anaesthesia-of the
brain has also its hyperaesthetic painful spot on the top of the head,
above the frontal lobe. It is the site of the famous hysterical clavus
which appears at the onset of the disease, and persists when other signs
have disappeared.

We have said enough to show the general drift and argument of the
book. While one may differ from the author’s conclusions, it is
nevertheless worth reading on account of the novelty and originality of
his views, and because there is a collection of material of the greatest
interest to the psychologist. While the greatest part of the book deals
with the relation of anaesthesia to hysteria, and the author looks upon
the presence of anaesthesia as of capital importance, he does not
consider it the sole basis of the condition ; his definition of hysteria is :
“ a physical , functional disorder of the brain , consisting in a numbness (or
torpor ) or localised or generalised sleeps temporary or permanent , of the
cerebral centres , manifesting itself in consequence , according to the centres
affected\ by vaso-motor , and trophic , visceral , sensorial and sensori¬
motor, and finally psychical phenomena , and according to its variations , its
degree , and its duration , by transitory symptoms , permanent stigmata , or
paroxysmal attacks. Confirmed hysterics are but ‘ vigilambulists ,’ whose
state of sleep is more or less deep , more or less extensive .”

Introduction ct la Medecine de PEsprit. Par le Dr. Maurice de Fleury.
Paris : Ancienne Librairie Germer, Baillifere et Cie.; F^lix Alcan,
dditeur, 1897. Pp. 477. Price 7 fr. 50 c.

In some respects this book, especially addressed to the general public,
may be said to have been written in vindication of the medical profes¬
sion. At a time when, especially in France, the novelist, the journalist,

Digitized by VjOOQle

164

REVIEWS.

[Jan.,

and dramatic author are at pains to magnify the abuses and foibles of
the doctors, Dr. de Fleury reminds one and all of the work which is
being silently accomplished by them. In the first part of his work
he dwells on the share which medical science has taken in expand¬
ing and emancipating human thought, and in the second he shows
that medical studies in physiological psychology lead to a moral—to
the truly efficacious therapeutics of the soul The knowledge of the
human brain is instrumental in diminishing suffering and in furthering
the culture of the ego. 9

In Chapter I is a summary of the teaching of la Salpltrihre , in which
full appreciation is given to the work of Charcot and his school in
elucidating the complex problems of hysteria, hypnotism, etc. Dr. de
Fleury, at the same time that he lays stress on the defined results of
their numerous experiments, and on the sound knowledge arising there¬
from (the light thrown on history, etc.), is careful to eliminate the chaff.
Of clairvoyancy, telepathy, transmission of thought, envoAtement , etc.,
we cannot be said to possess any real scientific knowledge.

Chapter II—“ Doctors and Justice ”—deals with important medico
legal questions. Medical men may be called upon to decide whether
hypnotism is concerned in certain crimes, but the author deprecates
hypnotising accused persons in order to obtain information. He recog¬
nises the rarity of crimes committed under hypnotic influence. The
interesting question of criminal responsibility is touched upon, and he
incidentally urges the advisability of magistrates possessing some know¬
ledge of psychology. Until the day—which he appears to hope will not
be far distant—when there will be a “formal negation of the doctrine
of free will,” he is in favour of verdicts of partial responsibility, and
favours Magnan’s ideas of the institution of hospital-prisons.

Dr. de Fleury bemoans the absence of the religious feeling in France,
and the suppression of religious instruction in schools. “ The fear of
eternal punishment is a curb of great powerand although the notion
is perhaps false, says he, it is of great practical utility. Perhaps, after
the experience of Messrs. Voulet and Chanoine, he would reconsider
his suggestion that a colonial army might usefully be compounded with
such ingredients as “ graine de meurtriers, de voleurs, d’anarchistes.”

In the chapter on “ Doctors and Literature ” we find a useful contri¬
bution to the question of “tobacco smoking,” with the opinions of
quite a number of celebrated French literary men concerning their
reaction to the “noxious weed.” The author looks forward to the
time when medical science will pursue its researches into the domain of
art, and learn much from the exaggeration and pessimism associated
with certain schools of literature. Incidentally there is some valuable
criticism of some aspects of modem French writings, and interesting
remarks on the creative and critical faculties in art.

Chapter IV is devoted to an attempt to convey to the uninitiated some
knowledge of the physiology of the brain, including recent researches
into the structure and functions of neurons.

In Chapter V, on “ Fatigue and Energy,” are discussed the factors
which facilitate the recuperation of the nervous system—rest, training,
and methodical stimulation. Dr. de Fleury is evidently much impressed

Digitized by VjOOQle

REVIEWS.

1900.]

165

with Dr. J. Charon’s work on hypodermic medication, and refers on
several occasions throughout this book to the great benefits to be derived
from the hypodermic injection of artificial serum or salt solution in
nerve exhaustion—“ the most powerful, the most manageable, and the
most useful of stimulants to the nervous system,” as he calls it on p. 397.
He is sceptical of the view that physical exercise, except in great modera¬
tion, is beneficial after mental overwork, considering that the brain only
undei^oes one form of fatigue. That some brains apparently seldom
experience this fatigue he illustrates by references to the labours of men
like Dumas, Balzac, and Michelet.

In the second part of the work we are shown how modem observa¬
tions and experiments lead to a rational treatment of the mind.
Indolence, sadness, morbid love, and anger being especially found
in neuropaths, successive chapters are devoted to these conditions, and
hints given concerning their treatment. It is here that the doctor must
lead and watch his patient. While such men as Darwin and Zola can
overcome unaided such tendencies to indolence, most subjects of this
weakness require rules of hygiene and the treatment which is generally
efficacious in neurasthenia. The substitution in the mind of some
beautiful fixed idea for an absurd obsession, with patience, may be
accomplished, and forcing the patient into good habits is urged,—a
habit, the author reminding us, being merely the substitution of an auto¬
matic act, practically unaccompanied with distress or fatigue, for a
voluntary act which induces brain weariness.

Dr. de Fleury recommends that intellectual work should be under¬
taken daily, should be regulated, begun at a fixed time, and matutinal.
Pessimism, which is so rampant in the modem literature of his own
country, is found in proportion as passive meditation is practised, and in
inverse ratio to the outward activity of the mind—“ Bonum est diffusum
sui.”

Sadness is a symptom of brain fatigue and nervous exhaustion, and
may be frequently cured by attention to details. A regulated dose of
serum is here most efficacious. Sadness and anger are especially analysed
with a view of showing that they can be reduced to problems of cerebral
mechanics ; and the author, in support of this view, draws deductions
almost d outrance from Lange and James’s work on the emotions, etc.
Hence treatment is to be carried out with mechanical stimulants, such
as the douche, salt baths, massage, static electricity, the air cure, and
lastly (but certainly not least in his estimation), hypodermic injections,
which act on the sensory nerves. “ Methodical progressive stimulation
in emotional disorders causes the nerve-cells to assume their * normal
tonus.’ ”

Chapter VII, dealing with love and jealousy, is curious and sugges¬
tive. Sentimental love is an emotional intoxication. Its course,
symptoms, treatment, etc., are those observed in intoxications by
morphia, drink, tobacco. Its usual accompaniment, jealousy, with its
characteristic attacks, is so markedly influenced, the author shows, by
purely physical conditions, that the mechanical theory receives addi¬
tional support or proof.

Anger is found especially in two classes of patients: on the one hand

Digitized by VjOOQle

REVIEWS.

[Jan.,

166

it is closely associated with brain fatigue and profound nervous exhaus¬
tion—the asthenic form ; and on the other hand it is found in the
“ hypersthenic.” “ Hypersthenic ” anger manifests itself in attacks—true
psychical convulsions—which are often the mental equivalent of epi¬
leptic attacks, and are observed in cases with bad heredity (alcoholism,
petit mal\ etc.). Bromides do good.

In ,the last chapter Dr. de Fleury endeavours to formulate some
modem system of ethics. Anglo-Saxon ideals appeal to him more than
the Latin, and incidentally he speaks in high praise of the sweet and
comforting influence of Sir John Lubbock’s writings. After a judicious
course of nerve tonics, and the adoption of measures calculated to
improve the nutrition of the brain and the temper of the will in
neuropaths, the perusal of The Use of Life , or some such like book,
should prove a practical and wholesome means of completing the
cure.

While one may well feel some doubt as to the simple mechanical view
of the author concerning the varying phases of emotions, and as to
the potency of the means at our command for favourably influencing
them, it is impossible not to conclude that, he has written a most
interesting and suggestive work. It is evidently the result of painstaking
labour—six years of observations and experiments, the author tells us,
—breathes a scientific spirit, and is permeated with a pleasurable aroma
of culture.

LAnnie psychologique. Par A. Binet. Paris: Schleicher, 1899.

Pp. 902, large 8vo. Price 15 fr.

This fifth issue of Dr. Binet’s year-book shows an interesting change
of method. We have more than once pointed out that the plan of
including a number of very special and detailed investigations in a
year-book, which should appeal to all interested in psychology, is a
serious error. The memoirs are still here—indeed, they now occupy
two thirds of the volume,—but they have wholly changed in character;
instead of detailing minute investigations carried out in the Sorbonne
laboratory, they present us with broad and comprehensive summaries of
the present state of various generally interesting questions. Some of
them are by the best living authorities on their subjects, and in
several cases extremely useful bibliographies are appended. On the
whole, Dr. Binet has thus greatly increased the value of his work, and
it is not now possible to bring forward any serious criticism.

The first memoir, a general review of the investigations on muscular
fatigue, is by Mile. Joteyko, who is known as a diligent inves¬
tigator into this subject. It begins with a reference to the Greeks,
and ends with a summary of the just published results of Maggiora ; to
it is appended a chronological bibliography from 1846 onwards. This
is followed by a discussion and account of experiments concerning the
question why objects seem to diminish in rising above the horizon,
written by Professor Bourdon. Dr. Claparede, of Geneva, then
discusses stereognostic perception; that is to say, the appreciation of

Digitized by VjOOQle

1900.]

REVIEWS.

167

form by touch. He finds that this is strictly a “ perception,” not
a “sense ;” he also deals with its absence, or “stereo-agnosia.” Then
the editor deals at length with suggestibility from the point of view of
individual psychology. The memoir has nothing to do with hypnotism,
but simply with those forms of suggestion which are exercised in daily
life. There is an interesting section on the suggestion exercised by the
conjurer. Then M. V. Henri deals briefly with the mathematical
question of the calculus of probability as applied to psychology; and in
another paper, also short, with the influence of intellectual work on
metabolism. Professor Claviere summarises the chief facts and theories
of colour-hearing, while M. Larguier des Bancels compares the different
methods of measuring intellectual fatigue. Professor Zwaardemaker, of
Utrecht, deals at some length with his own special subject, olfactive
sensations; he shows that when combined in suitable quantities certain
odours balance and annihilate each other, and suggests that we may
ultimately reach a vibratory theory of smell. Dr. Marage discusses the
use of the phonograph in studying vowels, and the same author has a
long and interesting historical study concerning the investigation into
the relation between intelligence and the size and form of the head;
he emphasises the result of Manouvrier (founded on Broca’s registers),
that the volume of the frontal lobes has no relation to intelligence,
since these lobes always remain at about the proportion of 43 per cent,
of the whole brain. How little we yet know is shown by the doubt
finally expressed by Dr. Marage: it is clear, he remarks, that a large
brain is associated with high intelligence; but as regards the various
parts, it is not yet even clear whether the proportions of the cranium are
not more significant than the proportions of the brain it encloses.
Professor Blum summarises recent investigations, especially Vitales,
into the characteristics of children. M. Demeny deals with chrono-
photographic apparatus, and other authors briefly describe various
apparatus, such as the ophthalmometer for measuring the anterior
curvature of the cornea, the ophthalmophalcometer for determining
the position and curvature of the crystalline lens, Maxwell’s colour-
box, etc.; while Professor Obersteiner, of Vienna, describes the
psychodometer, which he has devised in association with Professor
Exner for measuring reaction times in the insane (price and maker are
not mentioned): it is stated to be simple, solid, and cheap, though
less precise than the chronoscope. The longest memoir in the volume
(160 pages) is by M. V. Henri, and is a general review of the muscular
sense, though at the outset the writer protests against the term, as it
merely stands for an ensemble of sensations. This valuable study is
followed by a bibliography of not less than 391 entries. Finally,
Professor Manouvrier furnishes an aper$u of anthropological character,
dealing with the measurement of the head in the living subject. This
paper contains various useful suggestions by a highly experienced
investigator; at the outset he points out that no book knowledge can
replace practical instruction in learning anthropological methods, since
there are so many minute but important sources of fallacy; but he
remarks that an intelligent medical man only requires two hours of
practical apprenticeship so far as the head is concerned.

Digitized by

Google

REVIEWS.

168

[Jan.

It is impossible in a brief space to summarise lengthy memoirs
which are themselves condensed summaries. The foregoing enumera¬
tion, however, may suffice to show the valuable character of a volume
which every alienist taking any scientific interest in his work will do
well to keep among his reference books.

The Human Machine . By J. F. Nisbet. London : Grant Richards,
1899. Pp- 297, 8vo. Price 6 s.

This book is by the author of a volume on The Insanity of Genius
(reviewed in the Journal at the time), which attracted considerable
attention a few years ago. Notwithstanding, however, the skill and
lucidity with which it was written, and the author’s wide knowledge of
literary history, it was obviously not the work of a writer properly
equipped for his task on the pathological side, and we were unable to
regard it as a serious contribution to the difficult problem it attempted
to settle. The present book is its author’s last work; he died within a
few days of its appearance, at the age of forty-seven.

Nisbet cannot be considered a psychologist; at the best he was only
an amateur psychologist. By profession he was a journalist, and at his
death, and for some years previously, he was dramatic critic to the
Times , and a regular contributor to other journals. A native of
Glasgow, he came to London at an early age, and by native force of
character and stolid unobtrusive energy quickly won a position for him¬
self in the journalistic world, while devoting his leisure to more abstract
problems. Though not a psychologist, Nisbet had in intellectual
matters the temperament of the philosopher. He was always devoured
by a passion to see things clearly, and to see them for himself. Though
his vision of the world was often singularly one-sided, he was determined
to be relentlessly sincere, at whatever cost to himself or others. His
creed was a convinced and thorough going materialism of a somewhat
old-fashioned type, and this he was always prepared to defend. A man
of exceedingly slow and deliberate speech, he was never afraid to
express, even with some grimness on occasion, and no undue tender¬
ness for his interlocutor’s feelings, whatever seemed to him to be the
inflexibly exact truth concerning the matter in hand. These characters
he retained to the last. It so chanced that the present reviewer, who
had met Nisbet many years previously, spent much of last winter at a
little hotel near Malaga, at which Nisbet also appeared. Reduced by
influenza and its complications—acting on a constitution doubtless
enfeebled by his arduous profession and an acknowledged thirst to
know all that life can give—he was the mere shadow of his former
robust self, but with characteristic independence he came alone, and
when, a few weeks later, having corrected the final proofs of this work,
he left the warm sunshine of the South for London in March, to die a
few days after arrival, it was with the calm consciousness of the fate
awaiting him.

In the present work, which, according to its sub-title, is “ An Inquiry

Digitized by VjOOQle

REVIEWS.

1900.]

169

into the Diversity of the Human Faculty in its Bearings upon Social
Life, Religion, Education, and Politics,” Nisbet has left a very personal
testament and witness to the faith that was in him. He here sets down
his conclusions concerning all the questions that interested him, not
only on such special points as genius, criminality, dreams, but on all
the great and ultimate problems which every man must face for
himself. It will be found helpfyl and stimulating, not least so by those
who cannot always share the author’s point of view.

La Nouvelle Monadologie . Par Ch. Renouvier et L. Prat. Paris :

Armand Colin, 1899. Pp. 546, 8vo. Price 12 fr.

M. Renouvier, it is unnecessary to say, is one of the most distin¬
guished of French philosophers. In the present work, written in
co-operation with M. Prat, he has attempted the task—which in most
hands would be presumptuous—of inviting comparison with Leibnitz.
The book touches on all the questions of life and thought, with that
distinction and elevation which have always marked M. Renouvier. To
deal with such a book adequately would be quite beyond either our
limits or our scope, for it makes no special appeal to the psychologist
and alienist. The work is divided into seven parts, under the headings
successively of “ The Monad,” “ The Composition and Organisation of
Monads,” “ Mind,” “ Passion,” “ Will,” “ Societies,” “ Justice.”

The Evolution of General Ideas . By Th. Ribot. Authorised transla¬
tion by Frances A. Welby. Chicago : Open Court Publishing Co.,
1899. Pp. 231, 8vo. Price 6 s. 6 d.

This is a translation of the distinguished French psychologist’s Evo¬
lution des Idles generates, which appeared two years ago, and was duly
reviewed by us at the time. We note that the translator has sensibly
added an index.

On Deafness, Giddiness , and Noises in the Head. By Dr. Edward
Woakes, assisted by Claud Woakes. London : H. K. Lewis, 1896.
4th edition, 8vo, Part I, pp. 224, 5 illustrations. Price 10s. 6 d.

It is not every day that we have the pleasure of perusing a book
which might serve as a model of what a medical treatise ought to be, in
these days when medicine calls to its aid nearly all contemporary
science. Throughout, it is a closely reasoned sequence of statements,
precise and logical, with little or no redundancy or padding. It is only
in one place that the author embarks on an imaginative career. Wher¬
ever there is a gap in the evidence adduced, such is at once honestly
stated, and the hope expressed, and even the prophecy made, that in

Digitized by VjOOQle

170

REVIEWS.

[Jan.,

future years, so promisingly prolific in scientific research, such will be
repaired. The subject is one of no little interest to the alienist. With
regard to vertigo, the symptom-complex, subjective and objective,
renders it fairly distinguishable. The “ falling,” however, the coarsest
symptom of the vertiginous state, may closely simulate certain epileptoid
states, such as petit mat\ and it is questionable whether the two states
are not often correlated. The gait also of vertiginous patients may
become chronically affected, and may require distinguishing. Other
common symptoms are nausea, vomiting, and dyspepsia. Others suffer
from agoraphobia, a sense of dread, or an uncontrollable tendency to
sobbing and weeping. Aged subjects exhibit picking and fidgeting with
the fingers, and in prolonged cases increasing loss of memory, inco-
herence, and mental decrepitude are final sequelae.

The allied state of tinnitus is also important. The ever-present
clashing of bells, rhythmical thuds, chattering voices, bubbling waters,
etc., pursue the victim with relentless torture night and day; and it is
no small wonder that mental disease may supervene. It is in consider¬
ing this part of his subject that the author diverts us somewhat with
speculative history. He claims Mahomet and Joan of Arc to have
been distinguished sufferers from tinnitus, and the former also from
vertigo. While in the mountain of Hira, Mahomet became subject to
fits, voices, bells, and visions. The nature of the fits as recorded
points to their vertiginous origin; while the noises are explicable by
imagining the co-existence of tinnitus. Joan of Arc, a being of like
temperament, was the subject of tinnitus, chiefly of the chattering variety,
which she soon translated into “ commands spoken to her by the
saints.” Whether the environment of the

“ Cold mountains and the midnight air ”

was more favourable to the development of the ecstatic mood than to
the occurrence of catarrhal affection of the ear and nose, we leave to the
reader to decide.

Other chapters deal with progressive deafness, furuncle, post-nasal
growths, the ear affections of infancy, etc., and are written with the
same logical and scientific acumen so eminently characteristic of the
book.

Nervenleiden und Erziehung (Neuropathy and Education ). Von Prof.
H. Oppenheim. Berlin: Williams and Norgate, 1899. Royal
8vo, pp. 56. Price is. id .

In this pamphlet Dr. Oppenheim discusses a subject which the
physician in general practice should make himself well acquainted with,
for specialists in neurology are not often consulted unless the child’s
deficiency is of a pronounced character. The professor lays down at
length a scheme of treatment—dietetic, hygienic, and educational—for
a child in whom there is a neurotic tendency. He observes that the
susceptibility to be disagreeably affected by noises is a cardinal symptom
of such an infirm temperament; healthy children do not dislike noises,

Digitized by VjOOQle

i goo.]

REVIEWS.

171

especially if they themselves are the cause of them. Dr. Oppenheim’s
recommendations are likely to be accepted in this country—an
exciting diet, accustoming the child not to shrink from small discom¬
forts, a country life if attainable, and much exercise in the open air.
It is important that the child should have a good allowance of sleep.
Everything which forms a character, which makes the will fast and
strong, also serves to the maintenance of sound nerves. To make the
child have a pleasure in work is a part of the education. Nervous
children should be kept from premature vanities, and should not be
encouraged to overwork themselves at school in order that their parents
should boast that they keep at the head of the class. As the child gets
older the dangers increase, and demand much greater care and circum¬
spection. Anyone who has perplexities in dealing with the many
difficult questions which are sure to arise in so difficult a charge will
derive light from Dr. Oppenheim’s well-written pamphlet.

Kliniske Forelaesninger over Nervesygdomme (Clinical Lectures on
Nervous Diseases). Af Dr. Knud Pontoppidan. Copenhagen,
1898. Crown 8vo, pp. 158.

The author is known by his lectures in the Clinique of the Kommune
Hospital of Copenhagen. Some of these he has already published in
three volumes under the title of Psychiatric Lectures and Studies , clinical
descriptions of the various forms of insanity, which have spread his
reputation through Scandinavia and Germany. In the little book
under review the professor deals with diseases of the nervous system.
The first paper is on a case of softening of the brain complicated with
double hemianopsia occurring in a man of seventy-one years of age.
The second is on a case of cerebro-spinal meningitis in which a
puncture was practised in the lumbar region of the spinal cord. The
next paper is on cerebral apoplexy with accessory phenomena and
hemiplegia. The fourth is on masked hysteria and hysterical deceit.
The next is on a distressing case of cancer of the oesophagus and spinal
cord in which there were paraplegia, superior dolorosa amyotrophica,
and in the end complete paraplegia. The sixth is on some rare nervous
puerperal affections. Dr. Pontoppidan then deals with paralysis of the
medulla and tumour of the pons. The ninth is an essay upon traumatic
lesions of the brain, and the book finishes with a lecture on hypo¬
chondria and the psychical treatment of the functional neuroses. One
of the best features of these admirable lectures is the skilful elaboration
of a diagnosis worked out upon a careful study of every symptom,
taking advantage of all means of scientific observation. This book
cannot fail to be highly instructive to the student of the more serious
forms of diseases of the nervous system, and we should like to see it
translated into English.

Digitized by VjOOQle

172

AMERICAN RETROSPECT.

[Jan.,

Part III.—Psychological Retrospect.

AMERICA.

By Dr. H. M. Bannister.

An adequate review of the progress of psychiatry in America during
the past two years is not exactly an easy task. The field is so wide, and
the possible details so numerous, that any statement of the facts within
reasonable compass is difficult, if not impracticable. From another
point of view there is really not so much to write, and the discrimina¬
tion of what will be of interest is a matter of some embarrassment. I
shall therefore only note such matters as occur to me, and admit that
my judgment may be at fault in some particulars.

The session of the Medico-Psychological Association at St. Louis, in
1898, was in all respects a success; its spirit was excellent, and the
papers presented mainly of a superior order. The annual address by
Dr. Eskridge pictured an ideal hospital for the insane, an ideal that,
while in many respects it will be hard to realise, is altogether along
the lines of the best thought in this direction. Another paper of
special practical interest which aroused some discussion was that of
Dr. Burr, giving his impressions of the county asylums of Wisconsin.
As your readers are aware, there is a certain faction of philanthropists
who advocate the county care of the insane on the Wisconsin plan, and
this statement by a competent observer was of interest. It may not be
necessary to say that his impressions were not the most favourable, that
he found the care of the insane in these institutions far below that given
them in the state asylums. The counties here it should be remembered
are the minor divisions of the state, and it is only exceptional that their
tax-paying capabilities are such as to enable them to support a properly
equipped institution for the care and treatment of lunatics. It is only
in Wisconsin that county care is preferred to state care for any consider¬
able portion of the chronic insane, or where it is regarded as anything
but a necessary evil in the lack of proper state accommodation. It has
been, however, so vigorously advocated by the Wisconsin authorities,
that it is sometimes proposed elsewhere in legislatures when the question
of provision for the insane arises, but not so far with success. There is
no doubt but that the county asylums of Wisconsin are a great improve¬
ment over many of the poor-houses and gaols, where the overflow from
the asylums goes in many other states; but the claim that they furnish
an ideal or even an approximately adequate provision is absurd.

The New York meeting of the Association last May was equally a
success, judging from the testimony and reports of its proceedings,
though the writer cannot personally testify, on account of unavoidable
absence. The papers presented were generally of a high order,
indicating earnest and well-directed work, which it may, I think, be said

Digitized by VjOOQle

1900.] AMERICAN RETROSPECT. 1 73

is becoming more and more the rule in our better organised hospitals
for the insane. There has never been any backwardness in adapting
every practical discovery to its best utility or in originating new
features of value by our American alienists; but it is more within the
past few years than ever before that they have so generally shown the
tendency to contribute to the higher grade of scientific work in the
specialty. Two new periodical publications started within the past two
years are to some extent evidence of this fact. The Archives of
Nturology and Psycho-pathology , issued by the New York State
Laboratory, is one of these; it is perhaps not entirely a new publication,
being the successor of the State Hospitals Bulletin , but it has been
completely changed, and is in every respect even more than its pre¬
decessor a high-class scientific publication. The other serial alluded
to is the Bulletin of the Ohio State Hospital for Epileptics , which has
thus far been the medium of the publication of the work of its
pathologist, Dr. Ohmacher. His memoirs are thorough and scientific,
though every one may not accept his views as to the lymphatic origin of
so-called idiopathic epilepsy. Good work is also being done in other
places and in other states, but the results have not such a special means
of communication to the world, and are scattered through the general
and special medical periodical literature of the country. It is a fact,
not perhaps generally appreciated, that in all departments of medicine
American workers are probably more familiar with European medical
literature than foreigners are with American contributions. The
tendency of American neurologists to overdo the foreign references in
their articles was alluded to by Dr. Lloyd in his presidential address
before the American Neurological Association, and the tendency is not
confined altogether to the neurologists. It is a significant fact, however,
in one respect; if perhaps we do still have a little too much regard for
the “ made in Germany ” trade-mark, our writers are beginning in all
departments to keep themselves well informed not only in the con¬
tributions in their own language, but in all others. Owing to political
appointments, etc., our alienists have been in times past somewhat
behindhand in this respect, but we believe that this is yearly becoming
less the fact.

We cannot record any notable advance in the therapeutics of mental
diseases, other than to say that the ideal of a psychopathic hospital is
more and more before our alienists, and that practical suggestions in
this general direction are being tested in various quarters. The often
discussed question of the curative effects of gynaecological treatment of
insane women is being extensively written upon by one or two enthusi¬
astic Canadian authorities, who report very striking results. This it will
be remembered was one of the subjects strongly advocated by the late
Dr. Rob£, but since his death there have not been many, in this
country at least, who have taken it up as vigorously as he did. It is
probable that there are few alienists who do not recognise the right of
the insane woman to be relieved of her infirmities ; but there are not so
many who have had the encouraging experience from gynaecological
surgery that is reported by the writers referred to, and there are many
who think that there are possible valid objections to such treatment in

Digitized by CjOOQle

174

FRENCH RETROSPECT.

[Jan.,

very many cases. On the whole the consensus of opinion in this
country on this question, both among alienists and neurologists, based
on their experience covering many years, is, I think, conservative rather
than radical.

An interesting phenomenon from some psychological points of view,
and one that may be mentioned here, is the recent growth of certain
cults such as “ Christian Science,” “ Divine Healing,” etc. These of
course are not special to this country, but they have a large freedom here
and have developed accordingly. What will be their fate, whether they
will die out, or, losing some of their salient features, settle down amongst
the ruck of heterodox sects, is a question for the future. At present
“Christian Science” at least has quite an extensive following, not
confined by any means to the poorer classes. As an interesting fact
bearing on their ideas as to science, I may mention the protests made by
some of the adherents of “ Mother Eddy ” against the teaching of
physiology in the public schools of Chicago ; there being no such thing
as pathology, there can, of course, be no physiology, and the youthful
mind should not be burdened with such a useless and fictitious study.
Possibly a few years from now we will be able to make a psychiatric
study of the results of “ Christian Science,” “ Divinism,” and other
kindred delusions, to say nothing of “ Osteopathy ” and the like.

The movement for the special care of epileptics, though not as active,
is still in evidence, and it is probable that Illinois will before very long
follow the examples of New York and Ohio in providing a special
institution for their care. The subject was presented to the last
legislature, but it takes time for movements of this kind to mature and
overcome the timidity of economical legislators. Sooner or later,
however, it is probable that such institutions supported by public funds
will be common in this country, at least in the richer and older
portion.

FRANCE.

By Dr. R£ne Semelaigne.

Secondary systematised insanity .—According to Dr. Anglade, of
Toulouse, this disorder can be classified into—(i) Systematised insanity
secondary to mania. This really has its basis in one or more delirious
conceptions remaining fixed after one or several attacks of mania.
They are often contradictory and do not unite, the ideas becoming
iseparately systematised. These patients are generally megalomaniacs
with blunted affective processes and some loss of moral and social sense.
Memory and physical activity remain intact. Dementia, if it occurs,
appears late. (2) Systematised insanity secondary to melancholia, which
can be further divided into those depending upon some delirious idea
surviving the symptoms of agitation and sometimes hallucinations; into
those of a progressive systematised type, simulating paranoia, but in
reality having relationship to neither melancholia nor the latter, being the

Digitized by VjOOQle

FRENCH RETROSPECT.

175

1900.]

product of only a tendency on the part of the patient to these neuroses;
and also those post-melancholic states of an exclusively depressive
character. The dhlire des negations is a prototype of such mental states.
These subdivisions have characters in common occurring in persons of
neurotic heredity, a prominent symptom being disorders of general
sensibility, the result of morbid changes in the central and peripheral
nervous system due perhaps to auto-intoxications. (3) Systematised
insanity secondary to folie a double forme . (4) Systematised insanity

secondary to neurosis and intoxication. Neurosis is a source of painful
sensations, and may be the origin of insanity in predisposed persons.
Intoxication affects the peripheral nervous system and awakes painful
sensations which, wrongly interpreted, may produce systematised in¬
sanity. In the latter case the systematisation has a paranoiac taint.
Dr. R£gis, of Bordeaux, admits, with Dr. Anglade, the occurrence of
post-maniacal and post-melancholic insanities, but thinks they might be
divided into early and late, as they appear at the beginning or the end
of a maniacal or melancholic attack. Their early appearance is more
common in melancholia and the late in mania. The dttire des negations is
not always secondary. Melancholic persons commonly become negateurs .
There are also negateurs d?emblee (primary), as instanced by a patient
with visceral anaesthesia who denied the existence of his viscera without
having passed through a period of melancholia. Such anaesthesia is
generally the result of an auto intoxication. Dr. R£gis points out a
secondary insanity which occurs in the course of mental confusion.
One or two ideas arise which have a tendency to systematisation, and
persist after the mental confusion has disappeared.

Polyneuritic psychosis. — Dr. Ballet, of Paris, includes under this term
mental disorders having various clinical forms, the symptoms of which
are generally associated with polyneuritis, having origin in a toxic or infec¬
tive agent, which may influence the nervous system as a whole or in any
part. There are three principal forms. The first is characterised by
“ recovery ” during the day, a semi-insane state during the evening, with
hallucinations at night. This variety does not, as a general rule, last
more than three weeks, but not infrequently some delusions persist which
are more or less systematised. The second form is characterised by
primary mental confusion; and the third might be called amnesic.

Early dementia of puberty. —The main features of this disorder are
characterised by Dr. Christian by its appearance at the age of puberty,
a variability of symptoms at first, impulsiveness, and a rapid or more and
less complete and incurable dementia. The incubation period extends
from infancy to puberty, and although there are no noteworthy symptoms,
yet the onset of the disease can usually be recognised. The onset of
active disease is marked in a few cases by a loss of interest in the
child’s surroundings, a loss of memory, an inability to learn lessons, head¬
ache, and a progressive weakening of general intelligence. Such cases
are, however, rare. More commonly, the child suddenly complains of
fatigue, becomes indolent, capricious and disobedient, absent-minded,
forgetful, restless, irritable, and suffers from dizziness and headache.
After some weeks hypochondriasis develops, his affections change, he
finds fault with his brothers and sisters, is disregardful of, and imperti-

Digitized by VjOOQle

176

FRENCH RETROSPECT.

[Jan.,

nent to his parents, and is generally unruly. Sometimes his ideas
become ambitious and persecutory, but never systematised, and vanish
with the failing of intellect. In all cases one finds impulsiveness. Later
stage? are characterised by dementia. Any improvement is more apparent
than real; and the disease is of more or less long duration. If the acute
symptoms disappear, the child remains intellectually weak and is quite
useless in life. Attacks recur until the dementia is incurable. In
many cases the physical health does not suffer any alteration, but they
frequently have a senile appearance. The diagnosis of early dementia
from imbecility and idiocy is very easy, the history being the main
guiding point. The disease is incurable, but, according to Dr. Christian,
it may possibly be preventable.

Acromegaly in an epileptic dement. —M. Farnarier, of Paris, reports the
case of a man, aged 48, who had suffered epileptic fits from puberty, and
who was admitted to an asylum twenty-eight years ago. At present he
is demented and presents the typical features of acromegaly. The nose,
cheek-bones, jaws, tongue, penis, and feet are enlarged, the hands en
battoir (racket), he has cervico-dorsal kyphosis and ocular disorders.
According to the author, a neuro-arthritic or an insane heredity pre¬
disposes to acromegaly. The disease is due to a disturbance of the
glands of internal secretion, which react on an unstable nervous system,
producing nervous or mental symptoms according to predisposition, but
in all cases depending upon a special form of degeneration.

A case of general paralysis with hallucinations .— M. Truelle, of Paris,
describes a female case of general paralysis, in the course of which hallu¬
cinations of sight and hearing appeared. Her mother had suffered from
melancholia with refusal of food and suicidal proclivities. At the age of
thirty-seven she began to suffer from headache and dizziness. Six
months ago her memory failed, she became incoherent, began to drink
and to be extravagant in money matters. For six weeks sleep has been
impaired, she started suddenly and began to shout, and saw murders,
blood, snakes, wolves, and rabbits. She had no feeling that these
imaginary animals hurt her, they merely ran about her; but sometimes
she suffered great apprehension. Then aural hallucinations appeared.
She heard a small voice giving her evil advice, recognising in the voice
the tones of a man who lived with her many years ago, and who robbed
her of her money. She heard commands to kill her husband, to poison
herself, to jump out of the window, etc. At the same time confused
ideas of persecution supervened. Lately, the voice commanded her to
steal, and she did so. This resulted in her arrest, and she was sent to
St. Anne’s Asylum. On her admission she showed altered speech,
irregular pupils, fumbling movements of the fingers, fine tremors of the
tongue, amnesia, missed or cut-short words and syllables when writing.
She was careless, irresponsible, and self-satisfied. Visual hallucinations
seemed to have disappeared, but aural perversions persist.

Juvenile paralysis and epilepsy .—Dr. Toulouse, of Paris, reports the
case of a girl, set. 19, who was sent to the Asylum of Villejuif about the
latter end of December, 1897, as a case of mental debility and epilepsy.
She was agitated, incoherent, confused, violent, and refused her food.
Next day she had an attack characterised by dizziness, sudden pallor,

Digitized by VjOOQle

1900.] GERMAN RETROSPECT. 177

and syncope. A few days afterwards she had a genuine epileptic fit.
These symptoms occurred for twelve days, until one morning she seemed
to awake, as if from a dream, and asked what had happened, as she could
remember nothing. Her mother said that her daughter had suffered
from fits since the age of eleven ; the first following an attempt at rape
by her step-father. For the last two years the fits had been more or less
followed by the series of events noted since admission.

During her stay at the asylum she had about three seizures a month.
At the beginning of March, 1898, there occurred an excited attempt at
suicide, with hallucinations of sight and hearing. After some days she
was better again. In the May following another period of excitement
was noted, the patient remaining confused, with speech disturbance
and amnesia. The symptoms rapidly increased, and Dr. Toulouse came
to the conclusion that he was dealing with a case of general paralysis,
which was afterwards confirmed by a post-mortem examination.

GERMANY.

By Dr. J. Bresler.

The evolution of psychiatry in Germany, as in other countries, is by
no means rapid; yet the year 1899 can be looked back upon with
satisfaction. The year opened well with what was practically an act of
benevolence on the part of the Lunacy Board of the Province of
Brandenburg. It decided that for the future, both medical and adminis¬
trative officers should include in their period of service qualifying for a
pension the years they had formerly spent in private asylums, the work
in the latter being practically identical with that they afterwards engaged
in under public bodies.

The “After-care Association ” of the Grand Duchy of Hesse, founded
by Dr. Ludwig in Heppenheim twenty-five years ago, has since then been
a very active factor in the progress of lunacy administration in Germany.
A considerable raising of the pay of attendants is one of its latest accom¬
plishments, besides a Grand Ducal order that attendants, male and female,
after six years’ good service shall receive a donation of 1000 marks, and
that male attendants, after such service, can be employed by the State
or railway administration in inferior offices.

The question of the care of criminal lunatics has been to the fore
several times this year. The Prussian Government has acknowledged
the necessity for a proper care of the criminal with mental disturbances
while undergoing imprisonment, but declines to take any further steps
in the matter. The asylums must therefore continue to receive
criminal lunatics; and it is to be hoped that the lunacy boards will
soon resolve upon erecting special institutions for this class of patients.
A commencement has already been made at Diiren, in Rheinland.

The “ Association for combating the Abuse of Alcoholic Drinks ”
at Hildesheim, repeated its motion before Imperial Parliament for

XLVI. 12

Digitized by VjOOQle

i 7 8

GERMAN RETROSPECT.

[Jan.,

special legislation, but was not successful. The deputies paid but little
attention to it, and referred the question to the Government for con¬
sideration. As regards another matter, a true advance was made. It
was decided that, for the future, no individual should be licensed to
hold a private asylum but a legally qualified medical man with sufficient
experience in lunacy. A phenomenon, illustrating the improvement of
public opinion as regards lunacy, occurred recently in the Wurtemberg
Parliament. In former years, there has been a tendency for members
to dilate upon the unjustifiable detention of sane people in asylums,
and to make charges of bad treatment, etc. In these days it is much
more common, on the part of the majority of those who speak on the
subject, to accuse us of discharging patients who are not sufficiently
recovered.

The year under review saw the birth of a new association for alienists,
known as the “Association of Alienists of Northern Germany,” which
held its first meeting at Schleswig, on August 3rd. The meetings are
to be held annually.

All the German Universities have now psychiatrical cliniques with the
exception of the University of Kiel. It is satisfactory to note that the
new “ Clinical Asylum,” in connection with the latter, is fast reaching
completion.

The Inaugural Ceremony of the Uchtspringe Asylum occurred in
December. This hospital for the treatment of the insane, epileptic,
and feeble-minded was built under the direction of its medical super¬
intendent, Dr. Alt, and is provided with all possible appliances for
practical psychiatry, together with excellent appointments ensuring the
personal comforts of its patients.

On April 15th, at Goriitz, death removed from our midst one of our
greatest alienists in the person of Dr. Karl Ludwig Kahlbaum, at the
age of 70. It is needless to ask why he occupied such a high place in
our estimation. To him we are indebted for the clinical images of
several well-recognised mental diseases. His two elder sons are follow¬
ing in his footsteps, and have taken over the asylum formerly held by
him, and now famous in the annals of psychiatry.

The Annual Meeting of the Association of German Alienists was
held at Halle on April 21st and 22nd. Great attention was given to a
report by Prof. Wottenberg (Hamburg) upon the degree of responsibility
in those afflicted with mental disease, and to a paper by Dr. Hoche
(Strasburg) on the present position of the neuron theory. The
former was followed by an interesting discussion upon the so-called
“ diminished ” responsibility in mental disease. It was generally ac¬
cepted that there are many cases in which responsibility is not entirely
abrogated, but only diminished, as, for example, in epilepsy, hysteria,
neurasthenia, sexual perversion, eccentricity, etc. The practical side
of the question, both as regards those wholly responsible and those
only partially responsible, was acknowledged to be a difficult problem.
It was generally conceded, however, that any punishment must be quali¬
tative, not quantitative, with all except those wholly responsible.
Prof. Wottenberg feared, with reason, that the occurrence of diminished
responsibility having been conceded, it would often happen that those

Digitized by VjOOQle

1900.]

BELGIAN RETROSPECT.

179

wholly responsible would be considered and treated as if only partially
so. A proposition by Dr. Siemerling (Tubingen) was adopted, recom¬
mending that full information regarding the practical application of the
doctrine of diminished responsibility be collected and presented to the
Association. It cannot be said, however, that any real progress was
made in the matter. Much attention was also given to a paper by
Dr. Werner (Owinsk) on The Public Asylum ivith regard to its Size and
Administration . He advocated that no new asylum should be built for
more than 600 patients; that the director should give the fruits of his
long experience to the actual treatment of each patient individually; and
that there should be a medical officer for each 100 of the latter. The
Committee of the Association awarded a prize of 500 marks to Dr. Scholz
(Waldbruel), one of seven competitors, for the best Handbook for
Attendants. The founder of modern lunacy, Dr. Johann Christian
Reil, who died in 1813, having lived and worked in Halle, where the
meeting was held, Dr. Alt proposed to do honour to his memory, by
granting a sum of 1000 marks from the Treasury of the Association for
the renovation of his grave, which still exists, but in bad condition, on
the so-called Reilsberg of Halle.

BELGIUM.

By Dr. Jules Morel.

The past year has been marked by the very considerable amount of
attention given to the study of alcoholism. Certain of these papers are
of importance, and I send the following notes :

The responsibility of the alcoholic .—Dr. de Boeck devotes his pre¬
sidential address to the consideration of those cases of acute alcoholism
with delirium held to be irresponsible in Belgium, France, Germany,
and England. His conclusions are formulated on the basis of scientific,
moral, and social studies. Having referred to the opinions of Aristotle,
the Romans, and St. Thomas Aquinas, who agreed that accidental
drunkenness with loss of consciousness is not a condition involving
responsibility, while voluntary drunkenness, consequent on neglect or
carelessness, is a condition involving responsibility, Dr. de Boeck gave
an account of the German code, which makes a distinction between
drunkards who retain or lose consciousness. When consciousness is
affected the accused person is held partially responsible; when it is
completely lost he is held wholly irresponsible. Dr. de Boeck believes
that it is more reasonable to try to establish a scientific distinction
between a state of health (implying responsibility) and a state of disease
(implying irresponsibility); but he recognises the difficulty of defining
these conditions and of classifying intermediate cases, and therefore
admits the doctrine of partial responsibility. As the medical expert
appointed by the judge remains a physician, the accused must be a

Digitized by VjOOQle

i8o

BELGIAN RETROSPECT.

[Jan.,

diseased person. As alcoholism is so common it is almost impossible
for the public to regard its victims as diseased persons. The question
must be studied in view of the reaction of the individual to alcohol—
whether habitual or not, whether extra-cerebral abnormal factors inter¬
fere with it or not. Having related two very interesting cases of
pathological inebriety, Dr. de Boeck concludes that, as a necessary
condition of this state, the superior psychical centres—the centres of
inhibition—of the person must be weakened and degraded, and that
his cortical degradation is congenital, hereditary, or acquired. Still,
the task of the expert in forming an opinion is very difficult, owing to
the uncertainty of the feebly marked symptoms; but it would be
rendered easier if there were special legislation for habitual drunkards,
and if notification of irresponsibility were followed by detention in
special institutions.

The influence of alcohol on mental work. —Dr. de Boeck, referring to
the work of Krapelin and the deductions of Schmiedeberg and Bunge,
shows that the exciting action of alcohol is but temporary, that it is
soon followed by paralysis, and that it produces a qualitative and
quantitative alteration of the higher functions of the brain, while setting
free the lower centres. These observations very well explain the
phenomena of inebriety. I think that Dr. de Boeck has very ably
reconciled contradictory opinions arising from the objections made to
Krapelin having made his experiments with too large doses, and
Warren, who, on the contrary, used small quantities of alcohol.

A case of alcoholic paranoia .—This case was reported by Dr. S&iux,
and was characterised by the existence of no other cause than alcoholic
intoxication. Also by the fact that the insanity was preceded by
manifest alcoholic symptoms, which began suddenly and were accom¬
panied by a confusional state ; and, above all, there were special charac¬
teristics of the mental symptoms—the delusions and the hallucinations
of the patient were intimately connected with the idea of conjugal
infidelity, which, together with jealousy, is so frequent with alcoholics.
Although it may be doubted if this kind of case should be included in
the clinical conception of paranoia, Krafft-Ebing has described similar
cases under the title of alcoholic paranoia. An insanity of alcoholic
origin, beginning at forty-five years of age, characterised by various
hallucinations, ushered in by a confusional state, and tending to
dementia in less than two years, can hardly be classified as paranoia,
even if delusions of persecution be persistent.

Alcoholism from the medico-legal point of view .—Dr. Lentz considers
this subject from the point of view of legal responsibility and from the
point of view of detention of alcoholics in institutions. He makes a
distinction between the habitual drunkard and the alcoholised. In the
latter class alcohol has caused pathological manifestations which are
variable but characteristic. The habitual drunkard he considers to be
neither alcoholised nor intoxicated. He has, of course, a propensity to
drink, and may remain an habitual drunkard all his life. He suffers
from a moral disorder. Dr. Lentz, of course, admits there are
undefined cases existing between the pathological inebriate and the
habitual drunkard which are the despair of the physician. In regard

Digitized by VjOOQle

1900.] BELGIAN RETROSPECT. 1 8 1

to responsibility, Dr. Lentz considers three classes of drunkards: first,
habitual drunkards; second, the alcoholics; and third, the pseudo-
alcoholics. There is no question as to the legal responsibility of
habitual drunkards who show no trace of intoxication, but Dr. Lentz
reminds us that these persons are frequently degenerated, and that they
may be considered as pseudo-alcoholised if the alcohol gives rise to
abnormal reactions. As regards the second class, they may be divided
into two sections: first, with regard to acute intoxication (drunkenness^,
if irresponsibility is admitted, it can be but partial at first, although it
may progressively increase. In these cases there are modifications of
perceptions, emotional reactions, and voluntary reflexes. Conscious¬
ness and will being more or less dependent on moral dispositions* and
organic manifestations, and being altered by drunkenness, responsibility
must vary in proportion. Dr. Lentz considers that those persons whose
drunkenness is characterised by dangerous impulsive acts are irrespon¬
sible. With regard to chronic alcoholism marked by progressive decay
of the mental faculties, he holds that responsibility is commensurate
with the degree of the decay. It is often difficult to appreciate the
degree of responsibility, and the examination of the individual and the
circumstances must be very searching. Those alcoholic patients suffer¬
ing from obvious insanity present no difficulty, but in the pseudo¬
alcoholic state the morbid forms are difficult to recognise. The alcohol
is, no doubt, the cause of the disease, but there is also a certain degree
of moral degeneration. The diagnosis may be impossible. Dr. Lentz
distinguishes various forms—maniacal, somnambulistic, etc.

In considering those cases of alcoholism in which the brain is
affected and the treatment is of a therapeutical nature, Dr. Lentz is of
opinion that the ordinary asylums of the country are suitable, provided
that these patients are separated from the others, because a different
moral regimen is necessary. He would provide special asylums only in
great centres of population, not for the acute cases who are more
suitable for general hospitals, but for the vicious drunkards who are not
insane. Dr. Lentz asserts that those special institutions, already erected
at great expense, have not as yet produced brilliant results. As drunkards
require moral rather than medical attention, he suggests the erection of
a special asylum on private initiative. The value of the results being
insufficient from a social point of view is another reason against the
detention of inebriates in asylums for the insane. The enforced
temperance of ordinary prisoners during their detention does not
prevent their return to drunkenness when they regain their freedom.

Notwithstanding Dr. Lentz concludes that the State ought to inter¬
fere, because it is beyond doubt that alcohol is not only noxious to
drunkards, but also to society.

Digitized by VjOOQle

182

DUTCH RETROSPECT.

[Jan.,

HOLLAND.

By Dr. F. M. Cowan.

Long as the teaching of psychological medicine may have been
neglected, there are signs of a tendency at the present period to make
up for lost time. The Universities of Leyden and Amsterdam have
their chairs, and now it is proposed to create a professorship at Utrecht.
It has been sad to see how many physicians looked upon mental
diseases as a class which stood entirely outside the pale of medicine.
And sadder still to see how in some criminal cases matters were bungled
by incompetent medical experts.

A very striking instance may be mentioned in a “ cause c&ebre.” In
June, 1898, a retired captain of artillery, V—, shot his wife and a friend
of hers in the street. After firing his revolver he took a bottle out of
his pocket, and swallowed the contents. Having been arrested, he was
taken to the nearest police station, where he told the officers he had
swallowed strychnine, and as spasms set in he was removed to the
town hospital. After a stay of five days the head physician certified
to his insanity and wished to have him sent to an asylum. The tribunal
refused the necessary authorisation, and he was conveyed to prison.
Two medical experts were appointed, Dr. A. Long and Dr. L. Ruth.
These gentlemen drew the following conclusions:

“The accused has symptoms of nervous disease, which place him
under the normal level. Disturbances exist in the psychical sphere as
a consequence of degeneracy. The accused is only partially responsible
for the deed.”

Whether a free will does or does not exist is not a problem for a
medico-legal expert to solve, nor does the judge require him to give his
opinion on that knotty point. What is wanted is a clear and distinct
answer to the question, is the plaintiff diseased, or is he not ? What¬
ever the answer may be, the judge has to pass sentence. What makes
matters worse is that some physicians seem to be believers in a fraction
of a will, and found a medical verdict upon this preposterous
hypothesis.

The tribunal appointed two other experts. These first made an
attempt to have the culprit removed to an asylum for observation.
They urged that a prison was the very worst place for observing a
person suspected of insanity. This request was refused, but their
second demand, to have an experienced nurse to observe the prisoner,
was granted. As this was the first time that such an important
measure was taken, viz. that a nurse was appointed to observe and
attend upon a doubtful case in jail, it is only fair to remark that this
humane and practical step was carried out chiefly by the influence of
W. van Neusch, LL.D., the President of the Criminal Chamber.

The new experts collected a large number of facts from witnesses,
physicians, and last, but not least, from an extensive diary which the
unfortunate man had been keeping for the last two years.

Digitized by

Google

1900 .] DUTCH RETROSPECT. 183

Their conclusion was that V— was insane, but that they hesitated
to classify his insanity.

I here wish to observe that V— had suffered from epileptic fits till
his fourteenth year, and considering his impulsive and detestable temper
it is very likely that he was an insane epileptic.

The report was put into the hands of the first experts, and it was
asked what they had to say to it. And then appeared an answer so full
of strange assertions and foolish arguments that Carlyle would have
styled it an instance of hide-bound stupidity.

It was argued that a diagnosis of “insanity” without specifying
the form of disease was no diagnosis at all. This may be called a
proper answer for a drill corporal—what is not in the regulations does
not exist. The gentlemen seem not to be aware that a faultless
classification in mental medicine has not yet been obtained; and that
existing classifications have been made by mere mortals and are liable
to endless modifications; and that hundreds of forms of insanity are
still to be classed.

Next it was said that the culprit had shammed; this pitiable
argument was adduced as in their superficial examination they had
omitted properly to test the plaintiff’s memory, and probably they
were entirely ignorant of all that had been written about epilepsy and
allied diseases during the last thirty years.

It is a pity that space will not allow a thorough criticism of this
medico-legal report, which may be called a model of how such a paper
should not be made. If it were not for the highly important interests
concerned in the case, it might be called a medical comedy.

Dr. L. Ruth indicated that the patient should be placed in a criminal
asylum. However, as such an asylum does not exist in Holland, it is
rather difficult to see where he should have been cared for until it was
buih.

A new asylum has been opened at the small town of Grave. It is
meant to make it the nucleus for a colony like Gheel. To begin with,
one hundred quiet women were admitted. It is a pity that the
experiment was not made with some fifty quiet patients who had been
resident at Gheel, and who were accustomed to live in family. If
the plan succeeds, as it certainly must, a great advance in the care of
the demented may be said to have been made. As population increases,
so does the number of those who are unable to fight the battle of life,
and who have to be kept from being trampled upon in the struggle.
In proportion as their number increases larger demands are made
upon the public funds for the building of asylums. Asylums might be
largely relieved of the care of the demented and harmless patients.
Besides, the Gheel system might be improved, and a closer relation
might be maintained between the asylum and the patients sojourning
in the town.

Not only physicians, but many leading lawyers are beginning to urge
the necessity of an entire revision of our penal code. Punishment
should not be a sort of codified revenge, but should be therapeutic in
its effects. Society has a right to be protected from the ferocious
actions of the insane, but the insane person should be treated as a patient,

Digitized by VjOOQle

DANISH RETROSPECT.

184

[Jan.,

and not be plagued or annoyed. However, as Maudsley says, “the
gentle advent of truth takes a long time.”

Arrangements are being made for the Congress of Criminal Anthro¬
pology, which is to meet next year at Amsterdam, and to which
leading men in medicine and law from all countries are to be invited.

DENMARK.

By Dn Friis.

In this country during the past year there have been no changes or
events specially calling for notice in the institutions for the insane.
Psychological literature has also been very scarce, and there has been
published but one work, which is, however, of the first order, viz.:

Contributions to the Physiology of Enjoyment as a Basis for a
Rational aE sthetic , by C. Lange, Copenhagen. (225 pages.) This
work of the well-known Danish specialist in nervous diseases attempts
to found conditions and phenomena, which hitherto have been re¬
garded as purely intellectual, completely mental, on the basis of natural
science, and to explain them in a complete physiological manner, fol¬
lowing the common laws of physiology. It is so full of original thoughts
and views, its remarks are so appropriate, and the whole style is so
brilliant, that the mere reading is an intellectual pleasure. Of course
much of its contents are as yet hypothetical, and much can perhaps also
be seen from other points of view ; but the author himself asks that it
may only be regarded as an attempt, and that his intention has been
rather to give indications than to draw definite conclusions. A com¬
plete translation in the principal European languages would be well
deserved; but I shall at present be content to give a short r'esume of its
contents. I

This work is, in some degree, a continuation of the same author’s
book on emotion, as it specially treats of the causes of emotions and
sentiments, in so far as they can be elucidated by the mode of action of
the means of enjoyment. The book is in two grand divisions—the
means of enjoyment in general, and the arts as a special means of
enjoyment. The latter part is far the more extensive, and gives the
book its essential character.

The author defines enjoyment as the emotion one seeks to obtain;
and as a criterion that a sentiment is an enjoyment to any one is the
fact that he seeks it. Our endeavour to obtain enjoyments arises from
the want of an emotion or a sentiment, which the enjoyment tends to
produce. But as emotions, as shown in his previous work, are vaso¬
motor phenomena due to constrictions or dilatations of the blood¬
vessels, it is, of course, those we try to produce which give us pleasurable
sensations; the factors which can cause them are, therefore, means of
enjoyment. But as not every emotion is a delight to us, every means
which can induce these is not of itself a means of enjoyment; and the

Digitized by VjOOQle

1900.] DANISH RETROSPECT. 185

author therefore studies the different emotions (joy, anger, horror, etc.)
with regard to their value as enjoyments. Of the greatest importance
are those emotions which are caused by a dilatation of the blood-vessels,
and next the joy of those which are caused by a constriction, as, for
example, the enjoyment of the feeling of being kept in suspense. Ecstasy
is not quite the same as the other emotions, but is the purest and most
intense—as it were the abstract enjoyment, undoubtedly the highest of the
pleasurable sensations which the human organism can experience. A
lower degree of ecstasy is admiration, perhaps the most important of the
sensations, because it is so commonplace; its objects are to be found
in abundance in the surrounding world, and man is also capable of
creating them himself in arts; admiration, therefore, is of great im¬
portance to artistic enjoyments, which the author treats of at length in
the second division of the book. The cause of the different duration of
the different emotions can also be explained physiologically ; so can the
long protraction of joy be explained as being due to a paralysis of the
muscles of the blood-vessels, which many endure; while anger, sorrow,
etc., perhaps are owing to spasms, which can but last for a time, and
then are followed by weariness.

Only one emotion, disappointment, never seems to show itself as a
feeling of enjoyment, and the physiological explanation is perhaps to be
sought in its being accompanied by a feeling of atony.

The means of enjoyment are to be divided into the three main
groups of (1) those which act by nervous paths, (2) those which act
through the chemical constituents of the blood, and (3) those which
influence the circulation of the blood mechanically.

In the first group the impulses are transmitted to the vaso-motor cells,
either directly, by the nerves of sensation, or indirectly, through the
brain, by a “ psychical ” process; to this belong the sensations arising
from alterations of temperature, smelling substances, objects of taste,
colours, and sounds. By the first three the enjoyment is owing to
single sensations, by the two latter there is required a co-operation of
sensations. National differences and racial characteristics are of great
importance; the inhabitant of the south is characterised by duller senses,
and therefore requires stronger impressions than the inhabitant of the
north; the less cultivated than the educated, etc.

The means of enjoyment of the second group as a rule enter the
body through the alimentary canal, from which they pass into the blood
circulation and influence the vaso-motor centres, e.g. coffee, liquors,
etc. The feeling we hope to obtain by these is principally joyful.

The third class, the mechanical means, is very simple in its form. It
is obtained by strong exercises, especially dances, in which the children
of nature, quite instinctively, show their need of enjoyment. The
usual aim of the dance is pleasure; but anger can, as is well known,
also be aroused by the war-dances, while ecstasy is promoted by
religious dances.

Sometimes it may seem as if enjoyments can be aroused without
any emotional object, but this is perhaps never the case, since slight
states of emotion often may pass unnoticed, even by the individual
concerned.

Digitized by VjOOQle

DANISH RETROSPECT.

186

[Jan.,

Besides the different means of enjoyments quoted there are, however,
two conditions which are of the greatest importance in producing
pleasure, namely, change and sympathy. The need of change arises from
two different conditions, since every means of enjoyment by continued
use loses its effect, and every enjoyment itself at length becomes tiresome
and is succeeded by indifference or even dislike. Both these conse¬
quences are, however, temporary, and disappear; but they in no way
hinder other impressions from producing enjoyment, which therefore can
be continued by changing the means employed. Physiologically, how¬
ever, they are quite different conditions; the first is owing to the per¬
ceptive nervous elements, the latter to the vaso-motor centre. Every
protracted sensation by continuance becomes less strong, as the perceptive
nervous cells become less impressionable, and therefore the impulse
to the centre and the resulting emotion is also lessened. Weariness,
on the contrary, is owing to a too continuous vaso-motor excitation, by
which the muscular coat of the vessels is exhausted, the vessels are
paralysed, and the state of emotion disappears. Exhaustion can be
retarded for some time by a stronger irritation, but at last it will surely
occur. It is, however, not sufficient to procure a change ; it must also be
used methodically, and hence the reason that “ the rhythmical change ”
is so important in art, perhaps because in it we have an easy and practi¬
cable means of obtaining enjoyments by impressions which without it
would not be agreeable or productive of effect. The effect of the
change depends on its intensity, /. e. the difference in degree between
the alternating impressions, and on its rapidity ; the nature of the
rhythm is also evidently important because of the effect. As strength¬
ening the enjoyment of change and rhythm we have “ surprise ”—a
sudden breach of rhythm—and its resulting effect. In poetry this is
“comic art.”

The other condition of great importance in the psychology of enjoy¬
ments, especially those of the arts, is sympathy, in the original meaning
of this word. It is well known that a sympathetic transference of
emotions from one individual to another may happen, at least in
those of which physiological signs are marked or easily visible. It
is, however, but a transference of the pure bodily signs of emotion,
for if passion has no visible expression, it has no chance of acting on
those around, and a feigned passion is even as contagious as a real one.
This fact is from a physiological view very curious and very obscure,
but by no means exceptional; it is only a single feature of a psycho-
physiological phenomenon of wide bearing, the instinctive involuntary
impulse every one receives when observing the movement of another
to imitate it, or when hearing a sound to repeat it. More intricate is
the process when the sympathy is aroused by words spoken or written,
as in poetry, for here of course it is necessary that there be left in the
memory the image corresponding to the words.

As art, /. e . a production of art, the author defines every human work,
either a thing or a performance, arising from a conscious effort to pro¬
duce enjoyment through the ear or eye. Only in this way do we get
“spiritual” enjoyment; therefore, e.g. y cookery cannot be classed
among the arts. The pleasure which it is the object of art to procure

Digitized by VjOOQle

DANISH RETROSPECT.

187

I9OO.]

is brought about partly directly by the immediate effect of the sensations
on the vaso-motor centre, partly by associations of ideas and reminis¬
cences aroused in us; but these always imply that the cerebral cells have
undergone an alteration, that they have received an impression. These
two kinds of artistic enjoyment are from an aesthetic point of view to be
kept distinct from each other, to get a clear understanding of the real
state of the case. The first kind the author calls the absolute artistic
enjoyment, being immediate, with equal validity for all, like impressions
of smell or taste, and only for these can laws be given, and only these
can be debated scientifically. The latter, the individual , has only rela¬
tion to the individual himself, and cannot be inquired into.

Of great importance to artistic enjoyment is admiration arising from
the feeling or consciousness that some difficulty has been surmounted,
and often this feeling alone procures the whole enjoyment. The
importance of admiration, therefore, is more prominent in the valuation
of art the greater the knowledge of art is. On the contrary, admiration
passes away when the work gets common, 1. e . when the artist has
obtained his result too easily, and the thing has been heard or seen
before.

Besides admiration, the production of change and sympathy, as
previously stated, is the other main factor in evolving artistic enjoy¬
ment. There are many instances from the different branches of art—
decoration, architecture, sculpture, painting, poetry, and dramatic art,—
and from the different ages and schools of the arts in question, " hich
are discussed at length. The author makes out that there is no necessity
for taking into consideration other elements than the three named.
Change and sympathy are then the proper means of enjoyment, ad¬
miration itself is a peculiar kind of enjoyment. These three factors
have the power of producing the physiological vaso-motor phenomena
of which the feeling of enjoyment is the result, and therefore from the
side of physiology there is nothing which should prevent us from ac¬
cepting them as general means to the production of artistic enjoyment.
It is therefore easily intelligible, that men quite instinctively have
recourse to these three expedients to artificially satisfy their need of
enjoyment, which are always active, when the natural means were
insufficient. The results are the productions which, not on account
of the homogeneousness of their nature, but owing to their common
effect, are comprised under a single appellation and called art. The
rational definition of art, therefore, ought to be, that it is the compre¬
hension of those human works which by change, by sympathy, and by
producing admiration procure enjoyment—a sober, but perhaps a more
intelligible and useful definition than the usual one.

“ Mental Diseases ” is a very good popular book by Dr. C. Geill, written
to clear up the ideas of the laity on the causes and real nature of these
diseases and their proper treatment. Unhappily, however, it is not to
be expected that a single attempt will be sufficient to do what is intended;
so that the prejudices—well known in this country—against asylums and
alienists, which have shown themselves in clamour against the latter,
should be allayed, and that the progress of the clerical movement, the
aim of which may be traced to a desire to withdraw the treatment of

Digitized by VjOOQle

ASYLUM REPORTS.

t 88

[Jan.,

the insane from physicians, may be hindered. For alienists the book
contains nothing new.

ASYLUM REPORTS, 1898-9.

English County and Borough Asylums.

Berkshire .—Dr. Murdoch writes:

As bearing on the question of heredity, the following may be cited. Two female
patients, each having a family of four, were admitted suffering from a degree of
excitement accompanying childbirth, but in whom the primary mental state was
congenital defect. Is it to be wondered at that such an increasing tax is put upon
the ratepayers for the providing of asylum accommodation when the marriage of
such persons is so prevalent ?

Birmingham ( Winson Green).— Dr. Whitcombe is of opinion, from
facts such as those below, that legislation (beyond the new Inebriate
Act) must soon become an urgent question.

In my report last year I stated that the proportion of drink cases during that
year (1897) was the greatest that had come under my observation in one year
during twenty-eight years of asylum experience, and although in that year the
number reached the extraordinary proportion of 24 4 per cent, on the male, and
24-8 per cent, on the female admissions, this year I have to record an increased
proportion from this cause in males of 14 5 per cent, upon the previous year,
the number admitted being ninety-three, or 38 9 per cent, of the total male ad¬
missions.

Derby Borough. —The subjoined extract from Dr. Macphail’s report
gives point to a fear, which was expressed by some on the institution of
training and certification of attendants, that the certificate might be
found to be a valuable possession, enabling the holders to more easily
obtain private nursing, to the loss of the asylum which trained them.
That there is such a tendency is shown by other reports from time to
time. But notwithstanding the inconvenience caused, these resigna¬
tions supply the most valid argument in favour of pensions. Why, it
may be asked, should valuable services be lost to the trainers when they
could be retained by a proper superannuation scheme ?

There have been a great many changes among the nursing staff. Last year the
changes affected the older members, and not, as is usually the case, the new-comers.
No fewer than nine holders of the Medico-Psychological Nursing Certificate
resigned, three nurses to be married, one attendant to take up other work, and four
attendants and one nurse to engage in private nursing.

Dorsetshire .—Dr. Macdonald notes that the relative proportion of
cases of mania to those of melancholia are 7 to 1 in males and 6 to 1
in the females admitted in 1898. The Commissioners’ quinquennial
tables give the proportions for all England and Wales as 48 to 23 for
males and 48 to 32 for females. He finds, too, that this very high pro¬
portion of mania is not accompanied by the higher recovery rate
usually attached to it, as in many cases it was accompanied by con¬
fusion and other evidences of supervening dementia. Dr. Macdonald
also notes a lower admission rate.

Digitized by VjOOQle

ASYLUM REPORTS.

1900.]

189

Glamorgan .—This asylum draws its population from an area where
strikes are not infrequent, and are severely felt. Their influence on the
causation of insanity has been fully noted from time to time, not only
by Dr. Pringle, but also by Dr. Yellowlees, his predecessor. The fol¬
lowing extract is of interest:

In accordance with my experience of former strikes of colliers and ironworkers,
I expected a great decrease in the male admissions of the year, but, strange to say,
whilst this has not been the case—the numbers being quite up to the average of
recent years—a curious and interesting change in the causation of the cases was
observable, namely, whilst in 1897 there were 102 males admitted whose insanity
was ascribed to alcoholic intemperance, the number last year was only 56, whereas
cases due to inherited insanity increased from 61 to 71, owing probably to unusual
anxiety, worry, and poverty developing the disease in those who had the least
resistive power. There was also an increase amongst the males of cases due to
domestic trouble and adverse circumstances, but, strange to say, no such changes
as the above were found amongst the females.

Isle of Wight .—Dr. Harold Shaw has reason to complain heavily of
the provision of those elements in everyday life which test the proper
planning and building of a new asylum. The water is short and bad,
the drainage has been scamped, and the electric light is unsatisfactory.
All these matters are more or less preventable, and add seriously to the
worry of a superintendent's life, as well as to the burden on the rate¬
payers. And yet it is almost impossible to bring any one to account.

Salop .—We note that this county is going to follow the example of
Prestwich, and avail itself of Section 26 of the Lunacy Act for twenty-
five male patients to be placed in the Forden Union Workhouse.

Stafford {.Burntwood ).—In order to further provide for the disposal of
the asylum sewage, a Garfield coal-filter is being provided. It will be
interesting to know how it works.

Dr. Spence notes with satisfaction the loyalty and cheerfulness with
which the attendants (the male especially) have accepted the difficulties
and discomforts brought about by the heavy building operations carried
on throughout the year. These necessitated connecting up the old
parts with the new at no less than twenty-five different points, but
happily without any accident.

Sunderland {Borough). —The new teaching contained in the extract
below was defended by Drs. Elkins and Middlemass at the Annual
Meeting this year, as will be found in another part of the Journal. It
may be that our former practice is all wrong, but extensive trials in
many places will be required to establish the fact.

The asylum was also visited by a number of other persons, the chief object of
their interest being the night supervision and distribution of the patients. These
were instituted by Dr. Elkins, and have been found to be very successful. Their
main features consist in placing only quiet and well-behaved patients in single
rooms. Noisy, chattering, and destructive ones sleep in supervised dormitories,
and, as a result of this plan, it is found that they are much less noisy, sleep better,
and that destruction of clothing and bedding is practically unknown. Wet and
dirty habits are also much better corrected, and, altogether, the system is very
much to be commended.

Sussex {East). —The county is going to leave the county borough of
Brighton in possession of its old asylum at Haywards Heath, and is
building for itself a large new asylum near Hailsham. This will not be

Digitized by VjOOQle

ASYLUM REPORTS.

190

[Jan.,

ready for some years to come, and in the meantime temporary iron
buildings have been erected at Haywards Heath.

Sussex ( West). —We have before us the first annual report of the new
asylum at Chichester. It is a very full one, and Dr. Kidd has earned
the thanks of all future planners and promoters of new asylums by giving
a detailed account of its construction, methods of supplying light, air,
heat, water, etc. The full plans supplied with the report will be of
great service to those who cannot obtain them in other ways.

It is disconcerting to note that though the present accommodation is
for 450 (prepared for 600), yet at the commencement of 1899 there
were 412 patients belonging to the county. We hear rumours of
further building beyond the first limit of 600.

We note that Dr. Kidd has instituted the statistical tables of the
Association in all their strictness.

Scottish District Asylums.

Fife and Kinross. —In spite of the large addition to the accommoda¬
tion by the hospital opened only a year or two ago, want of room is
proclaiming itself, and Dr. Turnbull is calling for more beds. The
admissions have risen in alarming proportion in the last few years.

Glasgow District. —Last year we noted the inception of the Brabazon
scheme. It seems to work well.

To give some variety of employment, and to test the possibility of employing
the unemployed above referred to, the Brabazon Society of ladies offered their
services in the beginning of 1898, and have since been holding weekly meetings of
instruction to an average of nearly fifty patients, with much success. It is not the
more intelligent only that derive benefit and have pleasure in the work, but in the
dullest some dormant or latent intellectual power may be awakened.

Inverness. —No less than 32 per cent, of the admissions were re¬
admissions, and these account for the great total increase of the year.
Of these ten came for the fourth, three for the fifth, one for the sixth,
one for the seventh, and two for the eighth time. Of the 179 admis¬
sions 15 per cent, had physical signs of tuberculosis.

Since his appointment Dr. Keay has done much in improving the
asylum, and we congratulate him on the acknowledgments made by Sir
John Sibbald.

It is very satisfactory to find that the male hospital promises to be not only a
considerable addition to the capacity of the institution, but that it also constitutes
a very important improvement. It is admirably suited to its purpose, and will
enable the patients to be much more efficiently treated than has hitherto been
possible. When all the improvements and additions that are either in progress,
or soon to be undertaken, are completed, the asylum will be altogether changed in
character from what it used to be, and it may be confidently expected that it will
compare favourably with other district asylums. The alterations that have
already been carried out have given a much greater appearance of comfort to the
wards.

Holders of the Association certificate are allowed jQ 2 extra wages.

Midlothian and Peebles District. —We regret to find that the Associa¬
tion's statistical tables are not in use at this asylum.

Digitized by VjOOQle

1900.]

ASYLUM REPORTS.

I 9 I

Scottish Royal Asylums .

Aberdeen .—Steps are being taken to cast off the pauper patients of
Aberdeen City, it being found difficult to provide for all classes
together.

Edinburgh .—Dr. Clouston prophesies that the increase in asylum
population will continue for many years to come, though not from
positive increase of insanity. For this he looks to increasing realisation
of the benefit and convenience of hospitals for the insane, and also,
inter alia , to increased intolerance in families of the inconveniences of
insanity. But these have been going on for years, and one would
fancy that the margin between declared and undeclared insanity attribu¬
table to such agencies had almost been absorbed by now.

In stating the fact that the death rate at Morningside, which had been
8*8 per cent, on average residence from 1880 to 1889, rose in 1890 to
13*3, and has been 11*9 on the average for the last nine years, Dr.
Clouston shows that for the three years 1890-92 the general death rate for
Scotland from diseases of the nervous system showed a distinct increase,
which was reflected at Morningside by increased general paralysis, brain
softening, etc. But Dr. Clouston cannot explain the increase persisting
in his death rate since that time, influenza having also become much less
fatal. Tuberculosis accounts for some of the increase, but not all. A
reorganisation of the drains, etc., has been undertaken at an estimated
cost of ^2300.

Dr. Clouston in his report acknowledges the support he received as
President of the British Medical Psychological Section from the
members of the Association and others.

Glasgow. —Dr. Yellowlees supplies a good and probable reason for
old people, especially women, finding their way into asylums.

Suitable homes for the aged who are not paupers, and yet are in narrow circum¬
stances, would almost seem to be a want in our social system. The eagerness
with which women are now entering business life and undertaking work incom¬
patible with the care of aged relatives has perhaps helped to create this want. If
so, it is an unwelcome result of their desire for independence.

Note is made of the shortcomings of the new Inebriates Act, in that
it applies only to convicted criminals and not to ordinary drunkards.
Dr. Yellowlees considers the chief value of the Act is that it may be the
herald of wiser and fuller legislation.

Perth .—Dr. Urquhart refers to the dangers that are accompanying the
fashionable drugs which are now so accessible to the public.

The abuse of such substances as antipyrin, which seems to have taken its place
in the domestic medicine chest, to the detriment of the race, is almost as formid¬
able as the indiscriminate and continuous unauthorised dosing with sulphonal and
cocaine. Valuable as these remedies are when appropriately prescribed, each
entails its own special dangers. As soon as an anodyne or a soporific comes into
general use, the results are recorded in the statistics of our medical institutions.
We have lately reported a death consequent on a relatively small dose of sulphonal,
and apparently due to its disorganising effect on the system. This drug was
placed before the public as an absolutely safe hypnotic not many years ago, and it
is now used with a freedom which is perfectly appalling; yet it has not been
ascertained in what cases sulphonal is eminently dangerous, or where an idiosyn-

Digitized by VjOOQle

192

ASYLUM REPORTS.

[Jan.,

crasy exists forbidding its administration. We have also had under treatment a
patient who fell a victim to that insidious drug cocaine. Consequent on the relief
experienced, he was enabled for a time to carry on an extensive business; but,
while thus deadening the pain of persistent neuralgia, he was only treating a
prominent symptom, without combating the underlying causes of his malady.

Irish District Asylums .

Belfast .—Like the other Irish reports, this contains valedictory ad¬
dresses to the past Board, and advice to the newly created Committee.
The Inspector in his report in most cases acknowledges the laudable
way in which the defunct bodies have done their best for the asylums in
face of many serious difficulties.

Dr. Graham seems to be able to get a large amount of work out of
his staff and patients, a long list of heavy alterations and reconstruction
being given. Nearly five sixths of the patients are got to work. The
Committee and Inspectors speak warmly of his energy. The pro¬
portion of attendants now (after some increase) is 53 for 725 in the
main asylum. Of the 289 admissions 6 were general paralytics, all
men. In only 14 is intemperance assigned as a cause, while 5 per cent,
are put down to religious excitement; the proportion in England being
about 1 *5 per cent.

Cork .—Dr. Oscar Woods thinks that there is some ground for
asserting that insanity is on the increase in the district, the number of
first admissions having sprung from 228 to 262 in the year. Hereditary
influences account for 30 per cent., and intemperance for 16. Dr.
Woods maintains that the asylum accommodation will be called for at
the same alarming rate unless habitual drunkards are dealt with more
firmly and imprudent marriages become less frequent.

For the benefit of the incoming Committee he re-asserts his claim to
have the necessary new accommodation take the shape of a hospital
for recent and curable cases. So many of the Irish Boards appear to
have taken of late a liberal view of asylum management, that we may
hope that Dr. Woods will get his way.

No general paralytic existed in the asylum at the end of the year.

Down. —Dr. Nolan, in saying good-bye to his old Committee on their
disestablishment, hits the nail on the head.

Perhaps the secret of your success lay in the fact that you realised so well the
common interests of the insane and of those upon whom a share of the burden of
their maintenance was cast, having found as a result of your long experience that
in asylum administration, as in other matters, efficiency is the true economy.

No doubt a good number of asylum managers everywhere think that
philanthropy should be tempered by finance, and rightly so. But the
two are up to a certain point not antagonistic. The Inspector also
writes in his report:

They (the Committee) will hand over next year to their successors, the Asylum
Committee of the County Council, an institution in excellent order, of which they
may well feel proud. I hope that these successors will take as liberal and as
practical an interest in the success of the asylum and the welfare of the patients as
they have always shown.

There were no general paralytics at the end of the year.

Digitized by VjOOQle

NOTES AND NEWS.

193

1900.]

Ennis .—The Inspector marks this asylum down for much enlarge¬
ment at the hands of the new Committee, when it is taken over by
them. He rightly protests against the numbers being kept down to
suit the small asylum by transferring patients to workhouses where they
are kept under unsuitable conditions.

On the other hand he states that very great attention is paid to the
dietary and preparation of the food in the asylum. One general para¬
lytic was admitted and died during the year, there being none at the
end of the year.

Limerick .—No general paralytic was in the asylum at any time in the
year.

In respect of the cost per patient for maintenance, which is low, the
Government auditor reports:

1 do not hesitate to attribute this satisfactory result to the constant and unre¬
mitting attention paid by the superintendent and those working under him to
every detail connected with the financial affairs of the institution. From the
records and vouchers that come under my notice it is evident that the greatest
care is taken in the making of contracts; goods supplied under contract are
scrutinised so as to ensure that they are equal to standard and not deficient in
quantity; contractors’ accounts, before being submitted for payment, are carefully
checked to the minutest detail; and the superintendent is in immediate privity
with every transaction bearing upon the financial administration of the asylum.

The Inspector reports that the food was good, and we find that the
recovery rate is an average one.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

General Meeting.

A General Meeting was held in the rooms of the Association, 11, Chandos Street,
London, W., on Thursday, 9th November, under the presidency of Dr. J. Beveridge
Spence.

Present: Drs. J. B. Spence (President), H. Hayes Newington (Treasurer),
Fletcher Beach, R. Percy Smith, H. A. Benham (Registrar), G. H. Savage, Sir James
Crichton-Browne, T. Clifford Allbutt, T. Seymour Tuke, C. K. Hitchcock, L. A.
Weatherly, F. W. Mott, T. Outterson Wood, J. Peeke Richards, W. D. Moore,
W. Julius Mickle, F. A. Elkins, James Chambers, J. G. Soutar, R. H. Cole, W. J.
Seward, G. Stanley Elliott, W. feawes, D. G. Thomson, J. W. Stirling Christie,
C. Hubert Bond, Arthur N. Davis, T. Telford-Smith, W. H. B. Stoddart, Inglis
Taylor, R. H. Steen, R. Langdon-Down, R. N. Paton, W. J. Donaldson, Walter
Smith Kay, C. S. Morrison, A. E. Patterson, Alfred Miller, F. Sidney Gramshaw,
L. R. Whitwell, W. Handheld Haslett, Peers MacLulich, Charles D. Law, H. T.
Aveline, Alfred Turner, Eric France, A. H. Spicer, W. Douglas, S. R. Macphail,
T.C. Johnstone, David Bower, Crochley Clapham,and Robert Jones (Hon. General
Secretary).

Visitors: Sir William H. Broadbent, Bart., Drs. Henry Head, H. J. Butter,
T. Hampson Simpson, A. Warren.

Apologies for non-attendance were received from Drs. A. R. Urquhart, E. W.

XLVI. 13

Digitized by VjOOQle

NOTES AND NEWS.

194

LJan.,

White, Evelyn A. W. English, A. R. Turnbull, E. Goodall, F. C. Gayton, D. M.
Cassidy, W. R. Watson.

The following candidates were elected members :—Blackwood, Catherine Mabel,

L. R.C.P. and S., L.F.P. and S., Assistant Medical Officer, Wadsley Asylum, near
Sheffield; Donelan, Thomas O’Conor, L.M.R.C.P.T., L. and L.M.R.C.S.T.,
Assistant Medical Officer, West Riding Asylum, near Leeds; Goldschmidt, Oscar B.,

M. B., Ch.B., Viet., House Physician, Bethlem Royal Hospital, S.E.; Goodrich, Edith
Ellen, M.B., C.M.Glas., Assistant Medical Officer, West Riding Asylum, Menston,
near Leeds; MacMillan, Niel Harrismith, M.B.Edin., M.R.C.S.Eng., Assistant
Medical Officer, Claybury Asylum, Woodford Bridge, Essex; Mason, Gerald Bovell,
M.R.C.S.Eng., L.R.C.P.Lond., Resident Medical Officer, Ticehurst House, Sussex;
Nixon, John Clarke, B.A., R.U.I., M.B., B.Ch., Assistant Medical Officer, West
Riding Asylum, Menston, near Leeds; Penfold, William James, M.B., C.M.Edin.,
Assistant Medical Officer, County Asylum, Morpeth, Northumberland; Rice,
David, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer, Cheddleton
Asylum, Leek, Staffordshire; Stilwell, Reginald John, M.R.C.S.Eng., L.R.C.P.
Load., Moorcroft House, Hillingdon, Middlesex.

Microscopical Demonstration by Drs. E. Goodall and Peers
MacLulich.

Dr. MacLulich. —Three of the sections are taken from general paralytics
suffering from either mania or dementia. These, and others also, are shown
chiefly with the idea of marking the great difference in the wealth of “ association ”
fibres in some and the absence of them in others, but especially paucity or
absence of the “ tangential band.” I Most of the sections are taken from the central
lobe, because we found it was the least affected. We have also taken sections
from the frontal, occipital, and temporal. The one that chiefly shows paucity of
these fibres is the frontal; next comes the temporal, then the occipital, and lastly
the central. As a rule they show paucity of the various layers which comprise the
“ association ” fibres (and also of the “ projection ” fibres) in the following order:—
1. “Tangential.” 2. “Supra-radiary.” 3. The “ inter- radiary.” 4. The “pro¬
jection ” (which also often shows a wasted and broken appearance, but not in so
marked a degree as the others). Some of the sections show numerous varicosed
fibres very well. This is chiefly seen in the “ tangential ” band, is not so marked
in the others, and is rarely seen in the “ projection ” fibres. The sections were all
stained by the method of Kultschitzky-Wolters, they having been previously put
for seven days’ staining in the cold, and then into the incubator for forty-eight
hours at 40° C. Finally they were differentiated by Weigert-Paul’s method. If
put into the incubator to begin with they crack and shrivel, but not so if stained
in the cold first. I especially direct your attention to J—, a case of chronic
mania, who died aet. 77, in which the “ tangential ” fibres show up better than
in any of the others ; also to B—, who had melancholia for about two and a half
years, and died from exhaustion aet. 23. Under the microscope this latter speci¬
men shows almost complete absence of “ tangential ” fibres, and also of the
“supra-radiary” and “inter-radiary.” There is also a section from a general
paralytic, which shows in the uppermost convolution a good wealth of “ tangential,”
“ supra-radiary,” “ inter-radiary,” and “ projection ” fibres, whereas in the other
two convolutions there is almost complete absence of these fibres. There is one
fresh section from a case of chronic mania, which shows marked sclerosis in the
outermost zone; and also a hardened section from the same region showing a
very good wealth of “ tangential ” fibres occupying the same position in which this
sclerosis exists. Another fresh section, taken from a general paralytic, shows a
very well-marked band of “ spider ” cells in the outermost zone, and also down
amongst the fourth layer of cortical cells. We present these specimens to chiefly
demonstrate the great differences existing in the degeneration of the various layers
of the “association ” fibres (and also of the “ projection ”) irrespective of the form
of insanity, age, or other circumstances.

Dr. Mott. — I cannot quite agree with Dr. MacLulich. Having examined a
great number of cases of general paralysis, I regard Crook as being perfectly right
when he said that the absence of the tangential fibres was a very important indica¬
tion of general paralysis. The sections from the case of melancholia showii
to-day certainly exhibit complete absence of the tangential fibres. I have seen

Digitized by VjOOQle

NOTES AND NEWS.

195

I9OO.]

cases of general paralysis diagnosed as melancholia, although I do not mean to
say that this was so in this instance, because a number of spider cells can be seen,
and I have no doubt that the authors have carefully considered, so that they would
not fall into such an error. I still am of opinion that of all the mental diseases
general paralysis is the one which shows the absence of the tangential fibres more
than any other disease. I have used the Marchi method of staining, because I find
it the only reliable one for certainly showing the presence or absence of these*
fibres. At present one of the technical scholars is engaged on this subject, and
probably some results will be gained by his work, and perhaps it may show that I
may be mistaken in the opinion now expressed.

Dr. MacLulich. —In the general paralytics examined by us there certainly has
been paucity of the “ tangential ” fibres, but not so well marked as in some other
forms of insanity. In one convolution we may see a fair average wealth of fibres,
whereas in others these may be absent, or almost so. As far as we have made out
there appears to be no uniformity of absence or wealth of fibres in general
paralytics.

Discussion on Dr. Stoddart’s Paper “ Anaesthesia in the Insane.”

Dr. Savage. —I read Dr. Stoddart’s paper with a great interest. It is a record
of very careful observations and not of conclusions. He has had the same experi¬
ence as myself. After carefully mapping out the anaesthesia to-day, and going to
verify them to-morrow, one found that they changed; that the conditions of nervous
disorder and mental disorder do not seem in the majority of cases to have any very
distinct relationship in regard to areas of anaesthesia. I happen to have had the
opportunity of seeing the converse—certain cases in which there has been a great
deal of hyperaesthesia with a direct relationship to the delusions. Often these
persons had developed ideas of grandeur, as a feeling of greatness of body. Has
any observation been recorded in relation to the reverse? Of course there is
megalomania, the feeling of exaltation, and micromania, the feeling of littleness.
A lady known to me has for several years had the idea of everything being very
little. She talks of herself as being a little thing, and of me as being a little thing,
and everything about her is regarded as diminutive. I believe this used to be
looked upon as a characteristic sign of general paralysis. I do not think that view
can now be accepted. There undoubtedly is a very large field for the investigation
of varying conditions of sensibility in neurotic patients. I believe it was Sir
Samuel Wilks, in his inaugural address to the Neurological Society, who said that
we very carefully studied muscular disorders, but not sensory disorders. Of course,
a great deal has been done in registering normal sensations and their reactions,
but I am afraid that the majority of us who have to do with the insane find it
extremely difficult to come to any very definite conclusion as to these relationships
in insanity. I think that there should be certain definite groups, or that there
should be, at all events, a group with varieties such as that described by Dr.
Stoddart.

Dr. Head. —First of all Dr. Stoddart speaks of that type of cases in which no
sign is given of the perception of painful stimuli. This Dr. Stoddart quite rightly
calls “ apparent anaesthesia,” and he points out that when these persons recover
they are able to tell you that they have felt the stimuli at the time. In one case
the patient had even developed a definite delusion of persecution from the repeated
pin-pricks. That is a type of case which is well known to us all, as he says. The
patient, although feeling the stimulus, is unable, owing to stupor, to give any
motor expression to the sense of pain. I think that if Dr. Stoddart will apply the
following test he will be able to wake up a certain number of those other cases
who are not too deeply stuporosed to manifest expression of pain at the time.
This class of cases, the later form of stupor, with apparent complete analgesia, is
not a very uncommon form in the out-patient department of large hospitals, and I
will give you the observation upon a definite case now under treatment. You can
apply to the patient, who is a Jewess, the strongest faradic current you can obtain,
and she will make no sign whatever of feeling it. You may place an electrode
upon one hand and she will not brush it off with the other. Pins, of course, she
pays no attention to at all, and you can stick them into her flesh in any part and
/he does not move. Set her upon a stool, do not send any current through her,
but simply flash a nine-inch spark in front of her, and then give her quite a mild

Digitized by VjOOQle

196

NOTES AND NEWS.

[Jan.,

stimulus, and she will immediately show all the signs of pain. The nine-inch
spark does not represent a stimulus, except a psychical one, but it awakens her
consciousness to such an extent that she will give obvious motor expression of
feeling on any mild electrical shock. I therefore quite agree with Dr. Stoddart
that this is not an anaesthesia at all; it is only that the patient is in such a state of
stupor that she is unable to express her feeling. Dr. Stoddart passes on to his
second group of cases, and gives as his first example (on page 70a) R. P—, with
Figure 1. In none of the group is a clinical history given, except a hint in regard
to one mentioned on page 709, that probably she had been anaesthetic for three
years. However, it was my good fortune to have R. P— under my care for eight
years, and in fact I sent her to Bethlem. I am consequently able to supply a certain
number of deficiencies in Dr. Stoddart’s account of this patient. He quite rightly
says that she was totally anaesthetic, excepting for two spots in the groin in 1890.
In 1889 she was also anaesthetic, but not insane. I saw her continually through
1889, and again in 1890. She was then completely anaesthetic and had her fields
of vision reduced to extremely small points, she could only see within the extreme
centre of the field of vision. During the time of her sanity she had the most
typical hysterical fits, with all the phenomena described by Richet. She went on
remaining absolutely anaesthetic, occasionally recovering from her contractures,
fits, and secondary phenomena, until 1896, when she was noticed to be stuporose,
and was sent to Bethlem. There is a very important gap in this case. This
patient has been to my knowledge for nearly eight years totally anaesthetic. I have
very little doubt that for eight years or more preceding she was also in a similar
condition. She had every sign, every stigma of major history—the contractures
and the epileptic fits of the type common to this group, together with very marked
diminution of the field of vision and anaesthesia; but she was not insane. It is a
very unusual type in this country. Then we pass to the case mentioned on page
709. Dr. Stoddart mentions that for three years she has befen completely anaes¬
thetic, and that the medical certificate bore one of her statements, that if she put
her hand in the candle flame she could not be burnt. It is quite probable that she
could not feel, as Dr. Stoddart points out. He gives us no data on which to judge
whether this patient was anaesthetic for eight years before she became insane. Turn¬
ing to the figures themselves, I think that any one who has had any experience of
ordinary hysterical anaesthesia would say that most of them conform to that type;
so that to sum up my criticism of this paper I should say that, in the absence of
clinical history, Dr. Stoddart is in all probability quite right in putting the cases
together in one group, of which R. P— is the maximum example ; but that, just as
in the case of R. P—, this anaesthesia quite probably long preceded the insanity;
the insanity was possibly due to the anaesthesia, and not the anaesthesia due to the
insanity. This type of anaesthesia is exactly what would come into an ordinary
general hospital without insanity, and it is well recognised that these cases when
they tend to become completely analgesic and have extremely marked diminution
of the field of vision also tend to have an extremely marked diminution of the
psychical field and become stuporose.

Dr. Mickle. —It is probable that the cases reported by Dr. Stoddart are cases
in which the anaesthesia is purely of functional origin. The distribution is similar
to that which one observes in cases which are usually put down as being
hysterical. There is a difficulty in estimating the parts of the body likely to be
affected with anaesthesia by process of dissolution, a process which is the reverse
of the process of evolution by which the functions are built up. I think that an
explanation may be given of the close connection of abdominal states as being
those which longer than any others maintain their relations, and that it lies in the
connection between the nervous system and the abdominal viscera. I believe that
the process of evolution really consists of that which was originally part of the
alimentary canal of the lower organisms from which man sprang becoming, in
him, the cerebro-spinal system. In the course of time one part of that canal
becomes evolved into the cerebro-spinal system. Besides this there may be traced
a relationship between the cerebro-spinal system of man and the alimentary canal,
in the sympathetic ganglia which line the sides of the spinal column, and which
are connected on the one hand with the mrey matter of the cord, and on the other
with the plexuses in the alimentary canal.

The evolutionary history already referred to seems to show us why the emotions,

Digitized by

Google

NOTES AND NEWS.

197

1900 .]

the early mental phenomena in the process of evolution, still maintain a large
degree of their ancient connection with the abdominal organs. The fact that the
distribution of the anaesthesia in the cases described by Dr. Stoddart is the same
as that described in hysterical cases, to my mind shows the connection, not between
any organic lesion and the anaesthesia he observed, but between the anaesthesia
and changes in the personality—an essential condition in the hysterical state
which may be associated with these cases.

Dr. Stoddart. —Dr. Savage said that we ought not to be too anxious to explain
the phenomena which we observe, but I am afraid that is what a young psycholo-
gist is very anxious to do; and I think that it is well to raise discussion on these
phenomena, because the facts do not help us very much unless we try to learn
something from them. The fact that a person is anaesthetic does not teach us
anything, and my reason for attempting to explain the phenomena, perhaps in a
more complicated way than one is justified in doing, is that we ought to go further
if we are to learn. With regard to the association between defective sensation and
mental symptoms, I have not had enough cases to say what the association is. The
cases are not very frequent. The percentage of all which have come under my
observation is something under 3$ per cent., and in that 3$ per cent, many showed
quite transitory conditions of anaesthesia. Dr. Head's method of awakening the
attention of the patient is very interesting—not by a strong sensory stimulus, but
by slight sensory stimuli to all the senses. Similarly, one will perhaps show
a patient something that may attract her attention, shake her and talk loudly, and
so perhaps extract a word or two. Dr. Head’s method would be very well worth
trying. He refers to the case in which anaesthesia had probably existed for three
years. My reason for putting it that way was that the certificates indicated that
there was anaesthesia about eighteen months before I saw her; and when I first
examined her she had a very extensive anaesthesia, which is shown by Fig. 2 of my
paper. That case was very interesting, because I was able to observe the anaes¬
thesia until it had absolutely gone. It returned again after a short time, and is now
once more in very much the same condition as is represented in the figure. Of
course the question of R. P— being not insane in 1889, and yet having an exten¬
sive anaesthesia, is extremely important. I have not looked upon anaesthesia as a
cause of insanity, nor have I looked upon insanity as the cause of the anaesthesia.
I have regarded the physical basis for both these phenomena as one and the same,
of which the anaesthesia and the insanity are co-existent symptoms. I can say,
however, that in most of my cases I was able to observe the anaesthesia develop after
they became insane. When first examined there would perhaps be no anaesthesia,
especially in post-maniacal stupor. During the mania there was no anaesthesia;
in fact, I was rather under the impression that there was some hyperaesthesia. As
the patient developed the post-maniacal stupor the anaesthesia developed pari
passu , and generally in the way indicated in my paper. I quite agree with Dr.
Mickle that this anaesthesia is functional—that it is not due to organic disease. A
large percentage of cases recover. With regard to it being due to hysteria in all
cases, I should be inclined to object to that, not admitting dementia to be in any
way related to hysteria, except in so far as they are both psychical manifestations.
I should be inclined to say that hysteria was, as a rule, due to something of the
same nature as many cases of insanity. The association between the earliest
evolved part of the body and the nervous system is one which has, of course,
attracted a good deal of attention, but further than placing it upon that basis we
cannot go. Dr. Mickle has drawn attention to the connection between the viscera
and the sympathetic ganglia, and made reference to the ancient association
between the alimentary canal and the nervous system. That was not through the
sympathetic ganglia, but through what is now only referred to as the neuro-enteric
canal, of which a remnant exists possibly in connection with what is called the
coccygeal gland. The association between the nervous system and the intestines
is old, both in the actual anatomical connections in the foetus, and in the connec¬
tion of visceral phenomena with nervous phenomena in the insane.

The President called upon Dr. Harry Campbell to read his paper entitled
“ The Genesis of the Morbid Sense of BienMre .”

Drs. Mott and Robert Jones spoke, and Dr. Campbell replied.

The President then called upon Dr. France to read his paper upon 11 The

Digitized by VjOOQle

NOTES AND NEWS.

198

[Jan.,

Necessity for Isolating Cases of Phthisis among the Insane in Lunatic Asylums.”
(See page 1.) ... 4

The paper entitled “ Bodily Disease as a Cause and Complication of Insanity/’
by G. T. Conford, M.B., was taken as read.

Members afterwards dined together at the Cafe Royal at 7 p.m.

NORTHERN AND MIDLAND DIVISION.

A meeting of this Division was held at the West Riding Asylum, Menston, near
Leeds, on nth October, 1899.

Members present.— Drs. J. McDowall, Edgerley, and Mackeown (Menston);
Kay and Adair (Wadsley); Perceval (Whittingham); Hitchcock (Bootham);
Miller (Hatton); Hearder (Wakefield); Mackenzie (York Retreat); Ray (Harro¬
gate) ; and Crochley Clapham, Hon. Sec.

Visitors. —Drs. Crawford-Watson, Nixon, and Donelan.

Dr. J. McDowall was voted to the chair, and the minutes of the last meeting
were read and confirmed.

Nursing in Irish Workhouses.

A question on the subject of the nursing of insane in workhouses, submitted by
the Council of the Association for the consideration of the Division, was discussed,
and the following resolution unanimously carried respecting it:—“ That it is ad¬
visable that this Association represent to the Local Government Board that in
union workhouses in which insane persons are detained nurses properly qualified
and trained in mental nursing should be employed.”

Next Meeting.

The date and place of the next meeting was fixed for the County Asylum, Whit¬
tingham, near Preston, Lancashire, on the third Wednesday in April, 1900.

Dr. C. K. Hitchcock, of the Bootham Asylum, York, read a paper on “Two
Hundred and Six Consecutive Cases of Acute Mania treated without Sedatives.”
(See page 80.)

Previous to the business part of the meeting, Dr. McDowall and his staff showed
the members round the asylum, and subsequently entertained them at dinner.

A cordial vote of thanks was given to Dr. McDowall for his hospitality.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division of the Medico-Psychological
Association was held at the Bethlem Royal Hospital, St. George’s Road, London,
S.E., on Monday afternoon, 16th October. At 3 p.m. the Divisional Committee
met, and at 3.30 p.m. the General Meeting again. The following members were
presentDrs. T. O. Wood, H. G. Hill, C. H. Bond, T. S. Tuke, R. Jones, T. B.
Hyslop, F. Beacn, W. Stoddart, W. J. Mickle, H. M. Taylor, E. Savage, D. Bower,
M. Craig, H. Pulford, W. Rawes, A. H. Boyle, J. P. Richards, G. Elliot, R. L.
Down, H. F. Winslow, T. Stansfield, H. Kidd, G. Shuttleworth, R. P. Smith.
Visitors—Drs. Danford Thomas, Selvatico, and Sacypti.

Dr. Fletcher Beach was voted to the chair, and in opening the proceedings he
thanked the South-Eastern Division for its assistance in his election to the
Presidential Chair. A letter was read from the secretary, Dr. White, regretting his
inability to be present in consequence of illness, and stating that Dr. Outterson
Wood had kindly offered to undertake his duties.

The minutes of the last meeting as reported in the July number of the Journal
were taken as read and confirmed.

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

199

Nursing in Irish Workhouses.

, The following resolution of the Council was next considered:—“ That the question
as to the advisability of the Association representing to the Local Government
Board, that in a union workhouse in which insane persons are detained, a nurse
properly qualified and trained in mental nursing should be employed, be considered
at the divisional meetings in England and Scotland, and a report to be made to
the Council.” It was proposed by Dr. Beach, and seconded by Dr. Percy Smith,
that the Division considered it advisable that properly qualified and trained mental
nurses should be employed in union workhouses in which insane persons are
detained; this was carried unanimously.

Next meeting .—On the invitation of Dr. White, it was decided that the Spring
Meeting of 1900 be held at the City of London Asylum, near Dartford.

Dr. Hyslop then read his paper on “ Some Rare Forms of Skin Affections in the
Insane.” A lengthy discussion followed (see page 60).

A vote of thanks to Dr. Hyslop brought the meeting to a close. In the evening
the members dined together at the Cafe Monico.

SOUTH-WESTERN DIVISION.

The Aqtumn Meeting was held on Tuesday, 17th October, at Digby’s Asylum,
Exeter. Dr. Spence, President of the Association, was in the chair, and there
were also present Drs. Rutherford, Deas, Sheldon, Turner, Aveline, Davis,
Blachford, Forsyth, Pearce, Benham, Liston, MacDonald (Hon. Sec.), Hungerford,
Aldridge, Stevens, Wood, and Drs. Davy and Brash as visitors.

The minutes of the last meeting having been read and confirmed, the following
were elected as new members.—James Leslie Gordon, M.B., Ch.B., Assistant
Medical Officer, Wilts County Asylum; George Heneage Pearce, M.R.C.S.,
L.S.At, Assistant Medical Officer, Brislington House, Bristol; Charles E. P.
Forsyth, M.B., Ch.B., Assistant Medical Officer, Dorchester Asylum; Walter
Hood Ligertwood, L.R.C.P. and M.R.C.S., Assistant Medical Officer, Wells
Asylum.

Next meeting .—An invitation having been received to hold the Spring Meeting
at Bailbrook House, Bath, it was unanimously accepted, and 24th April, 1900, was
fixed as the date of meeting.

Nursing in Irish Workhouses.

The Secretary explained that the resolution passed at the Council Meeting of
the Association held in London in July, 1899, was as follows:— 11 That the question of
the advisability of the Association representing to the Local Government Board,
that in a union workhouse in which insane persons are detained a nurse properly

3 ualified and trained in mental nursing should be employed, be considered by the
ivisional meetings in England and Scotland, and that a report be made to the
Council.”

After a prolonged discussion, taken part in by the President, Dr. Deas, Dr.
Turner, Dr. Benham, Dr. Rutherford, the Hon. Sec., and others, the following
resolution, moved by Dr. Deas and seconded by Dr. Turner, was adopted:—“ That
this meeting considers that it should be represented to the Local Government
Board that in union workhouses in which insane persons are detained, a nurse
properly qualified and trained in mental nursing should be employed in the insane
wards.”

Dr. Hungerford read a paper entitled “ A Few Remarks on Hysteria and its
Relation to Insanity” (see page 83).

The Trusteeship of the Lunatic.

The Chairman announced with regret that Dr. Briscoe yas too unwell to
attend. He hoped, however, it would be merely a pleasure deferred.

On the motion of Dr. MacDonald, seconded by Dr. Aldridge, a hearty vote of
thanks was accorded Dr. Rutherford for his kindness and hospitality.

The members and visitors afterwards dined together at the London Hotel.

Digitized by CjOOQle

200

NOTES AND NEWS.

[Jan.,

SCOTTISH DIVISION.

The Autumn Meeting of the Scottish Division was held in the Laboratory of
the Scottish Asylums. 12, Bristo Place, Edinburgh, on Thursday, November 16th,
1899.

Dr. Beveridge Spence, President of the Association, was in the chair, and the
other members present were: Drs. Bruce, Campbell Clark, Clouston, Easter-
brook, Ireland, Keay, Law, Mitchell, Oswald, Parker, Ford Robertson, G. M.
Robertson, Rorie, J. Rutherford, sen., J. Rutherford, jun., Urquhart, Yellowlees,
and Turnbull (Secretary).

The minutes of the previous meeting were read and approved.

Nursing in Irish Workhouses.

The President, after expressing the pleasure he had in being present at the
meeting of the Scottish Division, submitted the remit from the Annual Meeting
in regard to qualified nursing for insane patients in union workhouses, and
explained the circumstances which had led to it. In connection therewith, Dr.
Yellowlees proposed, and Dr. Clouston seconded, the following motion:—
** That this branch deems it very desirable that the Association should represent
to the Local Government Board that in an union workhouse in which insane
patients are detained a nurse properly qualified and trained in mental nursing
should be employed; and reports to the Council accordingly." Considerable
discussion followed, a difference of opinion being shown as to how the amount of
necessary qualification should be defined; but ultimately the motion was unani¬
mously adopted as expressing the principle that trained nursing is required. Dr.
Keay then moved, and Dr. G. M. Robertson seconded, that the minimum of
training and qualification should be the holding of the certificate of the Medico-
Psychological Association by the nurses; but on a vote being taken the motion
was negatived by ten to five.

Position of Nurses in Scotland.

Dr. Urquhart submitted a motion for the appointment of a Divisional Com¬
mittee to consider the position of the nursing staffs in Scottish asylums in regard
to administrative questions. This was seconded by Dr. Rorie. An amendment
that the Committee be not appointed unless its objects are specifically defined was
brought forward by Dr. G. M. Robertson and seconded by Dr. Keay, and after
discussion was negatived by eight votes to four. The original motion was after¬
wards put, and carried by seven votes to six; and the following were appointed
members of the Committee:—Drs. Campbell Clark, Oswald, Turnbull, and
Urquhart, with power to add to their number.

The Platinum Method.

Dr. Ford Robertson gave a microscopic demonstration upon “ New Facts
regarding the Structure of the Central Nervous System revealed by the Platinum
Method." In making a few remarks in explanation of the points illustrated by
the microscopic specimens, he referred to a paper that he had already published
upon the platinum method in the Scottish Medical and Surgical Journal of January
last. Since that time he had studied a large number of additional preparations,
and had obtained some further light upon the nature of the structural features that
were revealed. For the benefit of those present who might not have seen his paper
he stated that the method consisted essentially in placing blocks of formalin-
hardened tissues for from two to six months in a mixture of platinum bichloride
(P 1 C 1 4 ) and formalin. A gradual reduction of the platinum salt took place, and
platinum black was deposited in the tissues, not diffusely, but, in the first instance
at least, within certain tissue elements. The structural features thus brought out
were especially those of the adventitia of the vessels, nerve-cells, and certain cell
elements which had hitherto been regarded as belonging to the neuroglia. The
connective-tissue fibres of the adventitia of the intra-cerebral vessels were very
clearly shown, and were proved to be continued upon the capillaries, which, there¬
fore, had a second coat. This fact had previously been inferred by Be van Lewis

Digitized by VjOOQle

NOTES AND NEWS.

201

1900.]

and others, chiefly from the presence of cellular elements which evidently did not
belong to the intima. The fibres were of a highly elastic character. The method
further brought out a new fact, namely, that many of these elastic fibres were con¬
tinued from one vessel to another. Such connecting fibres were exceedingly
numerous, especially between the neighbouring capillaries, and evidently served to
support the vessels and to help to fix them in position. He was satisfied that the
very minute capillaries described by Kronthal and Lapinsky had no existence, and
that what these observers had taken to be such were merely those fibres which
passed from one capillary to another. Coming next to the nerve-cells, he stated
that the method was capable of bringing out the acidophile reticulum and
granules of the nucleus, and to a certain extent confirmed the description that had
been given of this portion of the cell by Giuseppe Levi. In a few instances the
primitive fibrils of the nerve-cell protoplasm had been revealed with remarkable
distinctness, and he believed that the method, when further experience of it had
taught how its action could be better controlled, would render it possible to trace
the exact course of these fibrils in different categories of nerve-cells. The special
cell elements to which reference had been made were of great interest. They were
most commonly seen as cells with a large nucleus, a small amount of perinuclear
protoplasm, and from three to eight delicate, almost thread-like branches, which
divided dichotomously, and might extend to a distance equal to about ten times
the diameter of the cell body. Some of them, however, were quite devoid of
branches, and intermediate forms were also to be observed. These cells occurred
throughout the central nervous system. They were exceedingly numerous—from
six to twelve often being visible in a single field of the ordinary high-power
microscope. In reaction to this method, and morphologically, they were entirely
different from the neuroglia cells as these were commonly described. He was of
opinion that they were mesoblastic elements, while the true neuroglia cells were
essentially epiblastic in origin. He did not wish to discuss the question of the
single or double origin of the neuroglia, but he maintained that the evidence of
the platinum method did not confirm the views of those who believed that this
tissue was developed both from the epiblast and from the mesoblast. It proved
that there were really two entirely distinct tissues, which were as different from each
other as a leucocyte from a pyramidal nerve-cell. The evidence of the mesoblastic
origin of these special cell elements was so strong that he thought he might venture
to suggest that they should be termed “ mesoglia cells," in contradistinction to
" neuroglia cells,” the epiblastic origin of which was sufficiently recognised in the
“neuro.” He stated that there were many other interesting structural features
revealed by the method, but he would not deal with them at present.

The President said that Dr. Ford Robertson had demonstrated the very great
advantage of having a laboratory such as that they were holding the meeting in
that afternoon. The Scottish Division had set a great example to other countries
in their work, and he was sure that the success of this laboratory would be great
and brilliant. A very important laboratory had been established in connection
with the London County Council asylums, and in the Midlands they were trying
to induce the committees of asylums to do likewise. He thought that if they
could show them the good work done in Edinburgh they would soon get the
money. Dr. Miller, of Warwick, had been working very hard on this question,
and they had now got so far that they were about to ask for a certain allowance
for the purpose of establishing a laboratory in Birmingham or some other central
place. He knew that there was a slight opposition to the proposal, but he
thought that they were quite able to overcome that opposition, and that they
would be able to show much good work, and not the waste of material now taking
place in the asylums of the Midland counties.

Dr. Clouston asked if these peculiar cells were specially abundant in any par¬
ticular situations, and if Dr. Robertson could make any suggestion as to their
function.

Dr. Ford Robertson, in reply, said that the cells appeared to be most abundant
in the cerebral cortex, or wherever there were nerve-cells. He could not say definitely
what their function was, but it seemed to him that these cells to a certain extent
corresponded to the endothelial cells of fibrous tissues, and that their function was
probably similar, although it was in some way specialised. They certainly could
not form fibroblasts, as endothelial cells or connective-tissue corpuscles were

Digitized by VjOOQle

202

NOTES AND NEWS.

[Jan,

capable of doing. He had obtained satisfactory evidence that the granular cor¬
puscles that were to be observed in the neighbourhood of areas of softening in the
central nervous system were derived from these mesoglia cells.

Dr. Clouston said that he was sure they agreed with him in congratulating
Dr. Ford Robertson on this brilliant discovery, and that he would trace out the
pathology of those cells as he had shown them their histology.

Dr. Easterbrook read a paper on “ An Attack of Epilepsy (Status Epilepticus)
followed within six weeks by an Attack of Chorea, occurring in a patient suffering
from Acute Puerperal Insanity” (see page 114).

Dr. Urquhart showed, and made observations upon, a number of forms for
case-taking, etc., which had been prepared by Dr. Toulouse for use in the
Villejuif Asylum.

Dr. Yellowlres moved a vote of thanks to Dr. Spence for his conduct in the
chair, and conveyed to him the great gratification and honour which the Division
felt in having the President with them on that occasion.

PARLIAMENTARY NEWS.

State Inebriate Reformatories. — October 2 yrd % 1899.

Mr. Pickersgill asked the Secretary of State for the Home Department
whether his attention had been called to the observations of the learned Chairman
of the County of London Sessions on the 18th inst., in passing sentence on Joanna
Driscoll, that there was no State inebriate reformatory in existence to which he
could order her to be sent, as contemplated by the Inebriates Act; whether, seeing
that a man who had previously been convicted seven times in twelve months was
sentenced at the recent Lancaster Quarter Sessions to three years’ detention in an
inebriates’ reformatory, but the Home Office had informed the Governor of
Lancaster Castle that there was no reformatory for such inebriates, he would state
what course did he propose to take with regard to this prisoner, and whether
temporary arrangements had been made for the use of a portion of one of Her
Majesty’s prisons for a State inebriate reformatory as stated in the report of the
Departmental Committee, dated 12th December last, and if not, would he be good
enough to state what steps he had taken to give effect to the intention of
Parliament P

Sir M. White Ridley. —I have seen a newspaper report of the case at the
London Quarter Sessions, and I am making inquiry as to the circumstances. I
may say that primd facie the accused seems to be as well qualified for committal to
a certified reformatory—of which there are now several in existence—as to a State
reformatory. As regards the case at the Lancaster Quarter Sessions, I am also
making inquiry, as the circumstances of the committal are not clear. I may add
that there will be at least one certified reformatory ready for the reception of male
inebriates in a very short time. I have abandoned the project of adapting a portion
of one of Her Majesty’s prisons for use as a temporary State reformatory. My
reasons for so doing, as well as for hesitating to establish a permanent State
reformatory, are given fully in a circular which I issued last January to Her
Majesty’s judges, and of which I have directed a copy to be sent to the hon.
member. I will say here that subsequent experience has justified and confirmed
that hesitation.

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mercibr.

[The editors request that members will oblige by sending full newspaper reports of
all cases of interest as published by the local press at the time of the assizes.]

Reg. v. White.

Frederick White, police constable, was indicted for shop-breaking. He was seen
on more than one occasion to ransack shops at night, and when his house was

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

203

searched a number of purses, bags, and all sorts of things containing money were
found. He admitted that a certain number of these were the products of robberies.
For the defence it was urged that the prisoner was suffering from kleptomania, and
Dr. Mould g^ave evidence that in his opinion the condition of the prisoner’s mind
was such as to lead him to commit offences of this kind without being responsible
for his actions. The Court accepted this view, and the prisoner was bound over
to be of good behaviour for six months.— Manchester Guardian, October 24th.

It is very unusual for a plea of kleptomania to be sustained in the case of a
person not of good social position, and we must suppose that the evidence in this
case was very strong; but unfortunately the meagre report on which we have to
depend leaves us very much in the dark as to its character, all that is mentioned as
pointing to mental disorder being the fact that the prisoner had not disposed of any
of the stolen property, but had hoarded it up in his home.

Reg. v. Harmer.

Philip Henry Harmer was summoned before the Mark Cross Petty Sessions for
receiving a lunatic and receiving payment for the maintenance of a lunatic in an
unlicensed house. It was proved that the defendant did receive the patient, and
that while in the defendant’s house the patient manifested various signs of insanity.
For the defence it was urged that when the patient was first received he was not
insane; that from time to time the defendant questioned the medical attendant of
the patient as to whether the patient ought not to be certified, and that the medical
attendant was of opinion that he ought not; that as soon as the patient became
certifiable he was certified and removed. The case was dismissed.—Mark Cross
Petty Sessions, November 14th.— Sussex Daily News, November 15th.

The following case is kindly communicated by Dr. Savage :

Reg. v. L. H-.

Menibre's disease and crime. —L. H—, builder, was brought before the Sessions
October, 1899, at Newington, on appeal against sentence for three months’ hard
labour for indecent exposure of his person on July 30th, 1899.

The man, aged 38, married, a builder, of good character, against whom no
accusation had ever been made. He consulted a local doctor a few days before
the charge for headache, giddiness, sickness. He was found to be very deaf, with
history of old middle ear disease, and the diagnosis of Meniere’s disease was made.
His memory was noticed to be very defective, and he seemed easily to become
confused, almost incoherent, in his talk. He was accused of being found on a
spare piece of land with his trousers undone, and his penis exposed and in his left
hand, he is said to have soon been surrounded by children whom he incited to
sexual offences. A woman coming, he asked her to come ; then she threw something
at him, he took no notice, she went and fetched a policeman, and then the prisoner
asked the policeman if he would come. He did not seem in the least ashamed or
affected by the presence of the policeman, and the latter had really to help him to
dress and put his penis away. His manner was odd, he was rather like a man
under the influence of alcohol, and it may be here said that evidence was forth¬
coming that he had had only two-pennyworth of whisky during the day, and this
was afternoon. He staggered and was dazed. He was seen by Dr. Savage a few
days after, who found him with great defect of recent memory, with great deafness,
and with some changes in optic discs with marked defect of vision. He was seen
by Dr. Savage some weeks later, and was then in the same state with further
evidence of loss of memory and temporary loss of power, if not consciousness.
He did not in any way endeavour to excuse himself, he only said he had no recol¬
lection of the time, and that from time to time he found there were gaps in his
recollection. The general history of the man was that his deafness had slowly
increased, his headaches and his defect of vision likewise had got worse; he had
not been able to follow his occupation as a builder and decorator, but having some
small property of his own to look after, this employed his time. The general plea
was that the case was one in which with disease of the middle ear some extension
of disease of the membrane affecting the cortical surface is going on, that a form
of minor epilepsy has been established, and that during a period of automatism he
had performed the indecent acts. I think the case worth recording from its
relationship both to Meni&re’s disease and epilepsy; and, though unable to give any

Digitized by

Google

204

NOTES AND NEWS.

[Jan.,

explanation, I am able to state that I have seen at least four instances in which men
With disease allied to Meni&re’s disease, if not complete examples of the disease
affecting the middle ear, have been guilty of sexual faults. The Court decided to
remand the prisoner for three months, during which time provision for his safety
in the way of a nurse or attendant was to be provided. This being done the con¬
viction to be quashed.

ASYLUM NEWS.

Killamey District Asylum.—Poisoning by Water-parsnip (CEnanthe crocata).—
Dr. Griffin reports that a male patient was seized by what appeared to have been an
epileptic fit on 13th October. Another seizure was followed by vomiting, insensi¬
bility, and great prostration. Clonic fits supervened to the number of six, attaining
their greatest intensity in the lower limbs, the upper limbs, and the face succes¬
sively. He died before apomorphia had time to act, and the stomach-tube could
not be used owing to the convulsions. Death was due to asphyxia, the heart
having continued to beat for a few seconds after respiration ceased. Another
patient was similarly affected, but an emetic relieved his stomach, and he was not
insensible, although delirious. He had got a root from the patient who died,
while working in a garden, and ate a little of it. The plant grows in great
abundance in the soutn of Ireland, and is used as a poultice for boils, etc.

Adelaide Asylums. —We rejoice to learn that Dr. Clelland has been empowered
by the Government to appoint a resident medical assistant at the Parkside Asylum.
With Dr. Napier in residence at the Adelaide Asylum, the staff will now be stronger
than it has been before. Our former reference to this matter will be found in the
last number of the Journal.

Aberdeen New District Asylum. —Aberdeen Parish Council, as the New District
Lunacy Board, has agreed to purchase the properties of Rainnieshill and Kingseat,
in the parish of Newmachar, as a site for the proposed new asylum—the former at
a price somewhat under £ 30,000, the other about £jooo.

RETREATS UNDER THE INEBRIATES ACTS.

The nineteenth report of the Inspector of Retreats under the Inebriates Acts of
1879 and 1888 has been issued as a Parliamentary paper. It states that the satis¬
factory sanitary condition of all the fourteen establishments had been maintained,
and the health of the inmates had been very good on the whole. Only one death
had occurred. The licences of all the retreats existing in 1897 were renewed by
the justices, and two new establishments were opened at Wandsworth and Stret¬
ford for the reception of female patients. Compared with the year 1897, the
number of admissions has slightly decreased. The Acts of 1879 and 1888, although
defective on some points, had worked smoothly on the whole during the year. Sec¬
tions 13 to 20 of the Inebriates Act of 1898, which amend the previous Acts in
relation to retreats in several important particulars, had given universal satisfac¬
tion to the licensees of the existing retreats.

DIFFICULTIES UNDER THE INEBRIATES ACTS.

At Lancaster, the Chairman of Quarter Sessions, in speaking of a case of habitual
drunkenness, said that, while the man should be sent to a retreat, he would have to
be detained in gaol pending the instructions of the Secretary of State.

The Joint-Committee of the County and Non-county Boroughs have, however,
prepared a report suggesting a Board to be formed, like the Asylums Board, under
Act of Parliament. Pending this Act, the Committee suggest that the County

Digitized by VjOOQle

NOTES AND NEWS.

205

1900.]

Council should purchase a site or sites, and proceed with the erection of buildings.
One for fifty men, and another for a like number of women, would seem sufficient
to begin with.

On the other hand, a conference of the county and borough authorities of
Perth, Forfar, and Fife resulted in a declaration that, as matters stand, it was not
expedient to proceed to establish any certified inebriate reformatory for the counties
named. At Aberdeen, again, it was decided that police boroughs had no power to
contribute towards these reformatories, and the Secretary of State for Scotland
intimated that he had caused a draft of amendment to the rating provisions of the
Act of 1898 to be prepared, to await a favourable opportunity.

STATE INEBRIATE REFORMATORY FOR SCOTLAND.

We understand that the Secretary for Scotland has issued instructions to the
Prison Commissioners to proceed with the alterations necessary for utilising some
of the buildings attached to the prison at Perth as a State reformatory for inebri¬
ates under the Inebriates Act, 1898.

STATISTICS OF SIX THOUSAND CASES OF INSANITY AD¬
MITTED INTO DUNDEE ROYAL ASYLUM FROM ist APRIL,
1890, TO 2nd NOVEMBER, 1898. By James Rorie, M.D.

Table I. —Analysis of 6000 Cases of Insanity admitted into Dundee Royal Asylum
from the opening of the Institution to 2 nd November , 1898.

| Individuals.

Cases.

Males.

Females.

Total.

Males.

Females.

Total.

Admitted once .

1807

*994

3801

1807

*994

3801

»»

twice .

a6a

370

63a

5 H

740

1264

»*

3 times

165

328

267

495

4 n

104

196

5 11

6 „

7 »»

8 „

—

9 ,,

—

10 „

—

11 „

—

12 11

—

11 ] |

*5 »»

—

■9

2183

asoi

4M4

2758

3242

6000

Males.

Females.

Total.

First admissions

, .

. ,

2183

2501

4684

1 Relapsed

cases

•

SIB

74 *

13*6

* 7 S«

3242

6000

Digitized by VjOOQle

Table II. —Analysis 0/6000 Cases admitted into Dundee Royal Asylum from 1820 to 1898, subdivided into following periods :— 1 . From opening
of Asylum , 1820, to passing of Poor Law Act, 1845. 2. From passing of Poor Law Act to that of Lunacy Act , 1857. 3. From passing of

Lunacy Act to opening of Lunatic IVards in Dundee Poor houses, 1864. 4. From opening of Lunatic Wards to transferetice of Patients to

New Asylum , 1882. 5. From opening of New Asylum to 2nd November , 1898.

206

NOTES AND NEWS.

[Jan.,

Total 6000
cases

1O00 «-* fP.NO O O

On © VO O' # *t jr.00
- i*> ONOO o o *M
w; — — «

0©

1 S

pp; O - NO w -t CN

1 2

- t fp. U1 - O

i a

p» - - oo fp. o b

: §

rrj p» — PI

1 38

— -t 0C O >ON O

M- »0 W N W NO CN

N PO00 NO IOO P»

1 oo

PO — — pi

1 g

N « tN OnnO O

-t pp; cn - oo oo y

1 of,

o *ooo no V o po

PO PI — —

PO O 00 CnnO - PO

*£

PI -t ‘O — CN f N

Ni>

M O' O' p* V « -

i ?

« « N -

«o

-P

NO W -t ‘O — VO —

®2

w M fp. fp. Pf) o o

- -on - o p*

1 oo

%o •-> p» —

Total 6000
cases

W - o NO 00 O 00
— -too PO p* ©O'©

0009

-t --- 00 - NO

CO ©N -t WOO 00

p» «o t “)

V»

•O CN UO'O — 00 -t
pp. O 0C -t ON -t

*o P» PI PO

»o

IT,

c£

- ©0 00 00 *Oi PI 00

0C NO PO pp.

W WOO NO »O00 P.
NO NO p* 00

<©

O PC 00 NO CN — ro

pi oo — *o p« — p*

*0 — r* —

-t

Amentia

Mania . . . * .

Dementia .
Melancholia
Monomania

Moral insanity

General paralysis

——

J5 I©

•5

^ Cl
_ «
is 3

0 u
H

'S'

no pono no o no pono fo o w.
nO 00 nO nO O NO pp.nO 00 00 *C ©O

1 r* P r r* ^ p j* 7* Pry* r

j ^-00 00 do O' ON ONOO 00 «>. WOO

— OC PO pi PO M u) m n X PO PI
pp.nC 00 O O' w O — ©nnO OO On
** pOnO 00 NO 0>00 PO rr.NO po
t'. fs Cn O '00 ON 00 w WOO

O w; O NO NO ON NO NO w O' nO pi

O' - 00 M *0 00 n -tfO

- OO *0 -t W cn -t Pi ON On « jt

00 00 O' — do O' wnO «o Uoo

- O' o w - n© w ro -t W00

- O NO 00 - O 0C 00 rOOO 00 PO
wtjoonO i>. u> « h» w; n w i>.nO
00 n© w O '00 »o ©nn© w On On O

O **snO — *— 0"0 w -tOO O

nO — ro -t- «o O fN-.vO p» O' -t —

OO N O N jt JO woo nO ff. WOO

c o o woo o' o no do w *o

oooo ©* p* o>p* w ©ooc oo ooo
NO w ©n o oc oo oo oo oo w w Jo.

M »o o NO -t -t -toe »o - ©C00
-too ONP« ONNf *0 0 00 PP. »O00

- w »O0C nO 0C NO ONWJ^M)^
0000 ONOvt tN -t-00 O' -

-t 'O -t -too NO -t O no o O 00
p* po «- -t ^ n 4 - o on - p*

On 00 r- -t-oo -t — O' O' N -t PO
fP< wi W 3 t t •O'O Pf~. -t -t -t P 0

00 CnnO w w -ro it, i— O' — ON
WOO O - O CN O CN O 00 00 00

►» J8 Si «

5 <u *2 5 o 4j o o a)

Digitized by

Google

Social State. I Reduced to Percentages.

NOTES AND NEWS.

o O N 0 WJNNO

Mi — «fl m 0 00 VO VO 6 - 00 pc

1^. ON f^vp OV — pv N>6 « O

« « « *o oo - 6 o 'o

t^o t^oo © pc - «vo vo **• ossc ««■ ov

, ON ^ N\0 O W)« W)MJU)l«.0 O O

| - ov o pv pvp ^ o "too -*• *>. o pv <n o

o Vcoo bv - b « - bwb ic mb o o o

N - 0- «JH’tOvOW>«N-0-

rr.N nis ^vO 00 >0 o*vO N«5 n u)VO i

«vpqo joO ;*■ jfl vo oo O + p*vp ^ I

o Vo w 5 « 5 «< « b i> »o io « n o o

, « PC00 vO — PC — 0 t^oo U}NW) I ,

| N p •* P U)« pvo PV PV 00 | |

*o «« b '« »ovs "o oo so « W — o

-* ^«vo «

t»\0 PV SO o

O io - PV -

00 P* -tvo PV U)U}U)0 ^ O *^00 00 oo 00
00 M3 4 v#3 00 "too pv 00 00 t^OVP«00<»00

o pc os so - ^rqo ^ p - p-vp pv *>. o p
b o *o~

p-oo st p - 'tvo ps t" o 6
b <i Mi o '»» V w) w o oo

• VO O O O - Mi Mi o Os O 00 PV NI^»

«\0 OO 't r^s© PC - O pc —

« ui(ot>P. *—SO M3 PC PC — —

) 0 Ml PC PV sc Mi fS O Vf OS ^ PC Os PV
O O MiO - 00 tKfp.OSMl«
-.PVPVPCPCPCPVPV- —

O Mi VO oc ^ - 00 Mi Os Os O

r^vO O OS Os -Tf — 00 *— PC cv —

r M PV PC O 00 VO t'-OO 00 Mi O

pcvO frvvo Mis© Mi pc — — —

• Mi PC Os PV WVO PC « — Mi PV OS
M-PCPC^-^-^WOO MiVO «

g 28 l??i! 3 S-!? 8 , 3 « 8 <?S.» 8 # 8 »

*538

208

NOTES AND NEWS.

[Jan.,

DISINFECTION.

Prom time to time in asylum practice it is found necessary to disinfect apart*
ments, and as knowledge of disease increases the more attention is paid to the
various chemical substances offered for that purpose. Perhaps the most popular
and efficient is formalin, which has also been found very serviceable in the patho¬
logical department. Steam at low pressure has been declared effective for articles
of clothing, etc., and can readily be applied at most institutions. We shall be glad
to have communications in regard to this practical and important subject.

THE EMPLOYMENT OF THE INSANE.

The Lancet of 28th October refers to work done at the Wernersvilie State
Asylum, Pennsylvania, where chronic patients considered fit to labour are received
from the other State institutions. The results of five years’ experience of
agricultural labour are given as follows:—(a) Of the patients 6 per cent, can
perform work equal to paid labour, 30 per cent, can perform labour equal to one
half of paid*labour, and 50 per cent, are equal to one fourth of the value of paid
labour. The balance of 14 per cent, are non-working, and this includes those who
are ill or are found on trial not to be able to work. (6) The estimated value of the
gross amount of work done during the current year, on a basis of 400 men, is
$29,000. The estimated cost of food per head is 20 cents per diem, or $1*40 per
week, (f) The health and welfare of the patients are medically attended to, and
the medical reports regarding the health and mortality are found to be entirely
satisfactory. Indoor work, e. g. brush-making, is now being introduced as an
extension of the original industrial scheme, and it is believed that this also can be
pursued with profit. These results are representative of our experience in asylums
of this country where an adequate area of agricultural ground has been secured.
It is somewhat surprising that the Lancet should go on to recommend that the
example of Wernersvilie should be followed by other institutions in Britain and
America. Old-established asylums such as Wakefield and Utica are veritable
hives of industry; it is years since machinery was introduced in the shoemaking
department at the former, and the old men were encouraged to make and repair
stockings; while the useful trades at Utica are representative of the greatest
possible variety, and would be still more efficient but for the interference of trades
unions. Of course every asylum ought to have a farm proportionate to its size.
It is late in the day to advocate that primitive measure.

CORRESPONDENCE.

Syphilis and General Paralysis of the Insane.

From W. Gilmore Ellis, M.D., Medical Superintendent, Government
Lunatic Asylum, Singapore.

At the last Annual Meeting of the British Medical Association, Dr. Campbell,
of Rainhill, opening a discussion on syphilis and general paralysis in the psycho¬
logical section, says: “ The third argument against the syphilitic origin of General
Paralysis is that among certain races where syphilis is rife General Paralysis is
said to be uncommon. Christian, of Charenton, is responsible for such a statement
concerning the Arabs of Algeria, but I believe it requires substantiation.”

In the Straits Settlements syphilis is most prevalent, more especially so since
the unfortunate repeal of the (Contagious Diseases Acts by order of the home
government. With our teeming population of Chinese, about 120,000 in Singapore
alone, out of a total population of 104,554 at the 1891 census, with a percentage of
seven males to one female, to whom prostitution is but little if any disgrace,
what else can be expected ?

Digitized by VjOOQle

NOTES AND NEWS.

209

1900.]

During over eleven years* service in this colony 2524 lunatics have passed
through my hands. Of these 241 either gave histories of, or had undoubted signs of,
past or present syphilis, and doubtless many others had suffered from the disease.

Of the above 2524 patients, 45 were Europeans, 21 Eurasians, and the remainder
Asiatics (principally Chinese, Malay, and Southern Indians).

But one case of general paralysis has ever been noted in this asylum, a Danish
sailor who died here in 1891.

There have been two cases suspiciously like general paralysis in Chinese, but
the sequence of events were not such as is seen in that disease. The cases were
eventually diagnosed as syphilis, and on post-mortem examination there was found
in one a syphilomatous deposit over the left frontal convolutions, and in the other
patches of necrosed bone of the vault with adherent and inflamed patches of
dura mater and pia-arachnoid membrane.

It has seemed to me that our natives cannot be expected to be the subjects of
general paralysis with their simple life, few or no worries, and the fact that there is
no struggle for existence amongst them. In a country where there is no cold, but
little indulgence amongst natives in alcoholic excess, where food and lodgings are
cheap, and the least possible clothing required, a disease originating in anxiety,
mental worries, and great excesses, is little likely to develop, notwithstanding the
fact that the (?) preliminary disease be present.

Nomomber 1 6th, 1899.

Sblf-indicating Locks.

From Dr. Donaldson.

In answer to your inquiry, I have to state that the self-indicating locks in use
here are a great success. The lock has the following advantages: —1. Indicates at
a glance on entering a dormitory if the door of single room is locked. 2. Is noise¬
less. This advantage is great for night inspection of single rooms by night attend¬
ant. 3. If a patient is in bed in a single room the bolt can be locked in, so that it
is impossible for another patient to turn handle, and thus seclude patient in bed.
4. If a single room be not in use by day the bolt can be locked out, thus preventing
patients opening the door and getting into the single room. 5. When necessary
for a night attendant to go into a single room to attend to a patient the bolt can be
locked in, thus precluding the possibility of a patient in a dormitory locking
attendant in a single room. The makers are C. Smith and Sons, Limited,
Birmingham.

Canbhill Asylum ;

Dtctmbtr 4th, 1899.

COMPLIMENTARY.

Presentation to Dr. Alexander Robertson.

One of the senior members of our Association, Dr. Alexander Robertson, lately
retired trom the staff of visiting physicians to the Glasgow Royal Infirmary, and
was met by a representative group of past and present house physicians and
nurses in the infirmary, Dr. John Ritchie in the chair. In the course of his re¬
marks Dr. Ritchie expressed the great satisfaction which they had derived from
their very intimate association with Dr. Robertson, who had taught them much
that had been of the very greatest value in their respective professions. Dr.
Robertson’s pupils were to be found in all parts of the country. Many of them
were, or had been, specially engaged in that department of medical study which he
had made his own. One at least had a world-wide reputation, several were in
consulting practice, and some of his nurses were in charge of important institu¬
tions. To them all the Glasgow Royal Infirmary would be no longer the same
when Dr. Robertson left its wards, where he had been so long in active service,
where as student, resident, or physician he had spent so many years of usefulness.
Dr. Ritchie begged his acceptance, with their warmest wishes, of a silver salver as
an indication of the sentiments of esteem and friendship which they cherished
towards him as a teacher and a friend. Dr. Robertson, in returning thanks, referred

XLVI. 14

Digitized by VjOOQle

210

NOTES AND NEWS.

0 an. (

to his long connection with the town’s hospital and to his fifteen years’ service in
the Royal Infirmary. We join with Dr. Ritchie in his hope that recollection of
Dr. Robertson will remain fresh and inspiring for many years to come.

Presentation to Dr. C. B. Burr.

Dr. Burr, of the Oak Grove Sanatorium, Michigan, was entertained by a sur¬
prise party lately to commemorate the twenty-first anniversary of his connection
with hospital work. Dr. E. A. Christian, of Pontiac, in a happy speech presented
him with a loving-cup from his former professional associates. Dr. Burr’.* friends
on this side will unite in their best wishes on this auspicious occasion.

Portrait of the late Dr. Paul.

We are glad to draw attention to a presentation lately made to the Association.
Mrs. Casberd-Boteler has given a framed engraving of a portrait of her father, our
friend and treasurer, the late Dr. Paul, which has been hung in the room of the
Association at Chandos Street. Due acknowledgment of this interesting souvenir
will be made at the next general meeting.

OBITUARY.

Reginald Southey, M.D.Oxon., F.R.C.P.Lond., late Commissioner in Lunacy.

Dr. Reginald Southey, whose death occurred rather suddenly on November 8th,
at his country residence, Belringham, Sutton Valence, had been in failing health
for some time. As a member of the College Club he dined with some of his
old friends only nine days before his death, and no one then present could have
suspected the end to be so near.

Reginald Southey was born in 1835, being the youngest son of Henry Herbert
Southey, M.D., D.C.L., F.R.S., F.R.C.P., and nephew of Robert Southey the poet.
He received his early education at Westminster School, and in 1852 proceeded to
Christ Church, Oxford. From here he graduated as B.A., with a first class in the
Honour School of Natural Science in the year 1857. He pursued his medical
education at St. Bartholomew’s Hospital, reading with the late Sir William
Savory and Mr. Henry Power, and in the year i860 he passed the examination for
the membership of the Royal College of Physicians of London. In this year, too,
he was elected Radcliffe Travelling Fellow. In the following year (1861) he took
his M.B. at Oxford, and immediately, in accordance with the conditions attached to
his Fellowship, went abroad to continue his medical studies, working for a year in
the hospitals of Berlin, Prague, and Vienna. In 1862 he travelled to South
America, visiting Rio de Janeiro, Monte Video, and Buenos Ayres, passing the winter
of 1863 in Madeira. In 1864 he was elected physician to the City of London
Hospital for Diseases of the Chest, Victoria Park, and also physician to the Royal
General Dispensary in the City, posts which he held until the following year
(1865), when he was elected an assistant physician to St. Bartholomew’s Hospital.
In 1866 he took his M.D. degree at Oxford, and was in addition elected a Fellow
of the Royal College of Physicians of London, being appointed Goulstonian
Lecturer for 1867. For this set of lectures he chose as his subject the Nature and
Affinities of Tubercle. In 1870, atter unusually rapid promotion, he was elected as
full physician to and teacher of clinical medicine at St. Bartholomew’s Hospital,
where he also delivered an annual course of lectures upon Public Health and
Medical Jurisprudence in the Medical School. The latter lectureship he held for
a period of fourteen years. He had the honour of being placed upon the Council
of the Royal College of Physicians of London in the years 1878 and 1 879, and
from 1877 until 1883 he was physician to the Hospital for Incurable Children
at Cheyne Walk, continuing on the Committee until the year 1888. He delivered
the Lumleian Lectures in 1881 on Bright’s disease, and in connection with this
subject we may remind our readers that he was the inventor of Southey’s tubes for

• *

Digitized by tjOOQle

NOTES AND NEWS.

21 I

I9OO.]

slow drainage of anasarcous limbs. Dr. Southey was a vigorous writer. Amongst
his medical works may be mentioned the article on “ Personal Health ” in
Quain's Dictionary of Medicine. He contributed numerous and important
papers to the St. Bartholomew’s Hospital, Clinical, Pathological, and Royal
Medical and Chirurgical Societies, and also translated the articles on the
u Structural Diseases of the Kidney,” and the “ General Symptoms of Renal
Disorders,” as well as that on “ Diffuse Diseases of the Kidneys ” in vol. xv of
von Ziemssen’s Cyclopaedia of the Practice of Medicine. He was frequently
consulted in cases of questionable sanity, and in reference to the evidence of
lunacy in criminals, and in 1883 he resigned his various offices at St. Bartholo¬
mew’s Hospital on his appointment as Commissioner in Lunacy in succession to
Dr. Naime. He continued to discharge the onerous and yearly increasing duties
of that office for fifteen years, when failing health caused him to resign the
Commissionership in 1898.

During all those years it is not too much to say that he steadily acquired and
retained the good opinion and kindly regard of all with whom he was brought in
contact.

A conscientious worker himself, he readily recognised and acknowledged
conscientious work in others, but while striving towards a high ideal he did not
fail to realise the special difficulties of that department of it in which mental
physicians were engaged. He never lost the keen medical spirit which actuated
all his working life.

It is needless to add that his relations with his colleagues on the Commission
were of the pleasantest kind. His efficient and unstinted co-operation while
strength remained commanded their respect, and his genial and kindly nature secured
their affectionate regard.

Dr. Southey was an admirable specimen of the scholarly Oxford physician. He
was a good French and German linguist and well read in the literature of both
countries, an excellent clinical teacher, and a man of great ability; but he never
sought fame or advertisement, going on his path through life unpretendingly, and
doing what he had to do with faith and earnestness.

* \ f r f'

•' ' ' '* i S *■? >? 1 te ^ ^ ** .*

•NOTICES BY THE REGISTRAR.
Examination for the Nursing Certificate.

One hundred and thirty-one candidates applied for admission to the November
examination for this certificate. Of this number 106 were successful, 17 failed to
satisfy the examiners, and 8 withdrew.

The following is a list of the successful candidates:

City Asylum, Exeter. — Males: William Richard Tucker, John Thomas Head.
Female: Matilda Milford.

City Asylum , Bristol.—Males: Robert Daws, Samuel Richer. Females: Harriet
French, Isabel Blanche Hardy, Annie Louisa Raggatt, Hilda Toogood.

Borough Asylum , Rowditch, Derby.—Males: James Crooks, George Newbold.
Females: Gertrude Kelly, Ada Robinson, Harriet Singleton, Ethel Taylor.

The Wameford Asylum , Oxford. — Females: Alice Maude Goody, Beatrice
Alice Hallett.

Kent County Asylum , Maidstone. — Males: Roden Basil Hill, George Henry
Jeine, Herbert Ruler, Walter Tompkins. Females: Maria Annie Kate Earl,
Theresa Fennell, Isabella Hilton, Frances Nolan, Annie Poile Funnell.

James Murray's Royal Asylum , Perth. — Females: Louisa Chambers, Mary
Mackintosh, Nellie Robertson.

County Asylum , Mickleover , Derby.—Males : John Hutchinson, Thomas H.
Sanders. Females : Mary Campbell, Florence Curtis, Ethel Dunstan, Florence
Gordon, Florett Matilda Hitchenor, Ida Lightfoot, Minnie Florence Williams.

The Retreat , York. — Female : Charlotte Elizabeth Thomasson.

North Riding Asylum , Clifton , York. — Males: John Edmund Clifford Biggs,
Thomas Benson, Hezekiah Kennett. Females: Elizabeth Musgrove, Annie
Silversides.

Digitized by VjOOQle

212

NOTES AND NEWS.

[Jan.,

Borough Asylum , Sunderland.—Males: Septimus Noble, John Petrie. Females t
Edith Burdon, Elizabeth Butchers, Julia Robinson, Annie Edith Reid.

West Riding Asylum, Wakefield. — Male: George William Dixon. Females:
Dora Graham Braithwaite, Isabella Henderson Field, Elizabeth Ann Goldthorp,
Geneiva Watkins.

County Asylum, Lancaster.—Females: Dagmar Wilkes, Elizabeth Atkinson,
Jeanne R. Macgregor, Isabella Rotherey, Sarah Jane Robinson, Margaret Robson,
Agnes Mary Swaby.

County Asylum, Melton, Suffolk. — Males: Walter Edward Benham, Ralph
Tracey, Arthur Edward Warneck.

County Asylum, Newport, Isle of Wight.—Males: Albert Edward Prosser,
William Walter. Female: Emily Bell.

District Asylum, Londonderry. — Male: William Glenn. Females: Sarah Alex¬
ander, Margaret Sweeney.

St. Patrick's Hospital, Dublin.—Females: Lizzie Brien, Kate Byrne, Mary Anne
Simpson.

Woodilee Asylum, Leneie, Glasgow .— Males: John Bracken, Robert Donaldson.
Females: Agnes Hendrie, Minnie T. MacLaren.

County Asylum, Morpeth, Northumberland. — Males: George Henry Emerson,
George A. Frazer, Ernest Gibson, Percival James Todd, Francis Watson.

County Asylum, Thorpe, Norwich, Norfolk. — Males: Charles Creswell, Martin
William Davies, William H. Grant, John James Hope, Harry Smith. Female:
Kate Hornegold.

Bethlem Royal Hospital, London.—Females: Elenor Bailey, Minnie Honeybone,
Alice Reddaway, Charlotte Emily Scott, Annie Simpson, Matilda Wheeler, Mary
Annie Walters.

Highfield Asylum, Drumcondra, Dublin.—Female: Sarah Dowling.

Holloway Sanatorium, Virginia Water, Surrey. — Males: William Henry Collis,
William Lawrence, Herbert Youel Summons, Thomas Townsend, Frank Varney.
Females: Ada Elizabeth Apedaile, Mary Elizabeth Bush, Adelaide Fidler, Lily
May Livermore.

r The following is a list of the questions which appeared on the paper:

i. Describe the act of swallowing and the digestion of food in the mouth and
1 stomach. 2. Name the principal arteries of the arm. State their positions. 3.
What is the normal temperature of the human body P What is the proper tempe¬
rature of the air in a sick room P What is the temperature of the water in a warm
bath P 4. What would you notice regarding the passing of urine and regarding its
characters ? 5. In a case of suicidal wound of the throat, with alarming haemor¬
rhage, what immediate treatment would you adopt P 6. Describe how you would
treat a patient who is apparently suffering from poisoning by coal gas P 7. Men¬
tion the various kinds of enemata, and give examples. 8. What do you understand
by delusions of persecution ? Describe a case known to you. 9. Mention the
differences between home and institution treatment. 10. What precautions should
be observed in the case of patients suffering from pulmonary phthisis with the
view of preventing the spread of the disease in an asylum P
*—"^The Council decided that a special examination should be held for the South
African candidates, the results of which have not yet been received.

The next examination will be held on Monday, May 7th, 1900, and candidates
are earnestly requested to send in their schedules, duly filled up, to the Registrar
of the Association not later than Monday, April 9th, 1900, as that will be the last
day upon which, under the rules, applications can be received.

Note.

As the names of some of the persons to whom the Nursing Certificate has been
granted have been removed from the Register, employers are requested to refer to
the Registrar, in order to ascertain if a particular name is still on the roll of the
Association. In all inquiries the number of the certificate should be given.

Examination for the Professional Certificate.

The following gentlemen were successful at the examination for the Certificate
in Psychological Medicine held on December 14th, 1899:

Digitized by VjOOQle

NOTES AND NEWS.

213

1900 .]

Examined at Bethlem Hospital .—Dr. David Fleck.

Examined at the Royal Asylum , Edinburgh .—Dr. W. M. A. Smith.

Examined at the Royal Asylum , Aberdeen .—Mr. Eric W. Thomson, M.A.

The following is a list of the questions which appeared on the paper:

1. What mental disorders may appear during the period of adolescence ? What
differences are noticed in the two sexes in the insanity of this epoch, and what is
the prognosis ? 2. Describe the chief features of the various forms of mental dis¬
order associated with epilepsy, and explain their psychological connection with the
neurosis. 3. What do you understand by partial insanity ? Discuss the use of the
terms monomania, paranoia, systematised insanity. 4. What are the usual mental
and physical causes of refusal of food in insanity ? Describe the methods of
forcible feeding usually adopted. Suggest a suitable dietary for a patient who
persistently refuses food. 5. How does mania usually affect the senses of sight
and hearing ? 6. Discuss and compare the morbid anatomy of cases of dementia
paralytica, dementia epileptica, dementia alcoholica.

The next examination for the Certificate in Psychological Medicine will be held
in July, 1900.

Gaskell Prize.

The examination for the Gaskell Prize will take place at Bethlem Hospital,
London, in the same month.

Due notice of the exact dates will appear in the medical papers.

For further particulars respecting the various examinations of the Association,
apply to the Registrar, Dr. Benham, Bristol City Asylum, Fishponds.

THE PRIZE DISSERTATION.

Although the subjects for the essay in competition for the Bronze Medal and
Prize of the Association are not limited to the following, in accordance with custom
the President suggests—

1. Developmental general paralysis.

2. The surgical treatment of epilepsy and epileptiform seizures.

3. The effect of influenza in the production of states of mental unsoundness.

The Dissertation for the Association Medal and Prize of Ten Guineas must be

delivered to the Registrar, Dr. Benham, City of Bristol Asylum, before May 30th,
1900, from whom all particulars may be obtained.

CRAIG COLONY PRIZE FOR ORIGINAL RESEARCH IN EPILEPSY.

Last year Dr. Frederick Peterson, President of the Board of Managers of the
Craig Colony for Epileptics, offered a prize of 100 dols. for the best original
contribution to the pathology and treatment of epilepsy.

The seven papers received were submitted to three members (Drs. Bailey,
Jacoby, and Van Giesen) of the New York Neurological Society, who gave to the
board of managers of the Craig Colony the following report:

The Committee on the Craig Colony Prize for Original Work in Epilepsy has
decided that no award should be made this year. Some of the essays submitted
failed to comply with the conditions of the competition; others were more limited
in scope than a successful essay should be. Three deserve special mention—' 1 The

XLVI. 15

Digitized by

Google

214

NOTES AND NEWS.

[Jan., 1900

Pathology of Epilepsy,” by “CONH 2 OH,NH s ;” “Status Epilepticus,” by
“ Aura; ” and “ The Pathology of Epilepsy,” by “ On and Ever Onward.”

The prize of 1899 not having been awarded in accordance with the report of the
committee, Dr. Peterson now offers a prize of 200 dols. for the year 1900
under similar conditions. This sum will be awarded to the author of the best un¬
published contribution to the pathology and treatment of epilepsy. Originality is
the main condition.

The prize is open to universal competition, but all manuscripts must be submitted
in English. Each essay must be accompanied by a sealed envelope containing the
name and address of the author, and bearing upon the outside a motto or device,
which is to be inscribed upon the essay.

All papers will be submitted to a similar committee, consisting of three members
of the New York Neurological Society, and the award will be made upon its
recommendation at the annual meeting of the board of managers of the Craig
Colony, 9th October, 1900.

Manuscripts should be sent to Dr. Frederick Peterson, 4, West Fiftieth Street,
New York City, on or before September 1st, 1900. The successful essay becomes
the property of the Craig Colony, and will be published in its medical report.

NOTICES OF MEETINGS.

Medico-Psychological Association.

General Meeting. —'The next General Meeting will be held on February i^lh
(the third Thursday), 1900, at the West Sussex County Asylum, Chichester, by
courteous permission of Dr. Kidd.

South-Eastern Division. —The Spring Meeting will be held on Wednesday,
April 25th, 1900, at the City of London Asylum, Dartford.

Irish Division. —The Spring Meeting will be held early in April, 1900, at the
Royal College of Physicians, Dublin.

South-Western Division. —The Spring Meeting will be held at Bailbrook House,
Bath, on Tuesday, April 24th, 1900.

Northern and Midland Division. —The next meeting will be held on Wednesday,
April 18th, 1900, at Whittingham Asylum, Lancashire.

Scottish Division. —The Spring Meeting will be held in Glasgow on March 8th
(the second Thursday), 1900.

APPOINTMENTS.

Dr. William StJ. Skeen has been appointed Medical Superintendent to the
Durham County Asylum, vice Dr. R. Smith, retired on pension.

Dr. John Baker has been appointed Deputy Superintendent to the State Asylum,
Broadmoor, vice Dr. J. B. Isaac, retired on pension.

Mr. H. A. L. Willis, M.R.C.S., has been appointed Junior Assistant Medical
Officer to the Govan District Asylum, Hawkhead, Paisley.

Digitized by

Google

Digitized by VjOOQle

GALER1E HERVORRAGENDER ARZTE UND NATURFORSCHER.

THE

JOURNAL OF MENTAL SCIENCE

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

No. 193 [To 8 ?sT] APRIL, 1900. VOL. XLVI.

Part I.—Original Articles.

Isolation and Open-air Treatment of the Phthisical
Insane , with Notes on Seventy-four Cases treated .
By David Blair, M.D., County Asylum, Lancaster.

WHILE this subject is being discussed in the Journal of
Mental Science , a short account of an attempt to carry it out
may be of some interest.

About four years ago an isolation hospital for infectious
diseases was completed at the Lancaster Asylum. But in¬
fectious diseases—as ordinarily understood—proved for a time
so rare that the new building threatened to be always tenant¬
less. Dr. Cassidy, the medical superintendent, thereupon
resolved to utilise it for the isolation and treatment of con¬
sumptives, and for the past few years it has been reserved for
the reception and treatment of these alone.

Structure and Situation. —The hospital is situated on the
southern confines of the estate. It lies low, is well sheltered
from the north, east, and west, but has a free exposure towards
the south.

The main building consists of an eastern and a western wing
similar in all respects, and connected by the corridor. Each
wing contains twelve beds. Opening from the corridor towards
the south between the wings are a kitchen, two nurses* bed¬
rooms, and a dormitory for three patient workers. From each
end of the corridor towards the north separate slop-rooms,
lavatories, and water-closets open for the use of each wing.

A married attendant with his wife live in a detached two-

XLVI. 16

Digitized by VjOOQle

2 16 ISOLATION OF THE PHTHISICAL INSANE, [April,

storied house, which is connected by a covered way with the
main building. Here all the cooking for the hospital is done
by the attendant’s wife. A third edifice contains a steam
steriliser for the disinfection of clothes and a room for their
reception. The male attendant’s chief duty at the hospital is
to disinfect the clothes.

Such are the integral parts of the hospital, which is entirely
cut off from every other part of the building ; and as fifteen
hundred, or three fourths, of the patients of this asylum are
females, it has been reserved for them alone.

Practical Suggestions .—The existence of means for isolation
of consumptives soon made the necessity for early and accurate
diagnosis specially evident. Such early diagnosis is not always
easy. The tubercle bacillus cannot be found in many cases,
and while the tuberculin test has been occasionally resorted to
with satisfactory results in the differentiation of typhoid diar¬
rhoea from tubercular, and in the elucidation of phthisis in
ancient dements, in whom the disease runs a latent course, and
in whom its symptoms- are masked by co-existing bronchitis or
emphysema; yet in recoverable mental cases it has not com¬
mended itself as a justifiable means of diagnosis. In the
absence of physical signs, which are often masked by the mental
symptoms, the weighing machine and thermometor have been
our chief guides to isolation. Many cases have thus been
isolated who have only been suspected of the disease, and we
believe this course has been a right one. No case has ever
acquired phthisis in the hospital; but our short experience has
shown us that any isolation hospital which does not provide
special accommodation for suspects will be much less valuable
to the institution.

Still further, in order to efficiently serve an institution for
the insane, an isolation hospital must be a miniature asylum.
Phthisis attacks all classes of the insane, the acutely suicidal
and wildly maniacal as surely as the harmless imbecile. Single
and padded rooms are essential ; their absence has proved one
of the greatest wants in our consumptive hospital. More than
once have we seen a phthisical, noisy, and homicidal epileptic,
the very woman who, more than any other, scatters her excreta
broadcast, turned from the hospital because there was no
single room. At times we have observed that one single room
to every eight beds would not be too many.

Digitized by VjOOQle

1900.]

BY DAVID BLAIR, M.D.

217

The experiments of Spillman and Haushalter have demon¬
strated without doubt the dissemination of the bacilli by flies.
In summer these insects swarm in our hospital and feed upon
the sputum. They are a terrible plague to the more helpless
sufferers. Many appliances for their suppression have been
tried in vain. Perhaps frequent fumigation by formalin by
means of the alformant lamp is as good as any. The patient
is best protected by a mosquito curtain fitting tightly round
her bed.

Cats are perhaps more frequent disseminators of bacilli than
is generally believed. One cat living about this hospital died of
well-marked phthisis, while another, which was known to eat
sputum and to be ailing, was shot. Its left lung was consoli¬
dated, while groups of little white nodules were obvious in the
intestinal peritoneum under the serous coat. Cats not only eat
sputum, but carry it about on their fur. They ought never to
be allowed in a consumptive hospital for the insane.

Disinfection .—Every reasonable effort is made to suppress
the bacillus. Disinfectants are freely employed in the washing
of utensils and of the bodies of the patients. Owing to the
danger of patients drinking what is in the chamber-pot and
sputum mug, it is impossible to have carbolic or microbine
in them while they are in use, but a thin layer of turpentine
is employed with safety. Many are induced to use a rag to
spit on, which is afterwards burned ; while every drop of urine,
feces, or sputum which gets upon the floor is carefully wiped
by a rag soaked in carbolic. The floors are made of blocks of
pitch pine, and are cleaned and polished with beeswax and tur¬
pentine.

Treatment .—As to the treatment, the open-air method is
adopted ; no special system is followed to the letter. The
general principles aimed at are recognised and carried out as
thoroughly as circumstances will allow. These general
principles are—(1) as much exposure to fresh air as
possible ; (2) an abundant dietary limited only by the assimi¬
lative powers of the patient; (3) in certain cases exercise
regulated according to the patient’s strength; (4) careful
medical supervision of every detail of the patient’s life. Some
of the windows of the dormitories are kept open all the year
round, and the patients even in winter are allowed to sit outside
in shelters protecting them from the wind. Their seats are

Digitized by VjOOQle

218 isolation of the PHTHISICAL INSANE. [April,

always kept in the sun, and they are carefully moved round
with it from east to south, and from south to west. They
rarely complain of cold. In cases where the digestion is good
the following dietary is given :

At 6.30 a.m. bread, milk, and porridge.

At 8 a.m. tea, bread and butter, toast, and bacon.

At 10.30 a.m. mutton broth, beef-tea, or milk.

At 12, noon, fish meat and potatoes, and milk pudding.

At 4 p.m. tea with bread and butter.

At 7 p.m. bread and milk and porridge.

(All the milk used in the asylum is sterilised.)

Unless contra-indicated every patient gets cod-liver oil in
some form. They are encouraged to take as much as possible,
to eat a small biscuit with it, and to take it only between
meals.

For suitable cases daily walking exercises are prescribed,
and in some cases, which could not be got to take exercise,
artificial respiration has been performed for five minutes several
times a day, but with doubtful results.

As few drugs as possible are employed. In cases of weak
heart cardiac tonics are given and perpetual rest for a time
insisted on. Anything which upsets the digestion is imme¬
diately discarded, for if the digestion is bad so is the prognosis.
No case is hopeful which does not increase in weight. Paral¬
dehyde is the only hypnotic employed.

Mental Condition of those treated .—To demonstrate the
results of treatment we have selected seventy-four consecutive
cases in whom the disease was well marked. Their ages
ranged from twenty to sixty-two, and only three had acquired
phthisis before admission to the asylum. In twenty-five cases
there was no hereditary predisposition either to phthisis or
insanity; in twenty-seven no history could be got; in five
there was a hereditary predisposition to both phthisis and
insanity ; in six to phthisis alone; and in thirteen to insanity
alone.

Twenty-one of the seventy-four cases, or nearly 28 per cent.,
were epileptics, while epileptics only constitute about 9 per
cent, of the insane in the asylum ; twenty-seven, or 3 6’5 per
cent., were melancholiacs, but melancholia exists in 40 per
cent, of the total insanity ; seventeen were maniacs, and mania
exists in 30 per cent, of the total insane.

Digitized by VjOOQle

1900.]

THE FEELINGS.

219

Results .—The largest number of patients, relatively, have
been epileptics, and they have been found the least amenable
to treatment. Of the others, all were in a more or less
advanced stage of the disease ; in fact some only came to the
hospital to die. But in twenty-three the disease was effectually
checked and their condition much improved. Two, in addition
to the marked improvement in their lungs and general health,
recovered from their insanity and were discharged.

Practically all the suspects improve so much in general
health as to justify their return to the general wards.

But the benefit to the institution has not been limited to the
remedial measures applied to those about to fall into decline
and the actually diseased. Some margin of good has doubtless
resulted from the mere isolation, for since its introduction the
death rate from phthisis in the asylum has been reduced by
nearly a half.

For reasons already indicated perfect isolation of all con¬
sumptives has never yet been possible here, although it soon
will be. Yet allowing for this, as well as some margin for the
possibility of mere coincidence in the diminished death rate,
we think that the results indicate that isolation and hygienic
treatment of phthisis are to some extent effectual, and as
applicable to the insane in asylums as to any other class in
the community.

The Feelings. By Harry Campbell, M.D.Lond.

I. Psychological.

It is convenient to regard the mental part of man, or his ego,
as being made up of feeling, will, and thought. Feeling I place
first, because it takes precedence in evolution, and because it
may be said to constitute the foundation of mind.

There is little need to define these three terms. By thought
we understand the formulation of ideas ; and the end of every
mental process being action, the determining of the action we
speak of as being performed by the will. Of neither of these
do I propose to treat here, but of the feelings —a subject of

Digitized by

Google

220

THE FEELINGS,

[April,

wide interest to the physician. I shall first seek to show how
large a part of the mental personality is made up of them, and
then inquire into the bodily conditions which underlie them ;
and here let me observe that I shall treat the subject from the
strictly practical point of view, and shall refrain altogether from
psychological subtleties.

What, then, are the feelings ? They embrace the sensations
and the emotions^ 1 ) When the skin is pricked, when light
falls upon the eye, or when a piece of sugar is sucked, so many
sensations are felt; when a person flies into a rage or is stricken
with fear, he experiences an emotion . Some contend that such
elementary emotions are primitive unanalysable states of mind,
but it is more probable that they, and indeed all the emotions,
are compounded of sensations-—that they are, in fact, so many
chords of sensations. It is well known (hence, indeed, the origin
of the term “ emotion ”) that every emotion tends to be accom¬
panied by a commotion of the body, e.g. cardiac disturbance,
dilatation or contraction of arteries, a pouring out or drying up
of secretions, spasm or paralysis of muscles. Now these various
bodily changes, peculiar for each emotion, are necessarily ac¬
companied by sensations felt in the parts commoted, and there
can be little doubt that these sensations enter into the feeling
which constitutes the emotion. I shall assume (with Lange and
James) that they constitute the whole of the feeling, and that
if all these sensations were struck out, as would happen in the
case of total anaesthesia of the body, nothing would remain of
the emotion. It is true that the feeling we term an emotion
may seem to have very little sensory element in it which can be
definitely felt in the body ; and it is for this reason that emotions
are sometimes spoken of as feelings of the mind, in contradis¬
tinction to the sensations which are definitely felt in the body.
Thus we speak of grief as being a mental pain, and of joy as a
mental pleasure, in contradistinction to such a pain as that
caused by indigestion, or such a pleasure as the relish of food,
which are said to be physical or bodily. Nevertheless it is
probable that all emotions, whether simple, as in the case of
anger and grief, or complex, as in the emotion of love and the
aesthetic emotions, are made up of simple bodily sensations—
more particularly of the sensations pertaining to the parts of the
body emotionally agitated. Space does not allow me to give
my full reasons for adopting this view.

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

221

This conclusion has important practical bearings. It is a
matter of common observation that vigorous health, with the
pleasurable bodily sensations which go along with it, predisposes
to pleasant emotions; while, on the contrary, disturbed health
with its accompanying unpleasant bodily sensations is prone to
beget unpleasant emotions. At the end of a fagging day, when a
man feels tired and exhausted, when, in short, his general bodily
sensations are unpleasant, he is wont to get irritable, i. e . to
experience a certain measure of the painful emotion of anger,
but by the time he has been refreshed by food and feels rested
and comfortable, he is disposed to more pleasurable emotions.
Now this is just what our conclusion would lead us to suspect.
If the emotions are compounded of bodily sensations, then
pleasant bodily sensations, providing as they do the ingre¬
dients of pleasant emotions, will predispose to these, while
painful bodily sensations, furnishing the materials of painful
emotions, will tend to call forth these. Indeed I would go
further, and contend that when the entire body is permeated,
so to say, with unpleasant sensations, it is impossible to ex¬
perience a pleasurable emotion, and contrariwise. This must
be the case if our premises are correct. I say permeated , for
when a pleasurable or a painful sensation involves only a
limited part of the body, as when one sucks a sweet, or cuts
one’s finger, such sensation is quite consistent with the concur¬
rence of emotions of the opposite order.

It may be thought that this principle, though in the main
true, does not admit of universal application. Thus a person
possessed by a feeling of exuberant well-being might, on hearing
bad news, suddenly be plunged into painful emotion. Let us
not forget, however, that a depressing emotion of this kind tends
to destroy for the time being the pleasurable bodily sensations ;
but directly the latter reassert themselves the painful emotion
tends to fade away. Similarly a person pervaded with a pro¬
found sense of malaise may by good news, cheery conversation,
or stirring music, be temporarily roused into a pleasing emotional
state, which for a time mitigates or removes the painful bodily
feeling ; but in proportion as the latter revives, in that propor¬
tion does the pleasing emotion tend to grow faint and dis¬
appear.

Digitized by VjOOQle

222

THE FEELINGS,

[April,

Individuals differ greatly in regard to the Nature and Range of

their Feelings .

Individuals differ greatly in the nature and range of their
feelings. It is because of these differences that men differ in
temperament and disposition. Individuality depends essentially
upon the feelings. If all men felt exactly the same, differing
only in thinking power, each man would seem to be mentally
very like all others.

These differences in feeling are shown alike in respect of the
simplest sensations and of the most highly elaborated emotions.
How profoundly, for instance, do individuals differ in their
taste sensations ! What is agreeable to one may be disgusting
to another, and it is probable that the range or scale of taste
sensations differs much in different individuals. And the same
applies to other sensations, visual, auditory, sexual, and so
forth ; just as some have an exquisitely delicate colour-
sense, while others are colour-blind ; and just as some have a
keen sense for appreciating musical sounds, while others are
practically music-deaf; so some may have powerful erotic
feelings, while others are altogether devoid of them.

As further illustrating how individuals differ in regard to
their sensations, I may refer to those groups of sensations which
go to make up the feeling of physical well-being and ill-being.
These feelings have a special interest for the physician, whose
chief life-work is to bring about the one and drive away the
other. This is, indeed, the final end of all human effort. If
all of us were imbued with an exuberant sense of well-being,
this would indeed be a happy world.

There are different kinds of well-feeling—that is to say, we
do not always feel well in exactly the same way ; and there are
still more numerous varieties of unwell-feeling, or malaise .(*) We
may feel ill in many different ways. Let us, however, for con¬
venience regard well-feeling on the one hand, and malaise on the
other, as being always the same in nature and differing only in
degree. We may then construct a scale representing the various
degrees of well-feeling and malaise . In the centre we place the
indifferent feelings, passing thence upwards through ever-
increasing heights of well-feeling, and downwards through
ever-increasing depths of malaise .

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

223

Now, neglecting temporary variations, we may say that
every individual has his own particular note of feeling in this
scale. The habitual note of some is one of exuberant well¬
being ; of others—quite a large number—a feeling of indiffer¬
ence ; of others, again, a feeling of malaise .

The sense of exuberant well-being is most characteristically
met with in young people ; after adult life is reached it tends to
get less and less, being only exceptionally found in the aged.
That such a deterioration in the realm of feeling does actually
occur we gather from the testimony of individuals themselves,
and also from their conduct. The sense of exuberant well-being
always expresses itself by muscular activity, just as the sense of
malaise conduces to quiescence ; and it is certain that the steady
decline of muscular activity which takes place with advancing
years is marked by a parallel descent in the gamut of feeling.
All animals are most active during their growing years, when they
indulge in activity for mere activity’s sake, and it is then that
they feel most exuberantly well. Very few, even during their
physical prime, much less as they approach or actually enter
upon the period of decay, experience that intense joy of living
which belongs to the young. How soon it departs depends
upon various circumstances. It probably goes sooner in the
civilised than the uncivilised ; in the sedentary town-dweller
than in the country-dweller leading an active outdoor life; in
the poor than in the well-provided. In the poor of large towns
it departs very soon, and it may safely be asserted that the
second and third generations of very poor town-bred people
never feel exuberantly well, if, indeed, they can be said to feel
well at all; their habitual note of feeling is very low down in
the scale. It disappears in women before men. A large
number of women lose it soon after they have reached woman¬
hood, seldom feeling more than moderately well from this time
till after fifty, which is past the age for exuberant well-feeling.

It is this atrophied sense of well-being, and not merely the
disappointment of abandoned hopes and unrealised ideals, that
makes a person in later life exclaim with the poet—

“ But yet I know, where’er I go,

There has passed a glory from the earth.”

When a person gets blasS, it is not so much that he is
surfeited with pleasure, as that his keen sense of well-being has

Digitized by tjOOQle

THE FEELINGS,

224

[April,

been blunted. It is surely impossible to feel acutely well and
blast ; at one and the same time.

The pessimists of this world are those whose habitual note
is one of malaise ; feeling bad themselves, they take a gloomy
view of things in general; while the sanguine and the hopeful
are those who feel acutely well, and who look upon the world in
the light of their own feelings. A sense of exuberant well¬
feeling is, indeed, incompatible with painful emotions or painful
thoughts. It is largely on this account that children cannot
remain sad for any length of time, or harbour gloomy
thoughts.

“ A simple child,

That lightly draws its breath,

And feels its life in every limb—

What should it know of death ? "

Some lew—and they are chiefly, perhaps, men—retain to
extreme old age an acute sense of well-feeling and the
pleasurable emotions that go along with it. They are still
capable, as they walk by the sea-shore or gaze upon a sunset,
of that same emotional thrill which stirred them in the first
flush of youth ; they believe that this is a beautiful world, that
life is worth living, even to the very end. This is normal.
Those who scarcely ever rise to the height of well-feeling, but
remain habitually in the depths of malaise , are abnormal. Life
to many of these is not worth living ; nay, it may be a painful
thraldom from which they seek escape by self-destruction.

It need scarcely be said that those who seldom feel down¬
right well are greatly handicapped in their life’s work ; they are
apt to lack assurance and initiative, though we find not a few
notable exceptions. It is a remarkable fact that people get
accustomed to not feeling well.

Coming to the region of the emotions we find the same
differences obtaining. Observe, for instance, how great they
are in regard to the religious and aesthetic emotions. Some
have no religious feeling ; they cannot sit out a service, actually
chafing under conditions which produce in others a deep calm
or an ecstacy of happiness. And among those possessing the
religious temperament, what differences ! Whether a man is a
Ritualist, Low Churchman, or a Salvationist, depends fundamen¬
tally upon his feelings. Watch a group of Salvationists and a
group of Low Churchmen conducting an open-air service, and
you will best realise how profoundly they differ in their feelings ;

Digitized by

Google

' 1900.]

BY HARRY CAMPBELL, M.I).

225

and these differences, as I shall argue later, depend chiefly upon
differences in metabolism and blood-composition.

But it is perhaps in regard to the aesthetic emotions that the
differences in feeling capacity among men are most marked.
Very few realise the extent of these differences. Contrast in
this respect the great seer, to whom the meanest flower that
blows gives thoughts that often lie too deep for tears, with the
“wild rude carl,” to whom a primrose by the river brim is a yellow
primrose and nothing more. To a large number of people,
indeed, the beauty of nature and the great realm of art are as a
sealed book. The ordinary person can no more enter into the
feelings of the poet or the painter in his moments of inspira¬
tion, than can a man bom blind form an idea of colour or of
light. We, as a nation, seem to lack the sense of colour and of
form, or how could we come to build or to tolerate those
dreary miles of drab streets which make our large towns so
often the “ abomination of desolation ” to the sensitive eye ?
There are, on the other hand, unhappy individuals so con¬
stituted that to dwell in a mean street at the East End of
London, or even in one of the gimcrack “ villas ” of its more
prosperous suburbs, would sap their mental vigour and crush
all gaiety from their spirits. The minds of such can no more
thrive in an atmosphere of ugliness than can their bodies keep
healthy in poisoned air. I have known a child who was sent
up from a pretty country village to a particularly unlovely part
of the city brought perilously near to melancholia. Burne-
Jones was intensely sensitive to the weather. He could do no
work on an “ ugly ” day and many who are not greatly suscep¬
tible to aesthetic impressions show this peculiarity.

The Diversity in Feeling Capacity viewed Sociologically .

One of the results of the diversity of feeling capacity of
different individuals is that it prevents them from properly
understanding one another. To understand a person you must
be capable of yourself feeling his feelings, i. e . you must be able
to feel with y to sympathise with, him. Half, nay nine tenths,
of the misunderstandings and frictions in our social life depend
upon these differences in feeling capacity. “ How can two ”
(even) “ walk together except they be agreed ! ” When two
people feel very differently they can never know one another,

Digitized by VjOOQle

226

THE FEELINGS,

[April,

they have no common basis to go upon ; neither can properly
enter into the mental world of the other ; they remain, in spite
it may be of making a large part of the life-journey together in
the most intimate relations, as husband and wife perhaps, or as
parent and child, strangers to the end.

It is manifest that those who have the widest range of
feelings, and therefore the widest sympathies, have also the
deepest insight into human nature. A man with a limited
feeling capacity, be his intellect never so great, must be out of
touch with mankind at large, must ever remain isolated among
his fellows, shut out from any real communication with them.
Hence it is that the genius of a Shakespeare lies quite as much
in the extraordinary scope and variety of his feelings as in the
magnitude and subtlety of his intellect. Without such breadth
of feeling not only would he lack the real poetic touch, but his
characters would move like so many puppets, not with the true
human impulse.

Let, then, the physician try to realise how his patients feel,
and so get into some sort of touch with them. Indeed, unless
he does, he will often fail in his diagnosis and still more in his
treatment. I am not advocating any maudlin sympathy;
quite the contrary ; sympathy, like the gold of the decorator,
should be used with great delicacy—never “ laid on thick,” if I
may be permitted the expression ; but it is necessary to be
alive to the danger the physician runs of becoming a mere
learned man who regards his patients as so many “cases,”
interesting or otherwise, instead of so many instances of con¬
crete suffering depending on him for help.

The Influence of the Feelings on the Thoughts .

I have said that mental individuality depends essentially
upon the feelings, and this statement will be the more readily
accepted when we reflect that the feelings not only constitute
a large part of the ego y but also ( a ) control thought and ifl)
influence conduct.

(a) When a person has some special task in hand, a business
occupation it may be, or the thinking out of some problem, the
current of the thought is mainly determined by the task before
him, though even then the thoughts themselves are liable to be
coloured by the feelings. When, however, they are not thus

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

227

kept in definite channels, but are left to pursue, so to speak,
their own course, we shall find that they are very largely
determined by the feelings of the moment.( 3 ) The hungry
man thinks of his next meal, the erotic man has erotic thoughts,
the vindictive man revolves schemes of revenge, the man inflated
with ambition lays plans for the conquest of the world. How
different the trend of thought in the artist and the Philistine!
Observe, too, how a highly complex dream may be engendered
by, and centre round, some bodily sensation. Witness, again,
how the thoughts are influenced by the feeling of well-being
and malaise; when a man feels strong and well, when his
whole frame is pervaded by a buoyant feeling and pleasing
emotions arise, the thoughts turn on pleasing subjects ; but
when he feels weak, exhausted, and mentally depressed, he
thinks gloomy thoughts. These differences are strikingly
shown in insanity. The melancholic not only suffers from
sadness, which is an emotional state, but likewise from a
number of unpleasant bodily sensations ; indeed, I believe the
sadness is the outcome of these, and is incompatible with a
feeling of health and strength in every fibre of the body.
These unpleasant bodily sensations are for the most part mas¬
sive, subdued (*. e . not intense), and vague, by which I mean
that it is difficult to describe them or refer them to definite
regions of the body. This vague, massive, subdued sensorial
pain begets emotional pain, whereupon the mind is set thinking
on painful subjects, which, as might be expected, refer mainly,
if not wholly, to himself. He dwells upon his own wretchedness,
his incompetence, his unworthiness ; his feelings suggesting these
thoughts. By-and-by, as the intellect becomes disorganised,
the gloom is intensified, and the thoughts partake of the nature
of true delusions ; he is not merely incompetent, but wicked ; he
has committed a sin so awful that it can never be forgiven ; he
is being pursued by some avenging power and is doomed to
punishment eternal. How different is the case with the general
paralytic in the “ happy ” phase of the disease. Here there is
a feeling of bodily health and strength which engenders a
pleasing emotionality—happiness. These pleasant feelings
beget unwonted self-assurance ; his ideas turn on his own im¬
portance ; he believes himself capable of undertaking all sorts
of difficult things, and his thoughts run in the direction of great
schemes. These, later, when the intellect gets disorganised,

Digitized by VjOOQle

228

THE FEELINGS,

[April,

take the shape of grandiose delusions, and while his melancholic
brother is prostrate with the thought of his own unworthiness,
and racked with the fear of eternal torment, he on his part is
glorifying in the belief that he is the lord of the heavens and
the earth. And in this case, again, there can be no doubt that
the current of the thoughts is determined by the feelings.

The Influence of the Feelings on Conduct .

( b ) That the feelings profoundly influence conduct scarcely
needs insistence. The hungry man seeks food, the thirsty man
drink, and the enormous motive power of the sexual instinct is
self-evident. Feelings, indeed, constitute the springs of conscious
action. We are impelled by them to certain actions, feelings
which possess this impelling power being termed impulses.
Often this element of feeling in voluntary action is slight, so
slight, indeed, as to be unrecognisable, as in an action undertaken
as the result of a purely intellectual process. Actions of this
kind, though in them the element of feeling is still operative,
would not in ordinary language be said to be impelled by
feeling, and we speak of them as being determined by the head
in contradistinction to those which are dictated by the heart.
But although the head is a much more trustworthy guide than
the heart, and although one might expect it to be the more
potent factor in determining conduct, yet, as a matter of fact,
the decision of the intellect stands little chance against a
powerful impulse running counter to it. History shows that
men and nations are governed far more by their hearts than by
their heads, and that men seldom practise what they preach :
they preach what they think; they practise what they feel.
Hence the frequent inconsistency between a man’s public and
private life, as in the case of Schopenhauer, who in actual life
was very far removed from the pessimist, misogynist, and
ascetic he represents himself to be in his writings.

The law which governs all conscious actions is this: every
sentient creature seeks to obtain agreeable feelings and to avoid
the disagreeable; so that it may be said that all the conscious
actions of the individual ^re made with a view to securing
pleasure and avoiding pain. This principle in the main works
for the good, but not altogether, since some pleasures are
injurious while some pains may be beneficial. The exceptions

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

229

to the general rule are of all animals greatest in the human, who
has so widely diverged from the stereotyped ways of the instinct-
led brutes.

Inasmuch as men are led to seek after the agreeable and to
avoid painful feelings, and inasmuch, too, as they differ very
much in regard to their feelings, it follows that they will differ
much in regard to their conduct. A child seeks a sweetstuff
shop, the drunkard haunts the public-house, the man in whom
beautiful things produce pleasurable feelings surrounds himself
with them, as far as he can, and he may take to collecting pic¬
tures, engravings, old china, furniture, or indulge some similar
hobby. Others there are who, possessing the gift of public
speaking, find a great pleasure in exercising it, and these seek a
career as barristers, politicians, or preachers. It is needless to
multiply instances. My purpose is merely to show how feeling
governs conduct, how persons are always striving to secure for
themselves feelings which are agreeable and to avoid those
which are disagreeable, and how, since individuals differ so
widely in their feelings, they are impelled in different and often
opposite directions, some finding pleasure in what would cause
others actual pain.

It is an interesting study to observe this principle at work
among mankind; to note how differently individuals are impelled,
and yet with what undeviating regularity the rule operates.
Turn where we may we see the incessant struggle after the
pleasurable and the avoidance of the painful. VVe observe it
alike in' the child who feeds at its mother's breast and nestles
up to her for warmth, and in the old man who sits by the fire¬
side painfully solicitous of his creature comforts ; and we shall
find him guided by the same principle up to the end, and even
a few hours before his death the slave of his feelings, still
seeking after the pleasurable, still avoiding the painful.

Doubtless many of our impulses, tendencies, desires, have to
be struggled against, because they are either hurtful, igno¬
minious, or futile, and the restraining power varies in different
individuals ; but be it great or small—that is, be the character
noble or ignoble,— it is certain that the bias of a man's life is,
ever has been, and probably ever will be, determined by his
feelings. He looks in the direction they indicate, even if he
does not always move forward along that enticing path.
Happy he who may do so with impunity. ( 4 )

Digitized by VjOOQle

230 THE FEELINGS, [April,

Summary .— i. The feelings embrace the sensations and the
emotions.

2. The sensations are the feelings which are definitely
referred to the body.

3. The emotions, while in reality made up of sensations, in
particular of certain sensations felt in the parts of the body
commoted during the emotions, are not definitely referable to
the body, for which reason they are sometimes spoken of as
“ feelings of the mind.”

4. Emotions being compounded of (bodily) sensations, when
these latter are pleasurable they are apt to call up pleasurable
emotions; while painful bodily sensations tend to call forth
painful emotions.

5. Individuals differ greatly in their feeling capacity, both
in respect of simple sensations and emotions.

6. This difference in feeling capacity ( a ) determines the
differences in disposition observed among mankind ; (, b ) prevents
people from properly understanding one another, and is thus
responsible for much social friction and misunderstanding.

7. Those with a limited range of feeling are limited in their
sympathies and have but small insight into human nature ;
and contrariwise.

8. It is important to the physician to get into some sort of
touch with the feelings of his patient, or he may fail to get a
proper grip of his case and miss a valuable clue to treatment.

9. Just as the sensations tend to call up emotions in
harmony with them, so the feelings in general (/. e . sensations
and emotions) tend to excite ideas which chime in with them ;
pleasant feelings cause pleasant thoughts, painful feelings
painful thoughts. Hence the bodily sensations greatly influence
the thoughts.

10. The feelings influence conduct; conscious life is, viewed
from an elevation, a constant effort to obtain pleasurable
feelings and to avoid disagreeable feelings.

11. From all of which it is manifest that the feelings
constitute a very large part of the mental individuality or ego.

In the next section I shall treat of the genesis, or coming
into being of the feelings, and I shall endeavour to show how
closely they depend upon the composition of the blood, and
upon the metabolism of the organism at large.

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

331

II. Psycho-physiological.

The Genesis of the Sensations ,

I now propose to consider the genesis of the sensations, i. e.
the bodily conditions which underlie them. Wherever sensory
end-organs exist, there sensations may be felt, and this means
throughout the entire body,. They are not present in cartilage,
and they are either absent from, or very defectively supplied
to, the brain and spinal cord ; but we may for all practical
purposes say that sensations are felt throughout the whole
body.

Sensations are provoked by stimuli acting on these sensory
end-organs . These latter constitute the keyboard of the
sensorial instrument; the cerebral cortex may be compared to
the pipes, while the stimuli represent the players. The players
are constantly at work, and during conscious life a voluminous,
many-toned chord of sensorial music is continually being
struck.

The stimuli consist of various agents, e.g. of ether waves in
the case of the retinae, of sound vibrations in the case of the
auditory expanses, of massive contact, heat and cold, in the
case of the cutaneous end-organs ; and in the case of the less
specialised sensations which may be felt throughout the body,
including the skin, the stimuli are in the main chemical, and
reside in the fluids bathing the nerve-elements.

Now in considering the chords of sensations which an
individual experiences at any one moment, let us disregard the
more intellectual ones—those of sight, hearing, tactile sensi¬
bility of the fingers, and even the sensations of taste and
smell ( s )—and we have remaining a chord of comparatively
unspecialised organic sensations. This chord is equivalent to
what has been termed, and what I shall refer to in this essay
as, ccencesthesia ; by the Germans it is termed das Korperlische
GefiihL Though the cutaneous sensations which result from
massive contact and from modifications of temperature doubt¬
less enter largely into it, it is in the main a chord struck by
chemical stimuli; that is to say, to produce it, the end-organs,
with a few exceptions which need not be gone into, are played
upon by chemical stimuli and little else ; moreover, a consider¬
able portion of that large volume of sensations derived from

XLIV. 17

Digitized by VjOOQle

232

THE FEELINGS,

[April,

the skin is due, not to the operation of external agencies, but
to the chemical state of the blood circulating in the skin ;
witness the itching that may result from taking shell-fish, and
the numbness and tingling that occur in alcoholic neuritis.

I shall hope to make it plain as I proceed what I mean by
“ chemical stimuli; ” for the present it will suffice to say that I
understand by them non-nutrient substances, or, as we may
for convenience term them, drug-substances, circulating in the
blood: and I shall provisionally assume that the chord of
coenaesthesia is essentially struck by such chemical stimuli;
in other words, that the mere nutritional interchange between
nerve-matter and environing plasma does not constitute a
stimulus. This may sound a daring proposition, but I advance
it provisionally, if only for the purpose of directing attention to
the important part taken by chemical stimuli in the genesis of
ccenaesthesia.

Another doubtful point needs mention here. To what
extent can chemical stimuli act upon the sensory nerve-fiSres
and the sensory cortex , so as to evoke sensations? We know
that drugs have a selective power, that urari acts upon the
motor end-plates and strychnine upon the motor ganglia, and
doubtless the drugs acting upon the sensory nerve elements
have a similar selective power; but I have not yet had time to
go deeper into this subject, and can, therefore, only reason
a priori. I think, however, we may safely conclude, seeing
that end-organs are specially adapted to receive stimuli, that
the sensory instrument is struck mainly through them ; but
though I should expect the sensory fibres to be much less
responsive to chemical stimuli, I should at the same time look
for a definite response to some of them, whereas in regard to
the cortex I should expect it to be wholly, or almost wholly,
irresponsive. I can well imagine that the sensory cortex may
be so affected by chemical substances circulating in the plasma
as to modify its mode of response to impulses reaching it
through nerve-fibres, but I should be inclined to doubt whether
it could be induced to yield a sensation by direct chemical
irritation of its ganglia; in order to get a psychical change it
is necessary to have a very special and subtle form of physical
change, and it is doubtful whether a direct chemical stimulus
can bring this about.

That we may realise the important part played by the

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.D.

233

sensory end-organs in the genesis of ccenaesthesia, let us
imagine them to be all rendered anaesthetic. I think we shall
all agree that under such circumstances ccenaesthesia could
only exist in a very rudimentary form, if, indeed, it could exist
at all. I am not aware of any drug that can anaesthetise the
sensory end-organs without acting upon any other part of the
nervous system, but if an individual were brought under the
influence of such a drug we may safely conclude that he would
have little, if any, sense of bodily existence.

The Different Kinds of Cceneesthesia.

I proceed now to consider the different kinds of ccenaesthesia.
When we reflect upon the enormous number of notes which go to
form this voluminous chord of sensation, and in how many differ¬
ent ways those notes may be struck by the many stimuli present
in the blood, we shall see at once that there must be countless
varieties of it I shall refer only to two, and these broadly
contrasted :—(1) That in which there is a lively feeling of well¬
being and buoyancy; (2) that in which there is a well-marked
feeling of malaise and depression.

1. The sense of exuberant well-being is happily portrayed
by Romeo, when he says :

“ My bosom’s lord sits lightly on his throne,

And all this day an unaccustomed spirit

Lifts me above the ground with merry thoughts.”

In such a case the end-organs all over the body are stimu¬
lated in a way favourable to the induction of a pleasurable
ccenaesthesia—a harmonious chord is struck, and the individual
is pervaded by a feeling of health and strength. Now we have
seen that the bodily sensations control the emotions, and we
should therefore expect a pleasurable ccenaesthesia to call up a
pleasurable emotional state. Accordingly we find that with a
feeling of bodily well-being there is a pleasurable emotionality—
“ an unaccustomed spirit ” as Romeo puts it. Gradually more
specialised emotions appear; thus the sense of bodily strength
begets a feeling of self-assurance. These emotions carry with
them their own thoughts, all of which are in a happy vein ;
they are, in Romeo's words, “ merry thoughts."

This sense of exuberant well-being and joyousness has its
characteristic physical accompaniments. The respiratory move-

Digitized by VjOOQle

234

THE FEELINGS,

[April,

ments and the circulation are stimulated, and there is a tendency
to spontaneous muscular movements—in short, a heightening
of the bodily activities generally.

See, then, what widespread results follow upon a pleasurable
coenaesthesia, itself the result of chemical stimuli operating upon
the sensory end-organs.

I have already drawn attention to the influence of the bodily
sensations upon the emotions and thoughts. Here let me in¬
sist upon the predominant influence upon thought and emotion of
that vast sensorial chord which we denominate the coenaesthesia.
The sense of exuberant well-being fosters a belief in self, and
constitutes, I take it, the fundamental psychic characteristic of
the megalomaniac, whether as met with in everyday life or in
the asylum. It is this which determines the characteristic
emotions and the large delusions which are wont to appear
when the intellect becomes disorganised. True, a strong
character may, in spite of physical malaise , retain his self-
assurance in regard to his mental capabilities, such as his
ability to carry through a difficult scheme ; but this is strength
of will rather than self-assurance, and the very reverse of
morbid, being the outcome of an honest, healthy belief in self;
and I believe I am right in saying that the exaggerated belief
in self generally, such as we see most pronounced in the general
paralytic, only occurs when the individual is pervaded by a
strong sense of bien etre. No sense of bien ctre, no megalo¬
mania.

2. Let us now consider the opposite variety of coenaesthesia.
We will suppose that, not a harmonious chord but, a discord
is struck, producing a painful coenaesthesia—a sense of malaise .
This will call up a painful emotional state, such as gloom asso¬
ciated with self-distrust ; in consequence the thoughts will tend
in an unhappy direction, so that when the intellect becomes
disorganised the unfortunate victim has delusions of perse¬
cution.

The depression in the emotional sphere will have its corre¬
sponding physical expression ; circulation and respiration are
diminished, and there is a lowering of the vital activities
generally.

Here again we see how greatly the coenaesthesia affects the
psychic and physical being, and how the psychic side of us is
influenced by chemical stimuli circulating in the blood.

Digitized by VjOOQle

BY HARRY CAMPBELL, M.D.

235

1900.]

The influence of the coenaesthesia on the emotions and the
trend of the thoughts cannot be too strongly insisted on.
Painful emotions and unhappy thoughts are incompatible with
a pleasurable coenaesthesia, while pleasurable emotions and
happy thoughts are incompatible with a painful coenaesthesia.

Chemical Stimuli.

I come now to speak of the chemical stimuli which I have
assumed to play so large a part in the genesis of the coenae¬
sthesia. We must not think of the blood plasma as consisting
merely of water holding in solution food-stuffs (albumins, fats,
and saccharides), salines and deleterious waste products. The
blood, as I have recently contended elsewhere, contains also a
number of drug-like substances, substances which do not yield
energy and which take little or no direct part in nutrition, but
which are capable, after the manner of drugs artificially
administered, of modifying function. These substances we
may group, according to their origin, into four classes.

1. The internal secretions. These do not yield energy, and
although they doubtless influence nutrition, yet they do this
much in the same way as drugs artificially administered. Their
essential purpose is to influence function. The adrenal secre¬
tion is strikingly drug-like in its action, being the most powerful
vaso-motor constrictor known. The thyroid secretion again
acts much like a drug. When the artificial extract is given
there occur symptoms like those of Graves’s disease, the
patient becoming very nervous and suffering from palpitation,
tremor, and flushes. When, however, the supply of the thyroid
substance to the blood is deficient, we have the dulness and
hebetude of myxcedema, in other words, the lymphatic tem¬
perament. In short, the activity of the thyroid gland largely
determines whether a person is nervous and excitable on the
one hand, or stolid and lymphatic on the other. The ccenae-
sthesia is very different in these two opposite conditions. How
far this is to be attributed to the structural or nutritional state
of the nervous system resulting from defect or excess of the
thyroid secretion, and how far to the possible action of the
thyroid secretion as a chemical stimulus to the sensory end-
organs, I do not attempt to say. I think it probable, however,
that the secretion may act as such a stimulus.

Digitized by VjOOQle

236

THE FEELINGS,

[April,

2. Besides nutritive substances proper, food contains a
number of substances which have a direct influence on function.
Among others, for instance, it contains stimulants, of which
there is a specially large quantity in meat. These are absorbed
into the blood and act like drugs; many of them, no doubt, upon
the sensory end-organs. The modification of coenaesthesia
produced by a meal of meat is, I believe, in large measure due
to the action upon the nervous system of stimulating substances
contained in the meat. It is well known that meat has an
intoxicating effect.

3. A large number of drug-substances are produced in the
alimentary canal during the process of digestion. The most
notable are the ptomaines, alkaloid substances allied to the
vegetable alkaloids, such as strychnine and morphine. Many
of these when absorbed in unduly large quantities into the blood
are toxic, and profoundly influence coenaesthesia, a result which
we may, I think, safely conclude is due at least in part to their
action on the sensory end-organs.

Now it is generally assumed that these alkaloids and allied
bodies are wholly toxic in their action, or, if not toxic, at least
indifferent. We must remember, however, that the physiological
effects of an alkaloid depend upon the dose that is administered.
Strychnine and morphine, though in large doses deadly poisons,
are in minute quantities highly valuable remedies, and I see no
reason why many of the alkaloids formed in the alimentary
canal may not, when absorbed into the blood in small quantities,
play the part of nerve-tonics and stimulants; nor does it seem
improbable that other drug-substances, similarly absorbed, may
even in large quantities exercise a beneficial effect. In short, I
suggest that just as some drug-substances absorbed from the
stomach and intestines in certain quantities produce a painful
coenaesthesia, so these same substances in different quantities,
and other substances similarly absorbed, may tend to produce
a pleasurable coenaesthesia. That they are all necessarily
injurious or indifferent in their action seems to me unlikely.

4. Finally,it is probable that similar drug-substances produced
by the metabolism of the tissues have likewise a beneficial in¬
fluence on function. I cannot think that they are all either
toxic or merely innocuous. Many of them have certainly a
depressing action on nerve-function, but others have probably

Digitized by

Google

BY HARRY CAMPBELL, M.D.

1900.]

237

a stimulating and tonic effect. Uric acid, for instance, is said
when swallowed to act as a stimulant.

I claim, then, that the blood normally contains a number of
drug-substances, and that these play a necessary part in the
bodily functions, among other things acting as chemical stimuli
to the sensory end-organs, and being thus largely responsible for
the coenaesthesia.

Classification of Chemical Stimuli according to their Influence
on the Ccencesthesia,

It would be impossible to make an elaborate classification of
chemical stimuli according to their influence on coenaesthesia,
and it will be sufficient for our purpose to class them into
(1) the depressants, those which produce a painful coenaesthesia,
of which the most characteristic form is a sense of ill-being or
malaise , with mental depression ; and (2) the stimulants and
tonics, those which produce a pleasurable coenaesthesia, a feeling
of well-being {bien itre\ with mental exhilaration.

Supposing the nervous system to be normal, and the tissue
plasma also to be normal, save in the complete absence of
chemical stimuli, there is (so we may provisionally assume)
neither a feeling of bien Itre , or malaise , but simply one of
indifference. The same thing happens if the stimulants and
depressants exactly neutralise one another. When, however,
the stimulants preponderate there is a sense of bien ctre , while
a preponderance of the depressants leads to a sense of malaise .

Now, no one will, I presume, demur to the statement that
the blood may contain depressant substances, capable of causing
painful coenaesthesia and mental depression. It is sufficient to
refer to the symptoms which may attend disordered digestion,
notably disturbances in the functions of the liver, and to the
influence of blue pill and black draught in removing those
symptoms. But what evidence, it may be asked, have we that
the blood contains stimulants independently of those we
expressly take as such ?

Well, there is first the unmistakable fact that the food we eat
contains an abundance of stimulants ; then there is the fact that
some of the compounds normally manufactured in the body can
be proved experimentally to have a stimulant action ; and finally,
we have certain phenomena of disease which we can hardly doubt

Digitized by VjOOQle

238

THE FEELINGS,

[April,

are caused by stimulant substances produced in the disease. It
is well known that certain nerve-storms are often heralded by
a period of exceptional well-being : instance the familiar case
of megrim. Now this has been attributed to the absence from
the blood of some substance (or substances) having a depressant
action, but the explanation appears to me highly improbable.
That such absence might conduce to a feeling of average, or as
we may say normal, well-being, I can well believe, but that it
should bring about a supernormal condition, an actual exal¬
tation, I altogether refuse to admit. I think it much more
likely that the feeling of well-being in these cases is caused by
some stimulant substance circulating in the blood, the subse¬
quent phenomena of the actual attack being attributable to a
“ reaction,” such as may follow a night’s debauch, or a dose of
opium ; or else to the accumulation of the stimulant to an extent
rendering it no longer depressant; or still more likely to both
of these causes.

The phenomena of general paralysis of the insane, again,
lends support to the view that an auto-intoxication is taking
place. Sir Samuel Wilks was, I believe, the first to point out
the analogy between alcoholic intoxication and the symptoms
of general paralysis, an analogy so striking that, once observed,
the inference can scarcely be avoided, that the exuberant sense
of well-being sometimes observed in this disease, with the accom¬
panying megalomania, is the result, as in alcoholic intoxica¬
tion, of some stimulating poison or poisons circulating in the
blood. Dr. Mott has isolated certain poisons in cases of
general paralysis, and I should not be surprised if it were
discovered that some of them have an action very similar to
that of alcohol. On this view the exuberant general paralytic
is in a state of chronic intoxication, and his mental condition
may be compared to that of a person in the earlier stages of
alcoholic intoxication.

The Relative Part played by Nervous Structure and Chemical
Stimuli in determining the Nature of Coencesthesia .

One other question I shall touch upon, and then I have
done. It is this: Do the differences in ccenaesthesia and its
attendant emotions (i.e. temperament, mood) in (i) different
individuals, and (2) the same individual at different times,

Digitized by

Google

1900.]

BY HARRY CAMPBELL, M.D.

239

depend upon differences in nervous structure, or differences in
respect of chemical stimuli—upon differences in the instrument
or in the players ?

(1) Does one individual habitually feel exuberantly well and
in high spirits, and another habitually inert and depressed,
because the mind instrument is in the one case so constructed
that it readily yields pleasant sensations and emotions, plays as
it were merry tunes, and in the other is adapted rather for the
expression of miserable feelings—for the minor harmonies ; or
is it because the instrument is differently played upon in the
two cases, the blood being surcharged with stimulants in the
one, and depressants in the other ? According to the one view
we should say a man's temperament depends chiefly upon the
structure of the mind instrument ; while according to the other
view it would be mainly determined by his blood composition,
i, e. by the metabolic peculiarities of his tissues. In the latter
case the happy and the unhappy man would exchange tem¬
peraments if they could exchange bloods.

I do not think the question so absurd as it perhaps at first
sight appears ; for while it is certain that differences in sensorial
organisation must largely influence temperament—-witness the
varying response among different individuals in regard to such
an agent as alcohol, which by no means always produces its
characteristic exhilarating effect—yet we must remember that
any given instrument may be made to yield an infinite variety
of music according to the nature of the stimuli acting upon it.
A perfect instrument in the hands of an unskilled player may
awaken only to discords, while the hands of a master will
evoke most eloquent music, even out of an old harpsichord ;
and so it is with the mind instrument. When one reflects
upon the widely divergent effects on it of such stimuli as
haschisch, alcohol, and the toxins formed in the alimentary
canal, and when one considers that a brain in an advanced
stage of degeneration may by certain stimuli be made to yield
up a feeling of well-being and the pleasurable emotions and
thoughts belonging to it, there is no escaping the conclusion
that a man's habitual temperament may be determined far
more by blood constitution, or what comes to the same thing,
by metabolic idiosyncrasy, than has hitherto been supposed.

In this connection I would again refer to general paralysis
of the insane. One may see a victim of this disease so weak

Digitized by VjOOQle

240

THE FEELINGS,

[April,

that he cannot lift his hand, actually unable to swallow, with
his brain in the last stage of degeneration, and his intellect
correspondingly disorganised, yet exuberantly happy and full
of assurance as to his importance and his powers. Are we to
suppose that this exaltation in the realm of feeling is an
expression of cerebral degeneration, that the suvimum bonum %
the goal of human effort,—happiness—the best music the
mind instrument can sound, is the result of degraded function,
as we shall have to do if we attribute it to structural alteration
in the mind instrument ? Shall we not rather liken the mind
organ of our general paralytic to an old and broken instrument
from which some music can still be got by the touch of the
master hand. Surely yes, and I suggest that touch comes from
some chemical stimulus ; and if chemical stimuli can do so much,
is not one justified in thinking that blood composition may be
largely responsible for temperament ?

2. Whatever may be thought about the cause of the different
temperaments in different individuals, few will dispute that the
varying moods of different individuals, from day to day and
from hour to hour, are largely dependent upon the composition
of the blood in respect of chemical stimuli. Such differences
can scarcely be attributed to passing structural variations.
True, the mind instrument may temporarily alter in its most
intimate structure—in what may be termed its undiscoverable
structure, /. e. in the arrangement of its atoms and molecules,
just as it is said that musical instruments “ play ” much better
some days than others (though I much suspect that the
difference lies chiefly with the players) ; but I doubt if such
structural changes are greatly responsible for temporary changes
in the coenaesthesia. I feel persuaded that the frequent alterations
from a feeling of bicn itre to one of malaise —from good spirits
to bad spirits, and the reverse—are largely agencies due to the
action of various chemicals upon the supersensitive mind-organ.
The sense of well-being often experienced after a sound night’s
rest, and the opposite feeling of malaise which may come on
after a harassing day’s work, are essentially due, I would say,
to modifications in the blood composition. Our moments of
depression result, in the main, from the action of depressants,
our spells of exuberant well-being, of exhilaration, self-assurance,
ambition,—when all the world seems fair and no obstacle too
great to surmount, no goal too difficult to win—are really the

Digitized by VjOOQle

1900.]

BY HARRY CAMPBELL, M.L>.

24I

effects of mild auto-intoxication. So, too, it may be with the
inspired hours of the genius. Is it chimerical to suggest that
in those supreme moments there pass into the blood substances
which stimulate the brain to its highest achievements ?

Summary .— 1. The sensorial nerve instrument—that part of
the nervous system which has to do with sensation—may be
compared to such an instrument as an organ. The sensory
cortex is represented by the pipes, the sensory end-organs by
the keyboard. When the organ keyboard is played upon,
music results ; when the sensory keyboard is played upon, sen¬
sation results.

2. When certain notes in the sensory keyboard are struck
(e.g. in the retina, auditory expanse), intellectual sensations are
induced ( e.g . of sight and hearing); when the remaining notes
are struck, there result comparatively unspecialised, non-intellec¬
tual sensations. These collectively constitute a voluminous
sensorial chord which we designate the ccenaisthesia, or sense
of bodily existence.

3. There are many varieties of ccenaesthesia, but they may
be broadly divided into (a) the sense of well-being, and ( b )
malaise .

4. In Section I it was pointed out how the sensations influ¬
ence the emotions, and how both influence thought and con¬
duct. When, therefore, ccenaesthesia is pleasant, i.e. when
there is a sense of well-being, a pleasant emotionality and
happy thoughts arise ; but when ccenaesthesia is painful, i. e .
when there is malaise , painful emotions and unhappy thoughts
come into being.

5. The agencies which, playing upon the sensory keyboard,
produce ccenaesthesia, consist for the most part of chemical
stimuli circulating in the fluids of the body.

6. These stimuli may be broadly classed into the stimulant
and tonic on the one hand, and the depressant on the other.
When the former predominate ccenaesthesia is pleasurable;
when the latter are in excess it is painful.

7. From all which it follows that ccenaesthesia does not
merely depend upon the constitution of the sensory instrument,
but upon the.way that instrument is played,/.**. upon the
quantity and nature of the chemical stimuli present in the body
fluids ; and seeing that this factor is determined by the metabo-

Digitized by VjOOQle

242 ON EPILEPTIC SPEECH, [April,

lism of the body at large, it follows that such metabolism is
largely responsible for the coenaesthesia.

8 . Inasmuch as the coenaesthesia influences emotions, con¬
duct, thought, it follows that the ego which is a trinity of feel¬
ing, will, and thought, is largely determined by the metabolism
of the body at large.

(*) It is convenient to make the feelings embrace both the sensations and the
emotions, although all psychologists do not do so.—(*) Owing to the equivocal
meaning attaching to the term “ill-feeling”—which naturally suggests itself as the
opposite of “well-feeling”—I am obliged to substitute the term “malaise,” by
which I mean to express a widely diffused feeling of unwell-ness, no matter whether
this occurs in connection with well-marked disease or not.—(*) Some, indeed,
appear to think that all associations take place through the feelings. See Ribot,
The Psychology of the Emotions , p. 173.—( 4 ) This restraining power itself consti¬
tutes an impulse, and is of the nature of a feeling.—(*) I say nothing of “ muscular
sense.”

On Epileptic Speech . By A. Campbell Clark, M.D.,
Medical Superintendent, Lanark County Asylum, Hart-
wood ; Mackintosh Lecturer on Psychological Medicine,
St. Mungo’s College, Glasgow.

The speech faculty of the epileptic has hitherto received
very little attention, though passing references to it have been
made from time to time by several writers, viz. Kussmaul,
Ross, Wylie, and others. Wylie has stated the well-known
fact that temporary aphasia appears sometimes as the “ aura,”
sometimes as an immediate consequence of a fit. Kussmaul
confirms this, and Ross writes, “ In some cases the warning of
an epileptic attack consists of a sudden inability to speak, and
it is very probable that word-deafness and word-blindness are
by no means uncommon aurae.” While saying so much, Ross
admits what is certainly true, that motor aphasia is the more
readily noticed, and, as obscuring the question of aphasic aurae,
he admits the mental confusion attending the onset of uncon¬
sciousness, a factor of some importance. Bradylalia (slow
speech) and echolalia (echo speech) have also been noticed by
observers at home and abroad. They are, however, so fre¬
quently observed in developmental speech, and in other nervous
and mental diseases, that too much may be made of their
significance.

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

243

The relation of emotion to speech is well illustrated in
Bastian’s work on Aphasia (p. 5), where there is described the
case of a boy, the son of a leading barrister, who had been
subject to “ fits ” at intervals during his early childhood. The
first occurred at the age of nine months. They ceased at the
age of two years, and the child appeared to be all right,
intellectually and otherwise, except that he could not talk.
Before he was six years old, when an accident happened to
one of his favourite toys, he exclaimed “ What a pity,” although
he had never previously spoken a word. In the case of
children of backward speech this has frequently been observed,
and such must have come under the notice of not a few family
physicians. The point is that the tardy mechanism which
may have been making abortive attempts at speech for some
time previously, succeeds at last owing to an accession of vocal
energy. This accession of vocal energy is due to emotional
excitement acting upon the respiratory centre, and exciting a
deeper respiratory movement, which during expiration gives
the larynx the necessary blast of air at the precise moment
when the emissive energy of motor speech is discharged.

The innervation of the vocal speech mechanism requires to
be allowed for, if we could adequately comprehend the physio¬
logy of the production of words and sentences, but this I pass
by, merely observing that it is a factor of considerable import¬
ance in our study of epileptic speech. This innervation will
be regarded here also in relation to emotional states, for the
epileptic is a creature of moods and tenses in the highest
degree, and his speech is thereby affected. It has been stated
that aphasia is the condition which some observers have noted
as the most usual speech affection of the epileptic ; but aphasia
is now a term of very comprehensive meaning, and the modern
conception of the term holds within its limits certain varieties
which we do not find associated with epilepsy. Moreover,
dysphasia is a term which includes more of the speech affections
of the epileptic than does aphasia. The distinctions which will
be recognised here are—

( а ) Aphemia —inability to speak, depending on affection

of the co-ordinating centre for the muscles pro¬
ducing articulate sound.

( б ) Amnesia —loss of the memory of words.

Digitized by

Google

244

ON EPILEPTIC SPEECH,

[April,

In the examination of the cases to be immediately referred to,
the outlook for word-deafness and word-blindness was negative
in its results, but I do not dispute Ross’s proposition, though
when one considers the mental equation before and after
seizures, his statement must be regarded as a difficult one to
prove. The clinical study of the following cases was conducted
while their intelligence was unclouded by the shadow of a
seizure or its after stupor. They are men and women who
have been insane for varying periods, some two or three years,
others fifteen to twenty years. Naturally, we look for mental
deterioration in the older cases, just as we see it in chronic
mania or dementia, but in the latter the speech deterioration is
mental rather than motor, the emissive or co-ordinating faculty
is not impaired to anything like the same degree as in epilepsy.
In the early stages of epilepsy—apart from insanity altogether
—the speech affections are less marked, though early evidence
of them may in some cases be manifest, especially bradylalia.

In considering the matter systematically the following points
were kept in view :—(i) the mental state, distinguishing the
emotional and the intellectual ; (2) the receptive or subjective
function of speech ; (3) the expressive or objective function ;
(4) the vocal mechanism and its innervation ; (5) the oral
mechanism and its innervation; (6) variations in the individual.
The patients were each interviewed on two separate occasions.

Case i. —M. B—, aet. 47, insane eight years, education poor,
memory for past and recent events impaired. She is capricious,
easily roused, emotional instability is very marked, and her
speech, which in her placid moods is low, slow, stuttering, and
slurred, when her temper is roused becomes suddenly loud,
fierce, denunciatory, and free from stuttering, with staccato
pauses. Then her attitude is tragic, her arms are raised with
threatening gesture, her face is flushed, her chest heaves, and
her voice is loud and resonant.

To every patient the first question was, Have you ever
noticed any trouble with your speech ? Some resented the
idea ; most of them at first denied the imputation. Epileptics
usually deny that they have had a fit, and are very intolerant
of the suggestion that anything is the matter. With this
explanation in view, the answers will speak for themselves.
Letters, syllables, or words are spaced according to their
cohesion to each other or want of cohesion. Question: Have

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

245

you ever noticed any trouble with your speech ? The answer
comes in a jerky, spluttering stream of broken talk. Some¬
times she stops short with a sudden “catch in her breath/*
Her reply to the question was as follows:—“ Quite so—I de
be—,’* then, as if to excuse her faulty speech, “ Thir’s yin o*
my teeth kin* o* slack/* Here she does not stop, but dribbles
'away in slow monotone, “ doon to mel—ans—field—so will—
be coming on—for—my—age just now,—my faither—would
be coming to, so—came for him and my mother going together
forty-four/*

While speaking in this strain, it was noticed that the
apparent incoherence was due to amnesia. She had a diffi¬
culty in getting hold of the right word, and, like a person who
stutters and introduces irrelevant sentences to get out of a
difficulty, she introduces words to excuse herself, and often
makes confusion worse confounded.

The amnesia is not marked except when a proposition is
made to her, or when a question is asked which requires the
construction of sentences. If shown a key, watch, or knife
she names them correctly enough, but always cautiously, as if
conscious that she might trip in with the wrong word, thus :—
“ Well—I would call it—a key,** or, “ Well, I would say it is
ca*d the knife—thing,** or “ It*s a watch—if I would say it.**
She repeats the 23rd Psalm (metric version) correctly, and
with very little trouble ; but here the mental effort is less and
the words do not need to be made up in sentences ; these are
ready made for her. W'hen she is excited the voice is raised,
and the words come more trippingly, though irregularly, the
rhythm reminding one of the pulse beats of an irregular heart.
At such times the end of the sentence is cut short from failure
of breath owing to faulty vocal innervation. To sum up this
case, there is (1) amnesia—her vocabulary is very limited, and
she very frequently puts in the wrong word. (2) Defect of
articulation, stuttering, and explosive speech. The mouth in
quiet speech, which is her usual when not excited, is almost
closed, the action of the jaws being feeble; this may be said
also of the lips and tongue, which are by no means mobile,
and which with the supra-oral muscles are tremulous. (3)
Deficient phonation ; the respiration is shallow, and this may
account for it, as, when she gets excited and the chest heaves
the voice is much louder and articulation is more distinct.

Digitized by VjOOQle

246

ON EPILEPTIC SPEECH,

[April,

(4) There is marked bradylalia. Echolalia is sometimes
present. There is considerable gesticulation when excited.

CASE 2.— W. J—, jet. 30. Has taken fits since the age of 18,
the exciting cause of the first being the passage of a tape¬
worm. His expression is quiet and sad, but he is intelligent,
and by no means devoid of humour. He is when free from
fits quite reliable, and quite capable of giving intelligent answers
to questions.

To the question, “ Have you ever noticed any trouble with
your speech ? ” he replied, “ I’ve felt pretty far back in speech
this time back : the language that comes from me is rather
short of grammatical—feels as if there was a weight keeping
back the words.” All this is said very slowly and with
apparent deliberation. “ Do you feel a difficulty in getting
the right word?” “It takes a long time to compose it,”
meaning the sentences. If excited, i.e. if there is any
emotional disturbance, his reply is not quite so intelligible, as
when the same question was repeated some days later, he thus

replied, “ For a long time-education also to bring me up

to satisfaction, so as that I wanted to keep myself as I intended
at first.” His voice breaks, there being vocal tremor, especially
when he is emotionally roused. Before and after fits he is
quite conscious of the fact that speech is more difficult. He
observed, “ Half an hour after when I come out of a fit, if any
one spoke to me couldn’t answer them.” When asked if he
was ever altogether speechless, he answered, “Well, I can’t
consider for that; ” then a pause, as if for breath, then the
echo, “ altogether speechless.” There is no agraphia, no word-
blindness or word-deafness, and he has no recollection of either
of the two latter occurring as an “aura.” His invariable
“ aura ” is a sensation in the left arm and side.

Inspiration, even when asked to take a deep breath, is rather
shallow, but during emotional stress his respiration is more
active, and his voice is louder. We may therefore say that here
there is (1) partial amnesia, (2) diminished phonation, (3) weak
articulation, with tremors, and that according to his emotional
state these vary. The labio-dental movements are certainly
rather inert In this case there is very little gesture ; but that
is exceptional, and even this man when excited buttonholes
one in a confidential way, rather usual with epileptics in their
quiet moods.

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

247

Case 3.—P. H—, aet. 3 1. Insane five years. Ascribes first
fit at the age of 15 to a fright. Had taken to smoking before
then. The degeneration in this case is marked ; he has shown
considerable nervous failure in the last three years. It was
noticed on admission that his speech was slow, thick, and
indistinct, with an appearance as if he was swallowing some
obstacle after speaking each word. In his stuporose states
swallowing is difficult, and he is very liable to choke. His
vocabulary is very limited. Like not a few epileptics, he has
stereotyped phrases which he invariably employs in certain
given circumstances. His consciousness of amnesia has led
him to adopt them rather than struggle to compose fresh
sentences. Thus every morning and evening at the medical
visit he receives the superintendent and others with these
words, holding out at the same time his right hand for a
shake, “How—do—you do—Dr.—Clark—and Dr.—Kerr—
and Mr.—Campbell—and Nurse—Thomson—and—my re¬
spects—and—Pm quite well.”

He frequently repeats the words of questions put to him, as
if to give him time to jog his memory and stimulate recollec¬
tion. Instinctively he seems to feel that echolalia by its sen¬
sory stimulation of the auditory centre may rouse recollec¬
tion. Bradylalia here is very marked, but much less noticeable
under emotional excitement. When asked if he had any diffi¬
culty of speech, he replied, “ Sometimes—I am—very well at
it (/. e. getting the right word) some days I am—not very sure
—of myself—and I stop—but if—word is ready—and if—
difficulty is in mouth—big—words—I can’t say.” There is
not merely amnesia, but aphemia. Even when he knows what
he wants to say there is a difficulty owing to obstruction in
the speech mechanism. He explains this by speech and
action—“ There is ” (as he puts his hand to his throat) “ a diffi-
—culty as if stopped in the throat.”

He explains further that crabbedness (rise of temper) some¬
times makes him use the wrong words, and here again
emotional disturbance shows its effect not merely on the speech
mechanism but on memory itself.

There is slowness in answering, when questioned as to the
names of objects, his explanation being that he is afraid of
saying the wrong word. Feeling his ankle, which has been
sprained, and is still swollen and stiff, he says, “ It’s more

XLVI. 18

Digitized by VjOOQle

248

ON EPILEPTIC SPEECH,

[April,

stronger,—it's more stronger” (echolalia). He seems to feel
that pantomime helps him along, and probably this is why
epileptics are often demonstrative and gesticulate so much.

As regards oral and vocal speech, there is the same lack of
innervation, the same drawling, stuttering speech already
described, and the voice is low and respiration shallow. Not
only is there interruption of the speech current, but there is
inco-ordination of the laryngeal (vocal) and oral mechanism.
There is frequent tremor of the lips when speaking.

Case 4.—R. N—, aet. 60. Insane twenty-two years.
Epileptic for forty years, due to injury in a mine (wound on
temple) and probably fright. A hypochondriac, but a most
violent patient at times. There is less to notice about his
speech than in some more recent cases. There is no agraphia,
word-blindness or word-deafness, but there is amnesia, and his
speech is sometimes slow, hesitating, and tremulous. He is very
emotional, and this affects his voice. Asked if he ever noticed
anything wrong with his speech, he replied, “ Ne—ver noticed
anything wrong with my speech ” (echolalia), but later admitted
when “ ag—it—kin—a—tation ” (in a state of agitation). He
is very earnest and demonstrative with his hands, which fly
all over his body when telling his story of the pit accident.
Attention is at once drawn to the feebleness of the labio-dental
movement in speaking.

His vocabulary is very limited and his sentences inappro¬
priate to his purpose, his words clumsy in their application, not
incisive or explicit. This voluminous, almost meaningless,
speech is very characteristic. Talks in a monotonous, very
confidential tone of voice, also characteristic of many epileptics.
The following is an extract from a letter written to “ Mr. the
Governor Inspector of Scotland : ” “ When I write to the
Governor Inspector in 1881 and the answer that I got back on
Christmas morning was my dead letter that I was to come out
through death into life under her Magast serves and now the
time that I have been in I would like you to judge my case in
a medium way according to the rules of the Scriptures, and the
rules of the laws,” etc.

Case 5.—A. F—, aet. 24, of dark strumous type, with bad
family history of strumous character. She is weak-minded
and childish, and has had no education.

Her imbecile condition is rather a hindrance to our obtain-

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

249

ing a correct conception of the mental side of her speech
faculty, for she is weak of understanding, illiterate, and inca¬
pable of any subjective study of memory or recollection. Her
utterance is slow, thick, and, except when excited, anergic and
muttering in character. Certain conjunctions of syllables she
is unable to bring out, such as “ br ” in February ; she says
“ Fetherwary.” Her memory is weak. She says she is four
months here, whereas she has been four years. Echolalia is at
times very marked, e.g. she repeats in reply to questions, “a’
thegither, I wish—I wish—my airm—was better a* thegither ;
—I wish—I was a wee better—a* thegither ;—I wish I hadna
been here—a* thegither.” Addressing the nurse, she says,
“ My granny stays at Kilmarnock—she’s a puir auld woman—
my granny—a puir auld woman—I cam—tae stay here—tae
bide—afore ma puir auld mither deed—ay, ma puir mither
deed—I used—tae wash—ma puir mither’s hearth stane—Is
your puir mither no deed ? ” A negative reply. “ When are
ye—gaun tae see her—wull ye—tell your puir mither—that
A. F— was speerin*—for her—wull ye—tell her that puir
Agnes—has got a sair airm ? ” There is bradylalia noticeable
as well as echolalia, a limited, very limited, vocabulary, shallow
respiration, and feebleness in the oral mechanism. The strain
of the foregoing speech indicates, what is more noticeable in
the tone of the voice, the emotional character of the patient.
The simple statement, “Is this Monday?—then yesterday—
would be—the Sabbath day; ” the last words uttered with
reverence, shows her religious emotionalism ; it cannot be called
in her case intellectualism.

Imperfect as this case is from the clinical student’s point of
view, because of her weak intellect, it is in some degree a
contribution to the subject of undoubted value.

Case 6 . —R. B. L —, aet. 22. Insane at age of eighteen.
Is rather dull intellectually, religious emotionalism marked, and
religious delusions scarcely absent at any time. He takes few
seizures of grand mal or petit mat types. They are more
frequently mental and automatic in character, and he has no
recollection of them afterwards. The hypochondriacal element
is here very prominent. He has a dazed, far-away expression,
with a tinge of sadness in it, an expression as being “ not of
this world.” t

Asked regarding his speech, and what difficulties he noticed,

Digitized by VjOOQle

250

ON EPILEPTIC SPEECH,

[April,

he replied in halting speech and evidently with some mental
confusion, “ When—I have come—the right way—to a speech
—I know very well how to speak to any person.” He can
repeat verses of psalms and hymns with fair promptitude, but
intellectual operations are slow, and he puts in wrong words,
so that the meaning is confused. Innervation of vocal and
oral mechanisms is fairly good, the speech defect being more
mental and amnesic than motor. There is very little muscular
tremor, no agraphia, word-blindness, or word-deafness. Asked
if he ever took a fit, he replied, “ I would count the darkness
for the fit,” meaning that his sight failing was the first sign,
and then he added, “ I knew myself—I would do better every
day if—I was within the fresh air.” His memory is best when
talking of religious matters, the text or heads of last Sunday’s
sermon, etc. He is demonstrative in his speech, points with
his hand all the time, says “ praised ” for praying, “ meals
meat ” for meal of meat.

Case 7.—E. F. D— has been subject to fits for years,
exact period unknown. She has had several severe illnesses
during the last few years, e.g. an attack of coma with high
temperature for several days at one time, and acute bedsore at
another. She has been much reduced in strength. The
majority of her fits come on at night, and if she has a night fit
she is usually excited till she has two more. She is amnesic.
As I look at her she holds out her right hand, which is
trembling, and says, “ I—don’t—don’t,” and then there is a
long pause, and when I fill in what I think is the rest of her
sentence by saying, “ you don’t feel power in your right hand,”
she promptly replies, “No, I don’t.” When I remark, “ You
seem to have a difficulty in remembering words,” she replies,
“ Weel—I just be—no—kind—o’—,” a long pause as if para¬
lysed, and then the end of the sentence is uttered, “ the rale
thing just.” Questioned " Do you sometimes say the wrong
word—the word you don’t mean to say ? ” she answers
promptly, “ I do.” There is no word-deafness, and if she could
read there might probably be evidence that there is no word-
blindness, though her sight is affected after fits. There is at
times distinct echolalia. To the question, “ How old were you
when you took the first fit ? ” she replied, “ My—my—mither
—mith—no—that—I ken o'—I dinna ken o*—I had—to—
go—to—work—I had to go to work when I was ten years old

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

251

—I had—to—I had—to—I had to work that's—just—the—
truth. She doesna ken what she’s—talkin’—aboot—ma mither
said—ma mither said—ma mither said—there was ane—o’—
thae—kin o’—catch—thae fits—and—.” As here indicated,
bradylalia is well marked. Asked her age, she answered, 1 I’m
older than thirty years of age now.” Speaking immediately
after of her husband’s pay, she said, “ He had mair than thirty
years,” meaning thirty shillings a week. Her memory generally
is impaired. She cannot tell at what hour she gets breakfast,
dinner, or tea. When excited, amnesia and aphemia are less
noticeable. She is only slightly demonstrative when speaking,
except when excited. She talks in her quiet moods in a
confidential manner, hesitating very much at times, and in a
low voice, the lips and jaws parting slightly and the respiration
being very quiet and feeble. Tremors of all the facial muscles
are noticed, and still more so tremors of the hands, especially
the right. She puts her fingers to her lips when trying to
speak, as if conscious of muscular inertia, and from a desire to
help her utterance. The speech defects in this case, memorial
as well as motor, are more marked probably than in any of
those previously quoted, though M. B— and P. H— are both
very bad. These three are amnesic and dysphasic in a marked
degree.

Case 8.—D. R—, aet. 25, a miner. Has taken fits at vary¬
ing intervals from the age of eighteen. When asked if he has
noticed any difficulty with his speech, he replies, “ There is
something away from my speaks—and my—memory.” There
is no agraphia ; he understands what is said to him. He reads
correctly, but in a somewhat sing-song tone, raising his voice
at the end of every sentence, and pronouncing his words in
rather a snappish manner. There are no tremors. When
shown a sheet of foolscap, and asked to give it a name,
answers, “ Well—it's—a ”—pause—“ you can’t say it's a book
—but—it’s a pretty tidy book it—would—do—a grocer,”
meaning doubtless that it would do for wrapping-paper.
When shown an envelope, he replies, “ That is a tidy—
envelove ; ” shown a watch, answers, “ Well—it—will—be—
an English—lever.” Here there is again the redundancy
already noticed, to cover amnesic difficulties, and bradylalia is
quite noticeable. There is undoubtedly motor difficulty in
this case also.

Digitized by VjOOQle

252

ON EPILEPTIC SPEECH,

[April,

Case 9.—B. C—. This patient is an old asylum resident,
and was regarded as an epileptic twenty-five years ago. She
has of late years been much less subject to fits, and has not
had one for nearly a year. She is bright, active, and fairly
intelligent, considering her long residence in an asylum. She
can give a fairly correct account of her own case. When
asked, “ Have you ever any difficulty with your speech ? ” she
answered, “ Not this long time. I had when I used to take fits
—it was next morning—I couldna speak right. The attend¬
ants knew from my speech in the morning when I had taken
fits. I couldna get the full word out. I knew what I was
going to say, but I couldna get the full word out.” Here there
was dysphasia, but no amnesia.

Many more cases might be cited in detail, all confirming
those which have just been described, and before summing up
I will merely give brief statements regarding a few.

Case 10.—A male patient illustrates redundancy of speech,
as if conscious of amnesic defect, by answering the question,
“ What’s this ? ” (book) thus—“ A sort of library book.”

Case ii. —A male patient illustrates various defects of
articulate speech. He has noticed after fits that his speech
wanted strength. The emissive energy is spent before the
sentence is finished, and it dies away in inaudible words.
There is aphonia therefore. The muscular energy is feeble,
and the respiratory movements restricted. In his own words
he adds, “ I have many many times noticed a difficulty in
finding words to express myself.” There is, therefore, amnesia
also.

Case 12.—A male patient has thick, hesitating, drawling
speech.

Case 13.—A male patient says he is an elegant speller, and
is confused because he has not used the right word, which
should be “ excellent.”

Case 14.—A female patient says she and her brother were
both stutterers when they were young. Her sentences are
broken, and there is a circumlocution in describing events and
circumstances. Her memory for words fails at times, especially
after fits, and when trying to speak she feels as if her tongue
were paralysed.

Case 15.—A male patient describes his speech defect thus :
“ I feel a little now—not able to come to the point—have the

Digitized by VjOOQle

1900.]

BY A. CAMPBELL CLARK, M.D.

253

word ready—but I can’t get it out—tongue would not come
forward at the proper moment. ,, After fits he is always at a
loss for words.

Conclusion.

To sum up, I think it will be generally accepted that a con¬
siderable range of speech disturbance is to be found in epilepsy,
that there is much resemblance in the cases, and yet individual
diversities, and that when the normal mental habit is resumed
after one of those periodic outbursts of motor mental excite¬
ment which characterise epileptic insanity, the power of speech
is diminished. It is established (i) that before and after fits
amnesia and dysphasia are marked, (2) that when there is
emotional excitement these conditions are altered according
to the degree of the emotional excitement, (3) that when the
ordinary mental habit is resumed, and nervous tension has
disappeared, the patient suffers from reaction, which tells on
his speech faculty by reducing the energy of the memorial and
motor centres.

The Patient? Consciousness of Speech Defect .—Although, as
already observed, they incline at first to denial, they usually
admit it when their own stumblings find them out. Their
facial expression is quite sufficient to demonstrate that they
are anxious and disturbed when their speech is being tested,
and there is manifest effort, in the halting yet deliberate
speech, which reveals that the patient is anxious not to make
mistakes. This is seen also in the careful answers to such
question as, “ What is this ? ” (a key, e.g .) 9 answers characterised
by apologetic introductions, or qualified by unnecessary adjec¬
tives. The tremors are often worse, and the break in the voice
worse, when consciousness of a difficulty renders the patient
emotional.

Emotions as affecting Speech .—This is true of most people,
but emotional speech is rarely excited in ordinary circum¬
stances, just because emotions are not so acute and are more
under control. Just as we may have hysterical aphonia the
result of emotional disturbance, so there may be in the epileptic
respiratory spasm from a like cause. Undoubtedly the emotional
element must be taken into account in considering the different
speech abilities of the epileptic at different times. While this

Digitized by VjOOQle

254

ON EPILEPTIC SPEECH.

[April,

applies to human speech generally, it applies in a marked degree
to the epileptic. The pantomime of the epileptic is sometimes
vivid, frequently profuse and redundant, like his speech, and
indicates the emotional nature of the man.

Amnesia .—It will not be considered beyond a few words how
much this is due merely to the defect of recollection, but it
may be said in passing, that, as the amnesic state is at times
more marked than at others, the retentum may be in memory,
though not always forthcoming. It depends on special sensa¬
tions, and the particular emotional state, happiness, anger, rage,
etc., and on the degree, whether the faculty of recollection is
stimulated or inhibited. I have already pointed out that the
range of vocabulary is more or less limited with most epileptics,
and this is probably due to failure of memory (loss of retention)
apart from failure of reproduction (recollection).

Aphemia and Dysphasia .—Extreme aphemia is rarely
observed, and then only for a time, usually before and after
fits. Dysphasia best describes the articulate speech of the
epileptic. Here we have to take account of the vocal
mechanism, taking along with it the respiratory mechanism.
It may be taken, speaking generally, that there is usually a
reduction of emissive energy of all these mechanisms from
faulty innervation, and that there is want of synchronous
co-ordination. Hence we may have feeble, stuttering, or
staccato speech, and weak or spasmodic glosso-labio-dental
movements. We have also sensations of “ a catch in the
breath/* loss of phonation, or reduction of it, as seen in the
growing weakness of voice at the end of a sentence. This
points to nervous spasm or reduced innervation of the vocal
and respiratory mechanisms. Tremors of the facial muscles,
of the labial in particular, and tremor of voice indicate un¬
stable innervation.

I need only mention in a few words Bradylalia , which has
been abundantly demonstrated, and Echolalia , which is less
common, but sufficiently frequent to call for notice here.
Agraphia has not been noticed, but those patients who could
write were asked to sign their names, and there was found a
tremor, sometimes continuous, but mostly interrupted, in their
writing, suggestive of alcoholism.

Digitized by

Google

1900.]

SYSTEMATIC CASE-TAKING.

255

Systematic Case-taking\ By A. H. Newth, M.D., Haywards

Heath.

The analysis and arrangement in a statistical form of the
various entries made in the case-books of the different asylums
would form a valuable synopsis of clinical, therapeutical, and
pathological significance. But the labour involved would be
something enormous, and might dishearten the most enthusiastic
statistician ; even the work of arranging and tabulating the
entries in the case-books of one of the large asylums would be
very great.

If, however, it were possible to frame some simple, uniform
method of case-taking and persuade the superintendents of all
the asylums to use it, which possibly might be the most
difficult of all tasks, then some definite and valuable statistical
facts might be obtained.

Keeping up the case-books simply for the satisfaction of the
Commissioners, as a check on any charge of malpraxis or
neglect, for reference in case of inquiries, or as an evidence of
work done in the asylum is one thing; doing it from a
scientific point of view for the advancement of the study of
insanity is quite another thing. Yet it may be well to con¬
sider whether there may not be a possibility of combining
these two objects, and so making the entries that they will be
of use both legally and scientifically, at the same time saving
both labour and time in keeping the case-books.

There are few superintendents, or at any rate assistant
medical officers, who have to do the work, who do not consider
the trouble of case-taking, if not a perfect nuisance, at least
as occupying much valuable time which otherwise might be
more usefully employed. In fact many of them will cordially
endorse the remark made by one of the Commissioners when
inspecting the case-books of one of the large asylums—
u What nonsense ! ” The idea of two Commissioners in a few
hours going into the details of an asylum, examining all the
patients, and carefully scrutinising the elaborate entries relating
to several thousand patients in the case-books is too absurd ;
they cannot do it satisfactorily. With a simple method of

Digitized by VjOOQle

256

SYSTEMATIC CASE-TAKING,

[April,

case-taking, so that the state of each patient on admission, the
progress of the case, the treatment adopted, and the result
could easily be referred to, or even seen, as it were, at a glance,
their labour and difficulties would be considerably reduced.

There is a decided lack of uniformity as regards clinical and
therapeutical observations in the different asylums. The study
of insanity and the proper treatment to be carried out cannot
be made exact or satisfactory if it only depends, as it does
now, on the labours of a few earnest men working in isolated
grooves. There must be a collaboration of the observations of
a large number, and this can only be achieved by an uniform,
systematic method of case-taking. The vexed question of a
proper scientific nosology, a correct classification of disease,
and the most satisfactory treatment, might in some measure be
arrived at by a combined system of medical book-keeping.
Most of the scientific work done in asylums is pathological;
but, though pathology is most important, it has no significance
without clinical histories of the cases.

Dr. Clouston, in a very interesting paper read at a meeting
of the Association in November, 1869, strongly urged the
advisability of adopting a systematic plan of treating cases, so
as to arrive at some accuracy in the treatment of insanity.
This plan, I believe, was never attempted to be carried out,
though it had in it the germ of what ought to be done if
asylums are to be not merely institutions for the care, but
hospitals for the cure, of the insane.

Possibly nothing has been done because, as Dr. Clouston
suggests, the various medical officers " have had no time to do
this ; that their book-keeping and building, their multifarious
superintendence of servants and stewards, their distraction of
mind from theatricals and water-closets, is such that they
cannot devote attention enough to carry out such a scheme of
treating their patients.” This is very true, and he considers it
would be well if they were to neglect some of these things and
give the patients themselves a fairer share of their time and
mind. “ Surely,” he says, “ we have been long enough organis¬
ing and beautifying our aylums. It is the patients' turn for
an innings now.” In conclusion he adds, “surely it is no
mean ambition that we should all try and raise our department
of medicine up to the level of its other branches in scientific
progress. And if we could succeed in placing the treatment of

Digitized by VjOOQle

1900.]

BY A. H. NEWTH, M.D.

2 57

insanity ahead of all other branches of our art, resting it on a
sure basis of carefully observed fact and irrefutable generalisa¬
tion, this would be a noble reward for much hard work and
self-denying drudgery.”

The majority of asylums, no doubt, have an elaborate system
of medical case-taking, with entries notifying the almost daily
state of each patient. The case-books of the Royal Asylum,
Perth, are models of completeness in this respect, so arranged
that though the particulars as to the history and mental and
bodily condition, with the progress of each case, and also the
pathological appearances after death, are most minutely recorded,
they are made with as little trouble as possible. This is done
by having all the possible particulars printed for each case, and
then all that is necessary in making record of the cases is to
score out some parts and enter a few words at other parts.
Dr. Urquhart also has for his own private use check cards
giving a synopsis of each patient, the particulars of which are
culled from the case-books. These cards enable him to easily
arrange the patients under different states, and are most useful.

But the very completeness of detail in case-taking is a bar
to comparative study of cases. It makes the difficulty of
searching through the mass of material and obtaining facts for
classification or for comparison so much greater than if the
system of case-taking were simpler, although possibly not so
complete. Now, supposing the cases were so entered in the
case-books that, as it were, a bird’s-eye view could be obtained
as to the particular state of each patient; this, I think, would
be a great step towards a scientific investigation of insanity.

It is with some diffidence that I venture to offer the following
plan for a systematic method of case-taking, which is far from
being complete or perfect. But I offer it with the hope
that it may be suggestive, and I trust that others who have
better opportunities of framing a more useful one may be able
to formulate a plan which will meet the requirements of the
majority, and enable them to inaugurate a thoroughly satis¬
factory system of case-taking which will be applicable to every'
asylum, so that the entries may be on an uniform plan and so
comparable one with another. I venture to think that if some
such plan as this were adapted, it would relieve the assistant
medical officers of much onerous work, which only those who
have actually to do it can appreciate. I know from experience

Digitized by VjOOQle

2 5 8

SYSTEMATIC CASE-TAKING,

[April,

how terribly trying the labour was of keeping the case-books ; in
fact at one time I suffered from an attack of scrivener’s palsy
(which was only relieved by the use of the continuous galvanic
current), and also had a ganglion form at the extensor tendons of
the wrist. It is very possible that others who have to perform
this disagreeable duty of keeping the case-books will agree
with me that it would be a great boon to them if there could
be a simpler and easier method of case-taking.

My suggestion is to have the case-books of foolscap size,
ruled according to the accompanying scheme on one sheet, or two
pages ; this would afford space for the entries of the particulars
of thirty patients. The two next pages would be blank for
special particulars of the cases—such, for instance, as peculiar
delusions, more definite treatment, etc.,—attention being
called to these entries by a number in the appropriate column
or by an asterisk.

This plan necessitates the use of ciphers or letters, and
the objection might be urged against this that they would
not be easily remembered or understood. But this objection
could be easily overcome by making these ciphers as simple as
possible; and with a little practice anyone wotild soon be able
to read them as well as, if not better than, if the entries were
made in full.

That the plan is a feasible one I have proved, having some
years ago collected a large number of cases in this way.

Judging, however, from the number of valuable suggestions
which have been from time to time offered in the JOURNAL
for the advancement of the study of insanity, but which have
never been acted upon, it is to be feared that this scheme, or
even some such, will never be carried out.

Superintendents of asylums as a rule are too conservative
in their ways, and prefer to jog along the same old worn-out
grooves which have been followed for so many years. Many
will say that they prepare the statistical tables of the Associa¬
tion, which are all-sufficient. It is a question whether these
tables are of much value; at any rate no one seems to use
them for any real practical purpose. They are printed in the
asylum reports at considerable expense and trouble, and these
reports are distributed to the other asylums, where they are
glanced at, thrown into the waste-paper basket, or shut up in
some obscure cupboard, eventually to be taken out at some

Digitized by VjOOQle

BY A. H. NEWTH, M.D.

1900.]

259

future time to serve the only useful purpose of which they are
worthy, namely, to light the fire.

COL.

1. Registered No.

2. Initials.

3 - Age.

4. Condition of life.

5. Date of admission.

6. Occupation.

7. Religion.

8. Duration of disease.

9. No. of attacks.

10. Suicidal.

ix. Homicidal.

12. Epileptic.

13. Hereditary.

14. Relations insane.

15. Intemperate.

16. Habits of life.

17. Assigned cause.

18. Expression.

19. Complexion.

20 . Pupils.

21. Pulse.

22. Temperature.

23. Bodily condition.

24. \ w / On admission.

25. / Weight 0n discharge

26. Skin.

Males.

col.

27.

28.
29/
30 .
3«-
32.

33-

34-

35- ,

36J

37 ‘

40
4i-
42.
43*
44*
45-
46.

47-

48.

49.

50-

51-

•j

Reference No.

Page in case-book.

f Speech.

Mental stated

Memory

Delusions

Stated disease.

Treatment.

Employed.

Amusements.

Relapses.

Discharge.

Date.

Cause of death.
Reference No.

Sensation.

Reflexes.

Consciousness.

Excited.

Depressed.

Stupor.

L Coherence,
f For recent.

\ For past.
Senses.

Morals.

Emotions.

L Intellect.

Abbreviations—to be placed on first page in Case-book or on a separate sheet:

Religion. —A. Church of England. S. Church of Scotland. B. Baptist.

C. Calvinist. D. Dissenter. I. Independent. J. Jew. N. None.
P. Protestant. R. Roman Catholic. W. Wesleyan. X. Unknown.

Relations. —F. Father. M. Mother. S. Sister. B. Brother. A. Aunt.
U. Uncle. Gm. or Gf. Grandmother or grandfather. Ap. Paternal
aunt, etc.

Intemperate*I. S. Sober. M. Moderate drinker. T. Teetotaler.
Habits. —A. Active. L. Lively. M. Mischievous. Q. Quiet. S. Studious.

D. Dirty. B. Bestial.

Health. —G. Good. F. Fair. I. Indifferent. B. Bad. W. Weak.

P. Phthisical. S. Syphilitic. R. Rheumatic. D. Dying.

Expression. —V. Vacant. D. Dull. B. Bright. F. Foolish. M. Melan¬
cholic.

Complexion. —R. Ruddy. P. Pale. C. Congested.

Pupils. —E.— Equal. V. Unequal (a thick stroke to left or right indicates
which is the larger). C. Contracted. D. Dilated. I. Insensible.
Mind. —E. Excited. C. Childish. D. Deluded. L. Low spirits. M. Morose.

R. Rational. S. Suspicious. V. Vacant. I. Inhibition + or —.
Memory. —B. Bad. F. Fair. G. Good. D. Defective. I. Indifferent.

L. Lost.

Delusions.

Senses. —A. Auditory. F. Feeling. O. Ocular. N. Smelling. T. Tasting.
Emotions. —E. Erotic.

Aesthetic. —R. Religion. G. Grandeur.

Digitized by VjOOQle

26 o

RELATION OF ALCOHOLISM TO SUICIDE, [April,

Moral.—M. Monetary. D. Domestic.

Intellectual* I.

Pulse. —R. Regular. I. Intermittent. D. Dicrotic. F. Feeble. B. Bounding.

For further notes see overleaf. An asterisk in any column would mean refer to
notes or a number.

The Relation of Alcoholism to Suicide in England , with
Special Reference to Recent Statistics. By W. C.
Sullivan, M.D., Deputy Medical Officer, H.M. Prison,
Pentonville.

In the following paper it is proposed to study the influence
which alcoholism exerts upon suicide in this country, so far as
that influence can be traced in recent statistics of the movement
of these social phenomena. Our discussion will aim more par¬
ticularly at determining the role which alcoholism may have
played in the late increase of suicide in England, and at
establishing the distinctive characters which constitute the type
of alcoholic suicide.

Before, however, entering on the proper matter of our inquiry,
it will be desirable to refer briefly to the views of some of the
chief authorities who have dealt with the question of the alco¬
holic influence in suicide. It is premised, of course, that these
introductory remarks have no pretension to be a complete
summary of the extensive literature of the subject—an essay
far beyond the limits of this paper.

Introductory .—In the classic work in which he fixed the
clinical outlines of alcoholism, Magnus Huss^) indicated among
the characteristic symptoms of the disease its special proneness
to the development of suicidal tendencies. “ I venture to assert,”
he says, “that the suicidal impulse is a more frequent accompani¬
ment of the melancholia of drunkards than of melancholia from
other causes ; and, further, that amongst the uneducated classes
suicide frequently follows on the disordered emotional tone,
which, sooner or later, results from the abuse of alcoholic
liquors.” All subsequent clinical observation, whether directed
primarily to suicide or to alcoholism, has confirmed the accu¬
racy of this statement.

Naturally, the community being but the aggregate of its

Digitized by VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

26l

individual members, it is self-evident that if alcoholism be pre¬
valent in adequate extension, a similar relationship of phenomena
should be in some measure traceable on the larger scale of
statistics. Inquiries to test this inference have been numerous,
but the results reached by observers have not exhibited the
unanimity of clinical experience.

On the one hand, some authorities have maintained that
there exists an exact correspondence between the geographical
distribution of the two phenomena, and also between their
variations in different periods in the same country. This posi¬
tion in its most extreme form was notably defended by J. L.
Casper/*)

The majority of observers, however, have adopted a more
moderate view, and, regarding alcoholism as only one amongst
several causes of suicide, have contended that the two pheno¬
mena, though not exhibiting in their variations in time and
place an absolute parallelism, yet show an approximate corre¬
spondence sufficient to justify the inference of their relationship.
This is essentially the opinion held, for instance, by Lunier/ 8 )
Morselli,( 4 ) Baer/ 6 ) Westcott/ 6 ) Ferri/ 7 ) Grotjahn/ 8 ) though
some of these authors differ considerably in their estimate of
the degree and significance of the correspondence.

Lunier, whose views are in the main adopted by Morselli,
found in the different departments of France that a high
average consumption of alcohol was invariably accompanied by
a similarly high rate of suicide. The general validity of this
observation is, however, open to doubt. Baer, whose authority
on the question is unique, has demonstrated the absence of a
similar correspondence in Prussia, and cites also as a counter
argument the case of Sweden, where decrease in alcoholism has
failed to arrest the upward movement of suicide. His opinion
leans to a more moderate valuation of the alcoholic influence,
though still counting it as the most important of the individual
factors of suicide.

Grotjahn, who envisages alcoholism mainly as a direct result
of the condition of the proletariat under the capitalistic regime,
while admitting a certain coincidence in the regional and
periodic distribution of the two phenomena, regards their
relationship as that of co-effects of a common cause.

While all these authors agree in assigning to alcoholism
some part in the causation of suicide, there are others who

Digitized by

Google

262

RELATION OF ALCOHOLISM TO SUICIDE,

[April,

dissent altogether from this point of view, and who question
whether this agency has any effect at all considerable enough
to influence the statistical movement of suicide. This position
has been advocated by Colojanni ( 9 ) in Italy, by Durkheim ( 10 )
in France, and to a certain extent by Strahan ( u ) in England.

Durkheim in particular has elaborated this thesis ; regarding
suicide as a phenomenon exclusively dependent on the state of
the collective consciousness of the social group in which it
occurs, he denies to more elementary factors, such as insanity
or alcoholism, any extensive influence. In support of this
view as regards alcoholism he has endeavoured to show that,
contrary to the opinion of Lunier, the geographical distribution
of suicide in French departments presents only a very imper¬
fect correspondence with that of the various standards of
alcoholism—the per capita consumption of alcoholic liquors,
the frequency of arrests for drunkenness, the amount of
alcoholic insanity.

This mode of argument is, however, open to the reply which
Ferri effectually addressed to the similar contention of Colo¬
janni, viz. that it would prove merely that alcoholism was not
the sole cause of suicide, it would not prove that it was not
among its causes. Further, the fallaciousness of the method is
glaringly visible in the very maps on which Durkheim relies ;
* thus the chart showing the departmental consumption of alcohol
exhibits, as he himself admits, a certain correspondence with
the chart of suicide, insufficient, however, in his opinion, to
support the idea of causal relationship ; yet, as a glance at his
maps will show, this correspondence is actually closer than that
observable between this same chart of alcoholic consumption,
and the chart representing the distribution of alcoholic in¬
sanity.

On the whole it may be asserted that the balance of evidence
and argument leans to the observers who have taken the in¬
termediate position, and who look upon alcoholism as one of
several causes of suicide, its absolute and relative importance
differing in different places and at different epochs. This is
the point of view which we shall adopt in our inquiry, our
attention being practically limited to the relation of the two
phenomena in England and at the present time.

Recent Movement of Alcoholism .—We have first to inquire

Digitized by VjOOQle

1900.] BY W. C. SULLIVAN, M.D. 263

what has been the tendency of movement in alcoholism in this
country of recent years.

This is a point, the determination of which is beset by very
considerable difficulty, due more particularly to the absence of
any adequate measure of alcoholism. From our standpoint
that word must be taken to mean the ensemble of the morbid
results of alcoholic excess, and therefore the selection of any one
of these results as a standard necessarily involves a risk of fallacy.

How real this risk is will appear at once from the comparison
of a few of these possible standards. Thus in the mortality
returns of the Registrar-General we find that the number of
deaths attributed to intemperance, which amounted to 3 5 per
million in 1867, has risen steadily in successive periods, and in
1897 stood at 76 per million, an increase in thirty years of
over 100 per cent. The record of coroners* verdicts of “ death
from excessive drinking** shows a similar increase. On the
other hand the number of convictions for drunkenness has in
the same period undergone considerable decrease relative to
the growth of population.

Now it is obvious that, as a measure of alcoholism, the
Registrar-General*s returns have for us a greater validity than
the statistics of drunkenness ; apart from the intrinsic sources
of fallacy in these latter, due to the exclusive consideration of
the acute intoxication, there are clearly abundant elements in
local and general variations of public opinion, police efficiency,
prison accommodation, and the like, which influence the official
recognition of drunkenness. This might even conceivably be so to
such a degree as to make a high rate of drunkenness indicative
rather of keen public spirit than of abnormal intemperance in a
community. We may, therefore, conclude that the mortality
from alcoholism is a better guide than the frequency of arrests
for drunkenness.

We may also regard the question from another point of view ;
instead of seeking our measure of excess in its results, we may
seek it in its cause ; we may estimate the movement of alcoholism
by the variations in the amount of alcohol consumed. The
following table, taken from the appendix to Mr. Whittaker’s
admirable Memorandum, published with the report of the
Licensing Commission, gives the average per capita consumption
of beer and spirits in the United Kingdom for the years 1842-98.
The figures are summarised in five-year periods.

xlvi. 19

Digitized by VjOOQle

264

RELATION OF ALCOHOLISM TO SUICIDE,

[April,

Consumption of Spirits and Beer per Head of the Population
from 1842 to 1898.

1842-46 .

Spirits.

‘89 galls.

Beer.
20*0 galls.

1847-51 .

1*00 „

210 „

1852-56 .

106 „

221 „

1857-61 .

96 „

238 „

1862-66 .

92 „

271 »

1867-71 .

99 „

289 „

1872-76 .

1*22 „

33*3

1877-81 .

in „

29*4 „

1882-86 .

•99 „

27*3 „

1887-91 .

*97 „

287 „

1892-96 .

100 fl

29*9 ,,

1897

1*03 „

3>*4 „

1898

>*05 „

320 „

Thus it will be noted that in the case of both these forms of
alcoholic liquor the per capita consumption has of late shown an
upward tendency so marked as to bring the figures for recent
years almost up to the level reached in the early seventies, when,
coincident with the feverish industrialism of the period and the
enormous multiplication of licences, English drinking habits
attained their highest point

Now on the score of accuracy we may take it that these
statistics have distinct superiority, owing to the r 6 le of liquor
taxation in the national revenue; but we have to observe that,
as a measure of excess, they are open to certain fallacies. In
the first place, their reference to alcoholism is governed by the
question of the distribution of the liquor consumed.

As Mr. Whittaker points out, the immensely increased con¬
sumption of tea—in 1897 four and a half times per head what
it was in 1842—and the growth in the numbers of total
abstainers in the country, are two considerations which suggest
strongly that the alcohol-consuming section of the population
is at present relatively smaller than some years back, and that,
therefore, a moderately increased rate per capita of the whole
population may really involve a largely augmented consumption
by actual drinkers. And we have also to bear in mind that the
power of resistance to the drug is a varying quantity, and
probably tends to diminish in a population where a high degree
of alcoholism has prevailed for a long time.

When due weight is given to these considerations, it will
appear probable that the relatively slight upward tendency
shown by our figures represents really a large increase of

Digitized by VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

265

alcoholism. And this impression is confirmed by the steady
progression of the mortality from intemperance, to which we
have already referred.

Accordingly, without attempting to express the fact numeri¬
cally, we may take it as established on the available statistical
evidence that alcoholism has decidedly increased in this country
of late years.

Recent Movement of Suicide .—The next point with which we
have to deal is the recent movement of suicide.

The returns of the Registrar-General show that in England
there has been a steady increase in the suicide rate during the
last three decennial periods. Thus the proportion per million
inhabitants, which in the decennium 1861-70 stood at 65, rose
in the following decade to 70, and in the decade 1881-90
amounted to 77, representing an increase of over 18 per cent
on the figures for the first-named period.

The validity of these statistics has, however, as we are all
aware, been recently called in question. Sir John Sibbald,
arguing from the remarkable constancy of the rate of suicide by
hanging—the mode of death relation of which to self-destruction
is least doubtful—has contended that the apparent increase in
the total suicide rate is merely a result of faulty registration,
whereby cases which in former years would have been reckoned
as accidents, are now included under the rubric of suicide. This
consideration would apply especially to cases of drowning and
poison, the forms in which the alleged increase has been most
marked.

Against this ingenious theory, however, we have to set the fact
that in another category of suicidal manifestations, viz. attempts
to commit suicide, there has been a similar and even more
decided increase. Thus in the period 1867-71 the number of
cases of attempted suicide amounted to 35*5 per million
inhabitants ; in each succeeding quinquennial period it stood
higher, and in the period 1892-96 it rose to 57^9 per million,
an increase of over 78 per cent, on the first-cited figures.

Now statistics of suicidal attempts are not open to the same
risk of erroneous registration. They are, no doubt, liable to
other fallacies ; it is obvious, for instance, that their detection
will be easier in dense populations; and it may be that there is
now greater readiness than formerly to report and prosecute in
these cases. Such possible qualifying influences, however, would

Digitized by VjOOQle

266

RELATION OF ALCOHOLISM TO SUICIDE,

[April,

only apply to the earlier years, and could not explain the steady
progression in the last decade. We may, therefore, affirm with
some confidence that the increase in the frequency of these cases
represents a real growth of suicidal tendency ; and though, as we
shall see later on, there are decided reasons for thinking that the
causation of suicidal attempts is by no means entirely identical
with those of the majority of actual suicides, nevertheless these
two phenomena have sufficient factors in common to render it
improbable that a large increase in the one should not be accom¬
panied by some increase in the other. Hence we may consider
that the concurrence of the evidence derived from these two
sources goes far to confirm the validity of both.

The extent of that concurrence, and the importance of the
recent increase of suicide, is shown in the appended diagram,
taken from the Criminal Statistics for 1893 an d brought up to
date ; it presents the movement of actual suicide and of suicidal
attempts from 1874 to 1897, and the estimated movement of
population in the same period.

Two points are clearly brought out in this diagram, viz.
firstly, that suicidal tendencies have grown in a degree entirely
out of proportion to the increase in population ; secondly, that
their growth has been much more considerable in the category
of suicidal attempts than in that of actual suicides.

Comparison of Actual and Attempted Suicide .—In the absence
of any evidence to the contrary, it would appear natural to
ascribe the increase in these two forms of suicidal manifestation
mainly to the operation of the same cause, a cause, therefore,
which plays an overwhelming part in the genesis of abortive
attempts, but which is much less importantly related to the
production of actual suicide.

The first step towards the detection of this cause will be to
inquire whether suicidal attempts present any peculiar features
when compared with the mass of actual suicides. This is the
point which we propose to deal with in this section.

In the study of suicide in different civilised countries it is of
common knowledge that, besides those climatic, racial, and
political influences which are special to each nation, there exist
other factors whose operation is traceable as a constant force of
definite direction in every community. Broadly speaking we
may say that of these universal factors the most important are
age, sex, season, and religious cult. It is in regard of these

Digitized by VjOOQle

SUICIDAL ATTEMPTS, SUICIDES, AND PROSECUTIONS FOR
DRUNKENNESS IN THE COUNTIES OF ENGLAND.

The figures represent the average proportion of cases of each category per
100,000 of the estimated population during the years 1891-5 ; and the counties are
arranged in the order of the decreasing frequency of suicidal attempts.

Metropolitan District

Suic. attempts.
. 1280

Suicides.

1050

Drunkenness.

657

Warwick

8 01

1007

491

Southampton

764

840

294

Worcester .

663

.. 838 .

735

Northumberland .

6*24

992

1802

Northampton

607

1209

3 11

Lancashire .

590

910

970

Nottingham

569

1068

521

Lincoln

476

10*21

487

Leicester

458

IO56

324

Somerset

4 * 5 i

87. .

221

Gloucester .

4 24

765

337

Berkshire .

4 23

796

285

Sussex

4 *7

11*24

268

Kent .

4 15

10 88

297

Cheshire

396

796

609

Dorset

3 90

884

227

Devon

366

946

316

Oxford

366

837

133

Hereford

362

7*42

443

York .

352

8*59

505

Stafford

3 * 3 6

817

685

Derby

3*34

8 68

52 i

Buckingham

3*24

864

231

Shropshire .

3 '21

948

758

Monmouth .

2 48

6*28

654

Hertford

2 22

677

248

Wiltshire

2 18

551

132

Suffolk

1 99

1150

145

Durham

198

7* 1 5

1302

Norfolk

1 96

8*54

172

Westmoreland

1*81

9 99

293

Cumberland

1 80

7*80

704

Surrey

1 68

iioi

283

Bedford

1 62

810

219

Huntingdon

1 45

1016

132

Cambridge . .

1-29

8*29

111

Essex

114

9 49

224

Rutland

774

L 17

Cornwall

4 90

204

[Wales

5 17

798]

Digitized by tjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

267

factors, which operate within the limits of the social group, that
we may best compare the two categories of suicidal manifesta¬
tion. Unfortunately the information furnished in this country
concerning both actual and attempted suicide is so extremely
meagre that the comparison of the two phenomena, even in
these few points, is not free from difficulty.

We shall first consider them in relation to sexual incidence.
In actual suicides in England the average proportion of females
is 2 5 per cent. ; in suicidal attempts the proportion, calculated
on the accessible figures for the years 1893-97, is 27*1 percent.
That is to say, the sexual incidence in suicidal attempts differs
but slightly from that in actual suicide; hence we may infer
that in this respect the factors entering into the causation of the
two phenomena either are identical, or, if different, operate in
such similar direction and extent as to produce practically
identical effects.

We obtain a very different result when we investigate the
relation of the two suicidal categories to age.

Unluckily in the criminal statistics which deal with suicidal
attempts, and in the returns of the Registrar-General which
deal with actual suicide, age groups are classified on different
systems, and it is consequently impossible to place the figures
in complete parallelism. They present, however, a contrast so
marked as to appear vividly in spite of this difficulty.

Thus in the mortality returns of adult males it is found that
the proportion of suicides by persons aged over 45 years is 5 5*6
per cent., the period of maximum incidence being the decade
45—55. On the other hand, amongst adult males tried at
assizes and quarter sessions during the last five years for
attempting to commit suicide, the proportion aged over 40
years was only 467 per cent., and the period of maximum
incidence was the decade 30—40. A similar contrast is found
as regards females ; the maximum incidence in suicides of that
sex is in the decade 3 5—45, while in attempts to commit suicide
it is in the period 21—30. Hence it appears that abortive
suicidal attempts differ widely from actual suicides in that their
predominant cause tends to operate at a relatively early age.

In regard of seasonal influence the results of comparison are
negative ; actual suicide and suicidal attempts increase with
equal regularity from winter to summer, and decrease from
summer to winter.

Digitized by

Google

268 RELATION OF ALCOHOLISM TO SUICIDE, [April,

The fourth important influence which we have mentioned—
the form of religious cult—cannot be directly investigated,
owing to the absence of information on the point in respect of
both varieties of suicidal tendency ; we may attempt, however,
an indirect comparison of the phenomena by reference to suicide
in Ireland, where the religious conditions are different. Without
going into details, we may summarise the facts with regard to
that country by stating that, while in Ireland, as in most pre¬
dominantly Catholic countries, the rate of actual suicide is very
low, that of suicidal attempts is relatively high, and in recent
years has even been considerably in excess of the rate of actual
suicide. For instance, in the year 1896 attempted suicides
reached the proportion of 37 per million inhabitants, while
suicides amounted only to 28 per million. And this excess
has been comparatively much more decided in the Catholic
provinces than in Ulster. From these facts we may most
reasonably infer that if, as seems probable, the low suicide rate
of Ireland be due to the influence of Catholicism, that influence
is, relatively, ineffectual against the causes which determine
suicidal attempts.

Another point to which considerable interest might have
attached is a comparison of the modes of self-destruction in
actual and in attempted suicide, but the statistics of the latter
phenomenon give no information on this subject. In a series
of personal observations, too few, of course (only 143 in
number), to carry much weight, there was noted a marked pre¬
dominance of drowning and poison ( 5 7*3 percent.) overhanging
(7*6 per cent.). This is a reversal of the conditions found in
actual suicide, where hanging is the chief method resorted to ;
but it is interesting to observe, in connection with the earlier
age incidence of suicidal attempts, that the prevalence of hang¬
ing in actual suicide is normally least marked in the early age
groups. Wagner ( 12 ), by figures drawn from the Danish statistics,
has shown that while the proportion of suicides by hanging
steadily progresses in each age group above 15 years, the
reverse obtains for drowning and for poison. And the same
condition is found in English suicides ; for instance, in the
years 1890-91 amongst male suicides in England the propor¬
tion in persons aged under 45 was, in suicides by hanging
33 5 F^ 1 * cent., drowning 47*5 per cent., poison 50*0 per cent.

To sum up, therefore, the results of our comparison of actual

Digitized by

Google

1900.]

BY W. C. SULLIVAN, M.D.

269

and attempted suicide, we find that these two phenomena do
not appear to differ in regard of seasonal distribution and sexual
incidence ; that they probably differ in their predominant form,
hanging being more frequent in actual suicide, more impulsive
methods in suicidal attempts ; that they most probably differ
in their reaction to religious influence, which is potent in actual
suicide, insignificant in suicidal attempts ; and that they differ
clearly and decisively in regard of age incidence, suicidal attempts
being related to early, actual suicide to later age groups.

Age Incidence in Alcoholic Suicide .—Now the tendency to
occur at a relatively early age, which we have found to be the
chief distinctive feature of abortive suicidal attempts, is also a
characteristic of a special group of actual suicides, viz. those
dependent on alcoholism.

In the occupational groups dealt with in the returns of the
Registrar-General, there are several which present a very high
rate of alcoholism and a corresponding frequency of suicide.
These are more particularly the groups related to the liquor
traffic, or those where the social conditions lead directly to
alcoholic excess.

In these groups we may safely regard the suicide as a conse¬
quence of the alcoholism, since there is no evidence of the
special operation of other causes capable of originating an
abnormal degree of suicidal tendency.

From Dr. Tatham’s tables for the three years 1890-92 we
may select the following as examples of such alcoholic groups :
—Publicans, butchers, coach and cab service, commercial
travellers, hairdressers, and musicians. In the period named
these groups furnished 404 cases of suicide by persons aged
over twenty-five years. Of these 220 (54*4 per cent.) occurred
before the age of forty-five years. The normal average pro¬
portion of suicides below that age being, as we have seen,
44*4 per cent.

To demonstrate the significance of this contrast, and to avoid
possible fallacies due to differences in the age constitution of
the groups, we may compare the suicide rates per million living
at each period in this composite alcoholic class with the corre¬
sponding figures for all occupied males :

25- 35 " 45 - 55 - 65 -

Occupied males . . 137*1 ... 214*2 ... 307*6 ... 421*8 ... 553*1

Alcoholics .... 449*5 ... 404*0 ... 405*3 ... 622*1 ... 869*6

Digitized by VjOOQle

270

RELATION OF ALCOHOLISM TO SUICIDE, [April,

The meaning of the figures will be better seen if we translate
them into terms of a single standard. In the following table
this is done: the suicide rates per million living in each age
period of the composite alcoholic group, of publicans taken as
a purely alcoholic class, and of agriculturists taken as a
typically non-alcoholic class, are shown in percentage relation
to the corresponding rates for occupied males:

25-

35-

45"

55-

65-

Occupied males

. 100

. 100 ...

, 100

. 100 ..

. 100

Alcoholics.

. 181*9 ...

. 1886 ...

131*7 ••

. 147*4 -

- >57*2

Publicans .

. 260*3 ...

, 246*8 ...

166*9 ..

. 156-2 ..

. 100*9

Agriculturists .

. 64*2

. 68*8 ...

70*6 ..

.. 781 ..

. 866

In this table, comparing the two groups preceding with the
two following the age of forty-five, we observe that it is in the
former that the alcoholic influence is chiefly perceptible. In
the composite alcoholic group the excess over the average
suicide rate rises to more than 80 per cent, in the earlier
groups, to only 37 per cent, and 47 per cent, in the two later
groups. And the contrast is still more vividly apparent when
it is made between the opposed groups of publicans and agri¬
culturists. In the earlier age periods the deviation from the
standard is at its maximum ; in the decade twenty-five to
thirty-five in the class where alcoholic influence is least active
the suicide rate is more than 30 per cent, below the average,
in the class where that influence is most potent it is more than
150 per cent, above the average. In each successive age
group this influence is less perceptible, and in the last group—
above the age of sixty-five—the suicide rate in agriculturists is
only 14 per cent, below the average, while that of publicans
falls to a figure practically identical with the standard.

This is not a merely casual feature of the last census
figures. The same result is obtained if we examine earlier
statistics. For instance, in a paper read by Dr. Ogle ( ls ) before
the Statistical Society, figures are given showing details of the
age incidence of suicide in various occupations during the six
years 1878-83. Calculating from his figures we find that
compared with the total male suicide rate taken as 100, the
suicide rate amongst publicans amounted to 271*6 in the
vicennial age period twenty-five to forty-five, while falling to
168*5 P er cent - * n the period forty-five to sixty-five.

Digitized by VjOOQle

1900.] BY W. C. SULLIVAN, M.D. 271

We may take it as proved, therefore, that suicide due to
alcoholism is characterised by a tendency to occur at a rela¬
tively early age, thereby contrasting strikingly with suicide from
other causes, but approximating to the type of suicidal
attempts.

Alcoholism the Predominant Cause of Suicidal Attempts .—
The next stage of our inquiry will be to determine whether the
resemblance of suicidal attempts to alcoholic suicide is the
result of an identity of origin.

Clinical evidence, as I have endeavoured to establish else¬
where ( u ), tends to prove that the abortive suicidal impulse is
chiefly dependent on alcoholism, that it is related in its most
typical form to a state of cerebral automatism developed by a
bout of drunkenness supervening on a chronic intoxication.
Thus as compared with the mass of actual suicides these
attempts differ in their issue because they differ in their origin ;
they depend on a cause which evolves the suicidal impulse in
the conditions least favourable to its realisation.

There is an a priori probability that this view, derived from
a special and limited field of observation, has yet a general
validity. It is, in fact, difficult to see how any large proportion
of suicidal attempts could fail of execution unless they were
made under the influence of cerebral conditions interfering with
the normal power of co-ordinated action ; and, further, the only
agent of sufficiently wide-spread activity to produce these con¬
ditions on the requisite scale is alcoholism.

We have just noted how fully this hypothesis of an alcoholic
origin would harmonise with the peculiarities of age incidence
in suicidal attempts. We have now to inquire whether the
other characters of these attempts are equally consistent with
that view.

First, with regard to sexual incidence; we have found that
the female contribution to suicidal attempts amounts to 27*1
per cent. This figure is very near the judicial estimate of female
drunkenness, 29 per cent. If, therefore, alcoholism is the main
cause of attempts to commit suicide, and if its influence in that
respect is equal in the two sexes, the proportion of women
among attempted suicides would be normal.

In the influence of season, again, the facts accord with our
hypothesis ; as we have seen, the seasonal distribution of
suicidal attempts corresponds with that of actual suicide ; there

Digitized by VjOOQle

RELATION OF ALCOHOLISM TO SUICIDE,

272

[April,

is an exactly similar correspondence with the seasonal distribu¬
tion of alcoholic insanity ,( 16 )

Similarly the apparent independence of religious conditions,
and the tendency to the more direct and simple methods of
execution are characters which would belong naturally to
suicides of an impulsive type.

In all these points accessible to inquiry we find, therefore,
that the facts are most consistent with the theory which attri¬
butes suicidal attempts mainly to alcoholism.

RSle of Alcoholism in the Recent Increase of Suicide .—Now,
as we have already indicated, there is a prima facie probability
that the same agent which has produced the increase in the
abortive manifestation of suicidal tendency is also largely
responsible for the slighter coincident increase in actual
suicides.

If this view be correct, then the increase in actual suicide
should in its characters conform to the type of the suicidal
impulses of alcoholism, that is to say, tested by what we have
found to be the main distinction of that type, it should be most
marked in the earlier age groups.

From the decennial period, 1861-70, to the decennial period
1881-90, the increase in the suicide rate per million inhabitants
amounted amongst males to 19*1 per cent., amongst females to
8*3 per cent. How was this increase distributed in the age
groups ?

It is in the years from twenty-five to sixty-five in men, and
from twenty to fifty-five in women, that the vast majority—
considerably more than three fourths—of suicides occur, and
the variations of the age groups comprised in that period are
decisive of the general tendency in the statistical movement.

To determine the question at issue we may, therefore, take as
a central point the age of forty-five in men and thirty-five in
women, and we may examine the variations from the earlier to
the later decade in the suicide rate per million inhabitants
living in the two age groups preceding and the two following
these ages.

The result is given in the following table :

Digitized by VjOOQle

1900.] BY W. C. SULLIVAN, M.D. 273

Increase of Suicide-rate per Million Inhabitants living in each

Age Group from 1861

1881-90.

Age.

Increase.

Males

• 25—35

...

247 per cent.

35-45

203

45—55

17*5

55-65

15*9

Females .

. 20—25

aS‘8

25-35

...

20*0 „

35—45

24*5

45—55

1*2 „

Thus it will be noted that of the four groups whose numbers
entirely dominate the statistics of suicide, it is the earlier ages
—those in which we find the maximum incidence of suicide
from alcoholism—that have been most influenced by the recent
increase in suicide.

And an alcoholic origin would probably explain also the
other peculiar character of that increase, the character on
which Sir John Sibbald bases his doubt of its reality, namely,
its predominance in suicides by drowning and poison.

For, as we have already pointed out—and the experience of
attempted suicide confirms the idea—it is obvious that these
methods have a more natural relation to impulsive suicide than
has, for instance, the more elaborate process of hanging.( 16 ) And
we find indirect evidence in the same sense in the facts regard¬
ing suicide in Ireland. There, as we have already indicated,
suicides, particularly in the Catholic provinces, are rare, while
suicidal attempts are relatively frequent. Corresponding with
this fact we note that, while differing widely from England in
other respects, Ireland is only a very little less alcoholic than
that country.

It appears probable, therefore, that owing to the absence of
other factors, alcoholism occupies a relatively important position
in the causation of suicide in the Catholic provinces of Ireland
as compared with the northern province, or with England.

Now, contrasting suicide in Ulster with suicide in the rest of
Ireland we find that in the four years 1887-90 the proportion
of suicides by hanging amounted in Ulster to 32*1 per cent, of
all suicides in that province, in the rest of Ireland to 23 per
cent.

Hence we may assert that such evidence as is available points
to these modes of suicide as the predominant expression of
alcoholic genesis, and, therefore, the limitation of the increase

Digitized by VjOOQle

274

RELATION OF ALCOHOLISM TO SUICIDE.

[April,

in suicide to these methods does not so much impugn the
accuracy of the statistics as it supports the theory of augmented
alcoholic agency.

Alcoholism and Suicide in the Occupational Groups .—Having
examined the statistical evidence referring to the connection of
alcoholism and suicide in the population as a whole, we have
now to complete our inquiry by the investigation of their rela¬
tionship in social groups—groups defined either by similarity
of occupation or by geographical distribution.

We shall consider in the first instance the former class, con¬
cerning which the mortality reports of the Registrar-General
afford us very direct information.

The following table, extracted from Table IV of Dr.
Tatham’s Report, shows in a series of the larger occupational
groups the “ comparative mortality figures ” for suicide, alcohol¬
ism, and diseases of the liver, this latter being the form under
which alcoholism chiefly masquerades in the registration of
non-pauper patients. The groups are arranged in the order of
their decreasing alcoholism.

Comparative Mortality Figures for Alcoholism, Hepatic Diseases ,
and Suicide in the Occupational Groups .

Group.

Alcoholism.

Liver disease.

Suicide.

Publicans

. 94

• ••

174

Costers .

• 36

Butchers

• 35

Musicians

. 29

Cabmen

. 28

• • •

Bagmen

• 23

Transport Service .

. 21

Domestic servants .

• 17

• ••

Medical men .

. 14

Shopkeepers .

- 14

Labourers

. 14

1 3

Occupied males

• 13

Barristers

. 12

Tailors .

. 12

Bakers .

Metal workers

. 11

Building trades

. 11

Watchmakers, etc..

• 9

• ••

Shoemakers .

• 9

Scholastic

. 8

Textile manufactures

. 7

Miners .

• 4

Agriculturists

* 4

Fishermen

• 3

Clergymen

• • •

Digitized by VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

27s

As a glance at these figures will show, there is a certain
general correspondence between alcoholism and suicide in the
different groups, this correspondence being very much more
evident in the classes where alcoholism is above the average
for occupied males. The only striking exceptions to this rule
are the groups of medical men and watch and instrument
makers—whose suicide rate is, through the operation of readily
imagined causes, abnormally high—and the group of costers,
who, though highly placed on the alcoholic list, are not above
the average in suicide. The relatively low rate of liver disease
in this group, and the usual readiness to predicate drunkenness
of a coster, are considerations which suggest that alcoholism in
this class is over-estimated.

The interpretation of the facts regarding the other groups is
fairly obvious : alcoholism being an important cause of suicide,
its prevalence produces a relatively high suicide rate, cceteris
paribus ; on the other hand, as it is only one of several causes,
its decrease does not involve a diminution of suicide beyond a
certain point, as other factors of suicide continue to operate.

The same fact may be brought out in another way. If we
take a large occupational group in which alcoholism is frequent,
and if we subdivide it into local groups, then it will be found
that the variations of the mortality from alcoholism in these
sub-groups are accompanied by corresponding variations in the
mortality from suicide. On the other hand, if we submit to
the same process a group in which alcoholism is not specially
prevalent, we find no such correspondence between the varia¬
tions of the two phenomena in the sub-groups. The following
table of mortality figures for alcoholism and suicide in local
groups of publicans, taken as an alcoholic, and of coal miners,
taken as a relatively sober occupation, exhibits this point very
clearly.

Alcoholism and Suicide in Local Groups of Publicans and
Coal Miners .

Alcoholism.

Suicide.

Publicans ....

. 94

London ....

. 127

Industrial districts .

. 93

Agricultural

. 69

Digitized by VjOOQle

276 RELATION OF ALCOHOLISM TO SUICIDE, [April,

Miners.

Durham and Northumberland
Lancashire .

York, West Riding

Derby and Nottinghamshire .

Alcoholism.

Suicide.

Regional Distribution of Alcoholism , Suicide, and Suicidal
Attempts .—For our purpose the occupational group with which
we have just dealt is in several respects superior as an unit to
the regional group, which we have now to consider. In the
first place the effort to determine the local distribution of
alcoholism is impeded by the difficulty that we have no reliable
measure of the intoxication in the regional unit. The police
returns of the number of prosecutions for drunkenness are the
only semblance of such a measure, and we have already seen
how utterly inadequate they are for the purpose. And the
objections which lie' against their validity as a test of the
alcoholism of the country taken in its entirety hold even more
strongly against their use in the comparison of its different
regions.

A further source of fallacy resides in the fact that, in so far
as territorial divisions correspond to differences in social and
industrial conditions—and that from our point of view should
constitute their value—these conditions are themselves disturb¬
ing factors in the problem, and that in many ways. On the
one hand, drunkenness and abortive attempts to commit suicide
are events more likely to attract the attention of the police in
areas where the population is dense, and hence it is quite
possible that statistics may underrate their frequency in the
more thinly-populated areas. On the other hand, if it should
appear that suicide, actual or attempted, is really more frequent,
and drunkenness more rife in districts where special industrial
conditions prevail, then it might very reasonably be contended
—and the argument undoubtedly expresses part of the facts—
that the alcoholism in these districts stands in no casual
relation to the suicide, but that both are results of the industrial
environment.

If we give due weight to all these qualifying considerations,
it will appear abundantly clear that the results furnished by
this particular method of inquiry must be regarded as of very
secondary and relative value, useful at most in so far as they
may control evidence gained from other sources. For that

Digitized by VjOOQle

BY W. C. SULLIVAN, M.D.

1900.]

2 77

end, and not as possessing much intrinsic value, we include
them here.

I have prepared maps, based on figures taken from the
Criminal Statistics, 1891-95, showing the distribution of
suicide, suicidal attempts, and drunkenness in the English
counties during these five years.

The indications offered by these maps are somewhat vague,
and such general tendencies as can be traced in them are
largely tempered by exceptions. Certain main points can,
however, be made out.

In the first place, if we direct our attention to the regional
distribution of suicide and attempted suicide, we note that the
correspondence between these two phenomena is only partial,
that it is fairly evident where suicidal attempts are frequent,
very imperfect where these attempts are rare. This result
confirms the conclusion which we have already reached on
other grounds, viz. that the factors which govern the origin of
suicidal attempts play a much less important rSle in the
causation of actual suicide, and that consequently while their
activity, as shown by the frequency of these attempts, involves
some increase in the rate of actual suicide, their absence or
diminution does not necessarily produce a corresponding fall in
the suicide rate, as the other causes of suicide persist.

If we now regard the distribution of drunkenness in connec¬
tion with the other phenomena we find, as the considerations
already cited would lead us to anticipate, that these maps give
even more uncertain results. In general, however, drunkenness
appears to correspond more with attempts than with actual
suicides ; this holds true at least in the lower figures, that is to
say, with a low rate of drunkenness attempted suicide more
usually rules low, while actual suicide not uncommonly rules
high. It will further be observed that attempted suicide and
drunkenness are chiefly found in counties which include large
urban areas, while they are rare in agricultural districts, where,
on the contrary, actual suicide may be fairly frequent. And if
we take the urban districts alone, we find that in these centres
of alcoholism suicidal attempts may even increase to such a
degree as to be more frequent than actual suicides, though the
latter also rule very high. This is the case, for instance, in
London, Liverpool, and Manchester. The influence, of course,
of the special circumstances of town life other than alcoholism

Digitized by VjOOQle

278 RELATION OF ALCOHOLISM TO SUICIDE, [April,

is a factor which detracts somewhat from the value of this
evidence ; nevertheless, it retains considerable significance by
reason of its harmony with the facts from other sources.

Conclusion .—We have now reached the term of our inquiry,
and from the results which we have obtained we are in a
position to formulate a fairly definite statement of the relation¬
ship of alcoholism to the movement of suicide in England.

We have found that the recent increase of suicide has
coincided with a considerable development of abortive suicidal
attempts. These attempts, in such of their characters as are
ascertainable, have approximated to the type of alcoholic
suicide, thereby confirming the clinical evidence which attri¬
butes to alcoholism the chief rdle in the genesis of abortive
suicidal impulses. Further, we have found that the most
important of these characters—earlier age incidence—has also
marked the recent increase of actual suicide.

For these reasons we may regard it as most probable that
this increase of suicide has been in a large degree related to
the influence of alcoholism, an influence which in the same
period—as mortality statistics attest—has tended to augment.

And we may also draw a larger inference; out of the
fragments of evidence of various origin which we have examined
in the course of our inquiry we may construct the type of
alcoholic suicide as a special variety, with characteristics dis¬
tinguish it from suicide of other causation.

The chronic intoxication by alcohol, as we observe it
clinically, produces generalised disorders of visceral function
throughout the economy, whence there results an alteration
and disturbance of those organic stimuli which form the
ground-work of our personality, those stimuli whose activity,
as Maudsley( 17 ) puts it, “is even of more consequence in
determining the tone of our feeling or of our disposition and
the character of our impulses than that activity which follows
impressions received from the external world.”

The depressed emotional tone thereby induced prepares the
suicidal impulse, which in the more typical instances issues in
action when a supervening increase of the intoxication has still
further lowered the level of function in the enfeebled brain, and
has proportionately exalted the influence of the organic stimuli
in the cerebral processes.

As compared, therefore, with cases of deliberate and co-ordi-

Digitized by VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

279

nated suicide due to other causes, alcoholic suicide is found to
be more impulsive, more directly and immediately related to
organic conditions in the individual.

And when we pass from the clinical to the statistical stand¬
point—when, instead of isolated cases, we envisage alcoholic
suicide as a social phenomenon,—the consequences of this
special mode of evolution appear with equal definition.

Thus we find that the factors—those notably of the social
order, or operative as such—which dominate other forms of
suicide are of comparatively small account, or are of different
account in the suicide dependent on alcoholism ; and hence the
characters which these factors impress upon ordinary suicide are
frequently lacking, or are obscured in the alcoholic form.

So far, no doubt, as some of these factors are of a nature to
further alcoholic excess at the same time that they further
suicide, they co-operate in producing alcoholic suicide. This
holds true, for instance, of seasonal influence, and in respect of
it alcoholic suicide shows no divergence from ordinary suicide.

The relation is similar, though not perhaps essential, as
regards sexual incidence; alcoholism is a potent factor only in
about the same fraction of the female population as that ex¬
posed to the ordinary social causes of suicide, and for that
reason, and probably for that reason alone, the sexual inci¬
dence of the suicide which is alcoholic does not markedly differ
from that of the suicide which is not alcoholic.

In religious cult we have, on the other hand, a social factor of
decided influence on non-alcoholic suicide, but relatively insig¬
nificant—within the limits of the Christian sects—as regards
alcoholism. We find its action also insignificant on alcoholic
suicide ; the forms of Christian belief comparatively immune
from ordinary suicide are by no means protected from the self¬
destructive impulse arising from alcoholism.

Finally, in age we have a factor whose influence on alcoholic
suicide is not merely not co-operative with its influence on ordi¬
nary suicide, but is of directly opposite effect. In the relation
of age to ordinary suicide—a relation in part, at least, of the
complex social order—the forces which make for suicide grow
with the years ; their zenith is in the phases of decadence. It
is otherwise with alcoholic suicide; the visceral disorders from
which issues the suicidal impulse of the drunkard react with
greatest potency on the affective ego in the period of fullest

XLVI. 20

Digitized by VjOOQle

280 relation of alcoholism TO SUICIDE. [April,

vital activity. Hence it is in respect of this influence that
alcoholic suicide and ordinary suicide exhibit their utmost vari¬
ance ; the earlier age groups—the years of active manhood,
where normally the suicidal bent is slight—are those where
alcoholic suicide reaches its highest development From that
point it sinks in importance, until in advanced life its influence
is hardly traceable as a distinct force.

Thus the evidence of statistics is in entire harmony with the
inferences of clinical experience. The impulsive suicide of the
alcoholic, characterised as a phenomenon of the individual by
obscuration of consciousness and absence of deliberation, is
similarly marked as a social phenomenon by a relative inde¬
pendence of the ordinary factors of suicide, by an obscuration,
as it were, of the more complex activities of the collective
consciousness.

It is probable, of course, that this differentiation is not abso¬
lute in the social any more than it is in the individual instance ;
as the dream consciousness of the individual varies under
different conditions in its degree of independence of the waking
consciousness, so, also, doubtless the movement of toxic suicide
in a given community is not entirely uninfluenced by the factors
which govern social activities of a more deliberate order, includ¬
ing ordinary suicide ; that is to say, the state of the collective
consciousness, as reflected in these activities and in the organised
forces which lie behind them, may react also in greater or less
extent on the direction of the impulsive acts of the alcoholic,
which would tend, for example, more towards suicide than
towards homicide when and where suicide was normally more
prevalent, and vice versd. The varying degree and character of
this reaction probably account in part for local and periodic
differences in the correspondence between alcoholism and its
suicidal expression, and in the divergence between the latter and
ordinary suicide.

In general, however, these influences which we have just con¬
sidered are slight and partial; they never suffice to obscure in the
statistical view the special characters of alcoholic suicide—the
characters which indicate that the relation of that phenomenon
is to the forces which govern alcoholism, and not to the forces
which govern suicide.

(*) Magnus Huss, Chronische Alknholskrankheit. Ubersetz, von G. van dem
Busch, Stockholm, 1852.—(*) J. L. Casper, Uber den Selbstmord und seiner

Digitized by VjOOQle

IRRESPONSIBILITY IN CRIMINALS.

281

1900.]

Zunakme, Berlin, 1825.—( 3 ) Lunier, quoted by Morselli.—( 4 ) Morselli, II Suicidio,
Milan, 1879.—( 5 ) Baer, Der Alkoholismus, Berlin, 1878.—(•) Wynn Westcott,
Suicide, London, 1885.—( 7 ) Ferri, Sociologie Criminelle , edit. fran9aise, Paris, 1895.
—(•) Grotjahn, Der Alkoholismus, Leipzig, 1898.—(®) Colojanni, VAlcoolismo ,
Catania, 1887.—( 10 ) Durkheim, Le Suicide, Paris, 1897.—( u ) Strahan, Suicide and
Insanity, London, 1893.—( ls ) Adolph Wagner, Die Gesetamassigheit , etc., Ham¬
burg, 1864.—( u ) Journal of the Statistical Society, 1886.—( 14 ) “ Alcoholism and
Suicidal Impulses,” Journal of Mental Science, April, 1898.—( w ) Baer, “ Einfluss
der Jahreszeit auf die Trunksucht,” Berlin, klin. Wochenschr., 1899.—( 1# ) It may
be noted that in another variety of toxic suicide, that related to pellagra, drowning
is the method almost always employed; hanging is very exceptional. (Roussel,
quoted by Ritti in article on suicide in Dictionnaire des Sciences Medicates, Paris,
1884.)—( 17 ) Maudsley, Physiology of Mind, London, 1876.

Concerning Irresponsibility in Criminals . By Charles
Mercier, M.B.Lond.

Mr. Whiteway’s paper on this subject in the last number
but one of the JOURNAL is very interesting to medical men as an
indication of the view taken by an enlightened legal mind, and
it is especially interesting to us as proving that all legal minds
are not so steeped in mediaeval notions of responsibility as some
medical men are apt to suppose. It contains, however, state¬
ments that must not be allowed to go unchallenged, and it
pushes the doctrine of irresponsibility further than I, for one,
should be prepared to follow.

The statement that it is common knowledge that recently a
general paralytic was received into an English asylum from a
prison, with the marks of a flogging still fresh upon him, is
incorrect Such an incident may have occurred, but its occur¬
rence is not common knowledge ; and if Mr. Whiteway has any
proof of the fact, the proof should have been adduced ; for,
although Mr. Whiteway seems to have a brief to fall foul of all
our arrangements for dealing with criminals, from their birth to
their final exit upon the scaffold, there are other people who, if
less interesting, are not altogether outside the pale of our
sympathies. v Prison officials are, after all, God’s creatures as
well as criminals, and a charge brought against them should be
substantiated or withdrawn.

Mr. Whiteway is of opinion that Mary Ansell should have
been excused from the consequences of her crime on the ground
that, although not herself insane, she had several insane rela-

Digitized by VjOOQle

282

IRRESPONSIBILITY IN CRIMINALS.

[April,

tives, and was a degenerate. The first of these reasons we
regard, taken by itself, as totally inadmissible. Mr. Whiteway
is probably not aware that there are very few families indeed in
which there are not, or have not been, some insane members ;
and if once the insanity of a relative or relatives is admitted as
a substantiation of the plea of irresponsibility, responsibility is
practically abolished, and all prisons must be superseded by
lunatic asylums. That this position is held by some extremists
we are aware ; but it is not held by them on this ground, and it
does not appear that it is held at all by Mr. Whiteway himself.

If we admit, as we should not be slow to admit, that the ex¬
istence of a strong family history of insanity should be taken
into account in estimating the validity of the plea of insanity,
yet we do not admit that such a consideration ought to
entirely overbear and swamp that of the circumstances of the
crime itself.

As to the plea that she was a “ degenerate ” we must suspend
our judgment, and ask Mr. Whiteway and everyone else to
suspend their judgments, until they know precisely what
44 degenerate ” means.

Mr. Whiteway says that Mary Ansell “ wanted badly
£22 10 s.y and got the idea that by sending phosphorus paste to
her imbecile sister, if her sister ate it she would get the money.”
In this we should agree with him, and we would point out that
it is for people who badly want things, and who get the idea
that they can obtain these things by crimes, and then proceed
to put the idea to the test of experience, that the whole of the
criminal laws are enacted ; and that it is to such persons that
these laws are meant to apply. Mr. Whiteway accuses us
of begging the question when we infer that, since she knew that
she would gain personal advantage by the crime, therefore she
knew that she ought not to commit the crime ; and he says that
the nature and quality of her act she did not properly evaluate; and
this statement, we suppose, is not begging the question. A little
later he admits that it is a probability only, not a certainty, that
she did not know that she was doing wrong. Now as to this,
Mr. Whiteway, as a trained and experienced lawyer, must admit
that we ought to be guided by the facts of the case. What are
these facts ? The prisoner not merely knew that she was send¬
ing the poison for the purpose of killing her sister, and that if

Digitized by

Google

1900.]

BODILY DISEASE IN INSANITY.

283

her sister died she would get the money, but she took elaborate
precautions to conceal her tracks. She obtained the poison by
telling lies. She forged a letter some time beforehand to
induce the asylum authorities to believe that the parents of
their patient were dead, and so to prevent them from send¬
ing intelligence of the death, when it should take place. She
induced her father to forbid the making of a post-mortem
examination. She planned the deed with deliberate cunning,
and carried it out with remorseless cruelty. That no criminal
should under any circumstances be punished is a position which
we find intelligible, although we cannot agree with it ; but that
if any criminals whatever ought to be punished, such a criminal
as Mary Ansell should not, is a position which we cannot even
understand, for a crime more deliberate, more heinous, more
sordid, more wilful, more abominable in any way, we do not
remember, and we have a difficulty in even imagining.

On Bodily Disease as a Cause and Complication of Insanity .
By G. J. CONFORD, B.A., M.B., B.Ch.Oxon., M.R.C.S.Eng.,
L.R.C.P.Lond., late Assistant Medical Officer to the Coppice
Hospital for the Insane, Nottingham.

The observations upon which this essay is written have been
made in the Coppice Hospital, and refer to cases admitted
between 1st August, 1859, an d 1st August, 1893, and still
surviving at the latter date, and to cases thereafter admitted
consecutively, all of which have come under the writer’s care,
being 175 in all.

Of the whole number recorded, 80 are examples of mania,
29 being males and 51 females ; 55 of melancholia, 28 of whom
are males and 27 females; 12 of chronic mania, 7 males and 5
females ; 11 of general paralysis, all males; 9 of dementia, 5
males and 4 females; 6 of acute mania, 3 of each sex; 1 of
acute delirious mania ; and 1 of idiocy.

In the cases where bodily disease has preceded the insanity
it is not contended that the latter is caused entirely, or even
chiefly, by the physical condition, but only that this has an
important influence.

Digitized by

Google

284

BODILY DISEASE IN INSANITY,

[April,

Some exception may perhaps be taken to the manner in
which the terms mania and melancholia are used, but it is in
comparatively few instances that a case of melancholia or mania
runs such a course as to be classified in the same way at different
periods of its prevalence. In practice, mania and melancholia
are merely symptomatic terms and denote no definite entity of
symptoms, except where it is specially mentioned that a patient
is a typical example of the one or the other.

The term dementia, too, is used with varying significance
by different writers, and many cases described as chronic
mania by one, would be classified as dementia by another.
In chronic mania, and indeed in most cases of insanity, there
is a considerable loss of mental power, and in proportion as
stress is laid upon this weakening will be the tendency to
classify as dementia.

I. Diseases of the Vascular System .

Among the physical causes of insanity, diseases of the
circulatory system occupy an important if not the chief place.
Several authors have found it affected in over 50 per cent, of
insane cases. Although these results are disproved by later
observers, the negative results of investigators who have en¬
deavoured to demonstrate a vaso-motor nerve supply to the brain
may to some extent form the foundation of a working hypo¬
thesis, that the supply of blood is mainly regulated by the vigour
of the heart’s action, the general arterial pressure, and the tur-
gescence or emptiness of the venous system. The brain case
being a rigid cavity, slight alterations in blood pressure are of
much greater import to the brain than to any other organ in
the body, considering its delicate structure and the grave
psychical changes which follow alterations in its cells so slight
as to be scarcely perceptible under the microscope.

The loss of consciousness consequent upon the sudden failure
of the heart’s action (syncope) is due, of course, to cerebral
anaemia. Variations in the blood pressure, therefore, will be
accompanied by a corresponding change in the manifestations
of psychical energy.

The exhilaration which follows a moderate dose of alcohol is
almost entirely due to its exciting effect upon the circulation,
although the toxic phenomena of excessive indulgence are

Digitized by VjOOQle

1900.]

BY G. J. CONFORD, B.A., M.B.

285

probably due to its direct action upon the nervous system. The
effect of reduced blood pressure, on the other hand, is manifest
in the feeling of diminished energy or depression which results
from prolonged abstinence.

In a large number of insane cases suffering from circulatory
disorders, we are tolerably certain that but for these conditions
the mental alienation would never have occurred. Heart
disease frequently and directly causes permanent irritability with
variations of gloom or boisterousness, thus completely altering
character and conduct, though not sufficiently in the absence of
neurotic predisposition to produce technical insanity.

The cases of John Hunter and Matthew Arnold, quoted
by Dr. Kiernan, of Chicago, in a paper on the “ Emotional
Instability of Heart Disease” ( 1 ) form well-known instances of
this effect.

Sir T. Lauder Brunton refers to the case of a child whose irri¬
tability was considered unaccountable until an examination of
the chest revealed extensive mitral regurgitation. The mental
symptoms depended upon venous stasis in the brain and con¬
sequent incomplete elimination of its metabolic products. Much
relief followed the administration of salicylate of sodium, which
presumably acted by increasing the solubility and so aiding the
elimination of the nitrogenous waste matters.

The mental condition in nearly all cases of chronic heart
disease approaching dissolution, is often characterised by inter¬
mittent delirium, great mental feebleness, and obstinate insomnia,
with a querulous and suspicious attitude of mind.

Among the cases under review there were nine in which there
was definite organic disease of the heart, and in at least four of
these the cardiac lesion would appear to have been the chief
cause of insanity.

1. A. M. D—, aet. 41, sister insane, was admitted on 5th May,
i860, having then been insane for five years. First attack at the
age of thirty. She was found to have mitral disease and failure of
compensation, with rapid pulse and oedema of the feet. There was
mental exaltation, with considerable variation in degree of violence
from time to time, and ultimately chronic mania. There were certain
prevalent characteristics common to patients of this class—a constant
suspicion of the motives of those about her, a querulousness, and a
fear of impending evil, markedly different from the chronic state of
misery in melancholia. She died in March, 1898, at the age of seventy-
four, from an attack of broncho-pneumonia complicating influenza

Digitized by VjOOQle

286 BODILY DISEASE IN INSANITY, [April,

2. E. G—, aet. 61, admitted 31st October, 1895, after two days*
mental illness. She had had a slight temporary attack of mania about
ten months before. On admission she was suffering from mitral incom¬
petence, the heart being considerably hypertrophied. A well-marked
systolic murmur was conducted into the axilla. Her mental symptoms
were restlessness and excitement, with suspicions of her friends, and
the delusion that people were attempting to poison her by tampering
with her food, and blowing chloroform through the keyhole of her
room at night. She was afraid to remain at home, and had taken an
unnatural dislike to relatives who lived with her. There was no
ascertainable heredity in this case. The excitement subsided, and she
is now in a state of deep dementia. Her cardiac lesion is well com¬
pensated by the administration of strychnine and digitalis.

3. E. C—, aet. 76, sister an imbecile. Admitted on 6th August,
1896, suffering from dementia of a melancholic type, with a constant
fear of impending evil or injury by those about him, shouting “ murder ”
when approached, and frequently groaning when left to himself.
Mitral incompetence and displacement of the impulse of the heart
outwards, with a soft systolic murmur conducted into the axilla. The
pulse was feeble, and 92 per minute. There was slight oedema of the
feet and legs, but no albumen in the urine. He was treated with nux
vomica and digitalis, but the symptoms persisted, with occasional
remissions and exacerbations, until his death from cardiac failure on
May 23rd, 1897.

4. M. C—, aet. 67, admitted on August 14th, 1896, suffering from
melancholia, her leading symptoms being a constant state of apprehen¬
sion of some impending calamity, the nature of which she either could
not or would not explain, and a delusion that her son was starving.
She constantly ejaculated in a wailing voice, “ I don’t know what will
be done,” and both before and after admission made several suicidal
attempts by strangling. She was found to be suffering from mitral
regurgitation, which appeared to be well compensated.

The cardiac lesion in all the above examples was the same,
and it will be seen that the mental symptoms also presented a
certain amount of similarity. I do not attach undue importance
to this correspondence in a few cases, but it is suggestive.

It cannot be justly assumed that compensation, apparently
complete so far as serous effusions, oedema, or albuminuria are
concerned, necessarily implies that the delicate cerebral cells
will not suffer from the impaired condition of the circulation.

Dr. Solfanelli ( 2 ), of Rome, published in the Archivio y 1873-4,
a series of seventeen cases of insanity with heart disease, including
examples of aortic regurgitation, aortic stenosis, mitral regurgi¬
tation, and mitral stenosis. He found no correspondence
between the form of the mental disorder and the cardiac

Digitized by VjOOQle

1900.]

BY G. J. CON FORD, B.A., M.B.

287

lesion ; nor is there any in that respect in the four examples
just mentioned—one melancholia, one dementia, one chronic
mania, and one acute mania soon resulting in dementia.
Reference may also be made to Dr. Mickle’s Goulstonian
Lectures , published in 1888.

5. E. B—, act. 50, was admitted on 3rd March, 1870, suffering from
a third attack of insanity which had lasted for several years, her first
having occurred at the age of twenty. She was violent, abusive,
blasphemous, and indecent. There was no record of cardiac or renal
disease at that time, but she was always pale and cadaverous, liable to
bronchitic attacks and occasional severe abdominal pain. For years
she was taciturn and irritable, with occasional outbreaks of abusive
excitement In December, 1897, she had a left hemiplegia with a
purely motor aphasia. She could tell the use of objects and recognise
their names when mentioned, but was usually unable to name them
herself. When attempting to speak, a rare occurrence with her, she
was frequently at a loss for a word. She was not left-handed. On
examination, mitral stenosis and incompetence were discovered. The
pulse was remarkably tense, the arteries atheromatous, and the urine
contained albumen with a few granular casts.

Previously there were no symptoms sufficient to call for a thorough
clinical examination. For fifteen months thereafter the patient was
bedridden, having been treated with strychnine, digitalis, laxatives, etc.
She had two or three intercurrent attacks of localised pneumonia, prob¬
ably mainly hypostatic in character, but remained free from bedsores in
spite of her dirty habits. Death occurred in April last.

The remarkable longevity of this case is no doubt explained
to some extent by the regulated conditions of asylum life.
There was no record of neurosis in the family history, and the
cause of insanity is doubtful, but it is probable that the heart
disease existed since youth and played an important part in
disturbing the mental balance. The case shows the necessity
for thorough periodical clinical examination of chronic patients.

6. In the case E. C—, also suffering from cardiac disease, there was
a marked family history of neurosis and phthisis, but the symptoms
presented many points of similarity to those of the four cases quoted
above.

Of the 175 cases studied there was definite organic disease
of the heart in only 10. I have examined 8 of these.
Functional disorders of the circulation (from anaemia, malnutri¬
tion, etc.) existed in 36 additional cases.

Dr. Greenlees in this JOURNAL ( s ) recorded cardiac disease as
a cause of death in 14*67 per cent, calculated on 218 successive

Digitized by VjOOQle

288 BODILY DISEASE IN INSANITY, [April,

autopsies, but was not certain whether the disease existed in all
at the time of admission.

In a table of 672 cases in which the condition of the heart
on admission was ascertained, it was stated that 13 per cent, of
the total had some definite organic disease of the heart, while
44 per cent, had functional circulatory disorders of one kind
or another. These percentages are more than double those
obtained in my series of cases, but it must be remembered that
about a third of these are the survivals of the admissions of
nearly forty years. Dr. Greenlees found that functional disorders
of the heart are more common in recent and acute cases.
There is certainly every reason to believe that derangements of
this kind are, in the great majority of instances, consequent on
rather than antecedent to the insanity ; but in all such cases
there is action and reaction, leading possibly to a vicious circle
of phenomena, in which the unduly sensitive heart, responding
too readily to a comparatively slight stimulus, occasioned an
irregularity in the cerebral blood supply, increasing the disturb¬
ance already existing in the brain, which might otherwise have
been but temporary.

Many writers find a far larger percentage of cardiac cases
among the insane than that given above ; Esquirol, for instance,
found heart disease in nearly 7 per cent, of his melancholic
cases, Calmeil and Thore in as many as 30 per cent., while
Sutherland in an analysis of forty-two post-mortem examina¬
tions found the heart diseased in thirty-four.

Dr. Wilkie Burman (Heart Disease and Insanity , 1873)
says: ‘ There is a very striking and remarkable relation
between the two diseases. It would, of course, be very rash on
these general grounds to infer that because the relation does
exist it must therefore be causal, yet that the relation has some
special significance can scarcely be doubted, and it should be
an important element to take cognizance of in any attempt to
explain the differences that exist in the local distribution of
insanity and its chief varieties throughout England and Wales.”
He also states that heart disease is a most grave complication
of insanity, 32 per cent, of the cases dying from this cause
having lived only three months or less in the asylum.

Digitized by VjOOQle

1900.]

BY G. J. CONFORD, B.A., M.B.

289

II. Diseases of the Respiratory System .

Disorders of the respiratory apparatus are invariably attended
with more or less mental disturbance, as may be expected from
the increased effort required for the necessary oxygenation of
the blood, and the diminution, slight though it be, in the amount
of oxygen supplied to the brain. Deficiency of oxygen dimin¬
ishes the vitality of the cells, and their normal functions are
imperfectly performed. Anxiety, depression, and irritability are
stamped on the sufferer from chronic bronchitis, thus resembling
the effects of mitral disease, which are to some extent dependent
upon the same cause. Among the cases under review, one in
particular appeared to have as the exciting cause of her
insanity an attack of bronchitis and pleurisy.

7. M. H—, set. 49, admitted 24th November, 1896. Had been
healthy until about a year before admission, when she had an attack
of influenza with bronchitis and pleurisy; the latter was severe in
character, and attended by considerable effusion. While recovering
she became very depressed with the delusion that she had no lungs or
backbone, etc. She was placed under care at a licensed house, whence
she was transferred after a few months to the Coppice. There were
then signs of old pleurisy with some slight contraction of both lungs;
the cardiac dulness commencing at the third costal cartilage on the
left side, and the liver dulness at the fifth rib on the right; impairment
of resonance and diminished breath-sounds for a hand’s breadth at the
base of the right lung behind, and to a less extent on the left side.
The face was congested and somewhat blue. The patient complained
of feeling very cold, and said that she was condemned to live for ever
in torment, and that her only way of escape was by being burnt alive.
The leading delusion as to the absence of lungs in this case is interest¬
ing in view of the fact that the disease commenced after a pleuritic
attack. The ideas still persist but are less constantly dwelt upon, and
the depression is not so acute.

Morphia alone or combined with iron or strychnine, iron and
strychnine, strychnine and acids, alkalies, and nux vomica, and alkaline
bromides, have all been tried without benefit. The patient sleeps well
as a rule, though she labours under the delusion that she never has an
hour’s consecutive rest. She takes her food fairly, and is considered to
be gradually though slowly improving.

8. K. F. G—, aet. 56, admitted 15th October, 1898, is a case of
interest as the attack of insanity directly followed acute lobar pneumonia.
For many years this patient had been given to great alcoholic excess,
with intervals of sobriety. In her sane condition she was lively, witty,
and good-natured. Just before admission she had an attack of lobar

Digitized by VjOOQle

290

BODILY DISEASE IN INSANITY,

[April,

pneumonia with a temperature rising on several evenings to 105°, and
this was followed by jaundice. She was sent to the seaside for
convalescence, but was badly nursed and began to refuse her food,
which was not forced upon her. On her return she was almost in a
state of inanition, and though careful nursing and medical treatment
restored the physical condition, her mind was found to have given way
when her bodily strength returned, and she was brought to the Coppice
in a state of acute mania. In spite of her physical weakness she was
very violent, and though every care was exercised she sustained two
fractures. The first, of the left middle metacarpal bone, was caused by
the patient placing her hand underneath her body to raise herself up
in bed. The second was probably produced by the patient striking her
wrist on the end of a sofa, thus sustaining a fracture of the right ulna at
its lower end. Both fractures united well under appropriate treatment,
although the bones were so remarkably brittle. About a week after
they had occurred the patient contracted a second attack of lobar
pneumonia, which ran a very unusual course.

O11 the morning of 24th October the patient was noticed to be
unwell, but there was no elevation of temperature. In the evening,
however, she began to breathe very badly, and at 11.30 the respirations
were 48 per minute, and the pulse 128, while the face was pale and
cyano^ed, with a temperature of 104*8°. There was subtubular breath¬
ing with diminished resonance over the whole of the right lung, but
there was no fracture of ribs or any sign of injury. Ten grains of
quinine were given immediately with Spir. ^theris and Spir. Ammon.
Aromat. iia itjxxx and Tinct. Digitalis njviij every four hours. A
hypodermic injection of strychnine was also given on account of the
feebleness of the pulse. On the following morning the temperature had
dropped to 101*4 , and the respirations to 36 per minute, the patient
having perspired freely during the night. The respiratory sounds had
not become tubular as was expected, but a few fine crepitations were
heard over the whole of the back of the lung, most abundantly at the
base. The temperature subsequently fluctuated between 99° and ioi°,
never rising above the latter point, and became normal on 1st November.
Abundant food in the form of milk and eggs with four ounces of brandy
daily was given during the illness, which would appear to have been an
abortive attack of pneumonia. The patient rapidly convalesced, but
was kept in bed during the four or five following weeks, as the rest was
considered good for her, and she was thus more easily controlled.

Besides the occurrence of fractures and the rapidly developed
pneumonia, there are two circumstances which deserve notice;
firstly, that the insanity commenced during a visit to the seaside,
illustrating Blandford’s remark that sea air appears to have a
particularly prejudicial effect in the early stages of mental
disease ; secondly, that it is most dangerous to allow a patient
weakened by bodily illness and showing incipient mental sym¬
ptoms to lose strength from lack of food.

Digitized by VjOOQle

igoo.]

BY G. J. CONFORD, B.A., M.B.

291

9. J. W—, set. 53, admitted 25th March, 1899, suffering from
delusional melancholia, also emphasises the last-mentioned point. He
had primary syphilis about four months before admission, with secondary
symptoms, the chancre and inguinal glands having been, removed by
operation. Remorse was followed by melancholia, with delusions that
his relatives and servants were conspiring to poison him. At home he
was allowed to get into an extremely low state of nutrition and constipa¬
tion. On arrival he struggled so violently that no proper examination
could be made; but on the following morning his temperature was ioi p ,
his pulse 140, and his respirations 42. He had been forcibly fed on
admission, and had taken liquid food afterwards from the hand of an
attendant. He still resisted all attempts at physical examination, but
grew rapidly weaker, and died about thirty-six hours after admission. A
post-mortem examination revealed early pneumonia of the lower lobe
of each lung. Strychnine and digitalis were given hypodermically every
four hours, but the heart collapsed at once, although not organically
diseased, as soon as the onset of pneumonia made demands upon its
reserve strength.

10. S. F. S—, aet. 37, admitted 18th March, 1898, suffering from
acute mania with hallucinations of sight and hearing, and obstinate
refusal of food, also showed an abnormal course of pneumonia. She
had old tubercular consolidation at the right apex, and was subject to
petit mat. Four days after admission the patient was found to be
suffering from a slight cough and a temperature of ioi°, but on the
following morning the temperature had dropped to 99°, and in the
evening it was normal. During the night, however, the breathing
became very rapid, the face cyanosed, and the temperature rose to 103*4°,
and the patient's condition appeared so serious that hypodermic injec¬
tions of strychnine (gr. -fa ) were given every six hours. On the three
following evenings the temperature rose to over 105°, but on each occa¬
sion dropped to about 103° in less than an hour after the administration of
ten grains of quinine. The latter drug was given after food through the
nasal tube, as the patient refused to take anything by the mouth; and it
is remarkable, considering the severity of the fever, that she was able
to retain the large amount given, the total for twenty-four hours being
four pints of milk, six eggs, and six ounces of brandy. Signs of con¬
solidation first appeared over the right lower lobe, and afterwards
spread to the left side, so that both lower lobes were involved; but
notwithstanding this and the feeble character of the circulation, the
patient recovered, mainly, no doubt, in consequence of the amount of
food she was able to digest. On 27th March the patient’s condition
began to improve, and she got steadily better, though nasal feeding
had to be continued for weeks. She is now very much improved both
in bodily and mental health, and is looked upon as likely to recover
completely. The case is fully reported in the * Lancet ’ for September
24th, 1898.

In the three examples of pneumonia above recorded there
was an absence of premonitory signs, which is common among

Digitized by VjOOQle

292

BODILY DISEASE IN INSANITY,

[April,

the insane. This may possibly be due to a functional change
in the innervation of the viscera, or to an imperfect expression of
sensations. The cases also illustrated the difficulty of prognosis
in regard to acute maladies affecting the insane.

n. A. L. G—, jet. 23. admitted nth September, 1897, suffering from
subacute mania. She progressed favourably until 25th October, when
she began to suffer from toothache and became restless and excited.
Three decayed stumps were extracted on 27 th October, but without any
mental improvement. She became gradually more excited. On 1st
November she was acutely maniacal, refusing food and requiring forcible
feeding. Two days later she appeared to have a slight cold, and on
4th November she was sick after having been fed through the oeso¬
phageal tube. Next day, though the temperature was normal and there
were no signs of disease in the chest, she was put to bed. At 8 p.m.
the temperature rose to 104*4°, and the pulse was rapid and feeble.
She still resisted when any attempt was made to give her food or
medicine by the mouth, and was sick when fed through the tube,
though when thirsty would take a little iced milk and soda water. She
was accordingly fed every four hours by the rectum, while strychnine
(gr. ts) an d digitalin (gr. T were given every six hours hypoder¬
mically. Signs of consolidation appeared over the lower lobe of the
right lung on 6th November, but the disease never spread beyond
this area. The patient laughed and shouted constantly, and the tem¬
perature remained high, keeping an average of about 103*5° until her
death on 10th November.

The only rest obtained was for a few hours after hypodermic
injections of morphia (gr. £), which were given two or three
times, as bromides and sulphonal appeared to have no effect
The unfavourable termination is easily understood, as the irri¬
tability of the stomach led to exhaustion.

Nourishment is imperatively required in the treatment of
most fevers, and especially among the insane, where there is an
extraordinary waste.

III. Phthisis.

The members of a phthisical stock are as a rule of a sensitive
and emotional disposition, and insanity is certainly frequent in
tubercular families. The marriage of a phthisical with a neurotic
person is properly regarded as dangerous for the offspring on
account of their great liability to become insane. Clouston*s( 4 )
work and opinions on this subject are well known.

Digitized by VjOOQle

1900.]

BY G. J. C0NF0RD, B.A., M.B.

293

12. A. B—, aet. 30, admitted 9th October, 1889. The first signs of
phthisis were discovered after an attack of haemoptysis in February,
1898. There was no evidence of hereditary neurosis, though the
mother’s family was phthisical. There were delusions of electrical
influences, constant sexual excitement, with erotic conversation, and
hallucinations of hearing. He gradually deteriorated mentally, and in
1897 was noticed to be losing flesh, but this was attributed to constant
masturbation, from which it was impossible to restrain him. His
temperature was of the hectic type, rising regularly to ioo° or ioi° in
the evening, and falling as a rule to 98° in the morning. At the same
time he began to suffer from diarrhoea, and suspicions were entertained
that his bowels were affected by tubercular ulceration, which was not
unlikely to be the case, as he absolutely refused to spit out his sputum,
and invariably swallowed it.

In August, 1898, there was evidence of disease over the whole of the
upper lobe of the right lung, and the apex of the left was also affected.
In October both lungs gave evidence of extensive disease, signs of
excavation being observed in the subclavicular region of the left lung
as well as at the apex of the right. The patient now rapidly emaciated,
and died in November, 1898.

After the discovery of his disease the patient was treated regularly
with quinine, alkalies, and vegetable bitters, maltine, and cod-liver oil.
He was originally a powerful and athletic man, and had gained distinc¬
tion in various sports, but the disease ran a rapid course. The history
of a case of this kind might lead one to believe that asylum confine¬
ment would tend to produce phthisis in those who were not originally
predisposed to it, but this does not appear to be the case if large
numbers of instances are examined.

13. J* W—, aet. 21, admitted 10th April, 1862, suffering from melan¬
cholia and gonorrhoea, may be referred to as contrasting with the last
recorded case. After contracting phthisis here, he recovered from it,
and is still under treatment after a residence of over thirty-six years.
His mother had died of phthisis in an asylum, and one sister was
insane. He had delusions as to being poisoned, was suspicious,
obstinate and silenf, and constantly masturbated. His general health
continued to be fairly good until 1890, when he had an attack of
pleurisy with effusion on the left side. The fluid continued unabsorbed
for months, and signs of tubercular disease were found at the apices of
both lungs. At the present time, however (1899) there are no signs of
active disease, though there is flattening at both apices, and the
breathing is harsh and subtubular in character, while for a hand’s
breadth at the base of the left lung behind the breath-sounds are very
faint, and there is diminution of vocal fremitus and resonance. The
heart is not displaced to any appreciable extent. For several years
this patient has been almost completely demented, and has had to be fed;
notwithstanding which he has not lost flesh. He spends the morning in
bed, and is only allowed to go out in bright warm weather.

Neither of these cases can be described as typical examples
of phthisical insanity, and no such case occurs in the series

Digitized by VjOOQle

294

BODILY DISEASE IN INSANITY,

[April,

now under review ; yet Clouston (1874—1882) diagnosed and
classified 27 percent, of the admissions at the Royal Edinburgh
Asylum as examples of this malady.

IV. Diseases of the Digestive System.

In almost every case of melancholia which comes under
treatment it is found that there is disordered digestion, which
of course may in some cases be the result of nervous depression,
but which is not uncommonly the exciting cause of the mental
malady ; the efferent impulses from the brain to the viscera
being disturbed and abnormal in character, so that the work of
secretion or specialised tissue change is not properly carried
out, while as a result of this, abnormal afferent impulses are
sent back to the nerve centres, and their regular automatic or
reflex activity is still further thrown out of gear. It is obvious
that in such cases our only hope of cure is to give as much
rest to both functions as is compatible with improved nutrition.
This, of course, may be secured by avoidance of worry or un¬
pleasant excitement of any kind, abstinence from excessive
exertion of mind or body, occupation in light amusing recrea¬
tion, and the careful medical and dietetic treatment of the
disordered digestion. In my series of cases there are twenty-
three in whom there was at the time of admission some disorder
of the digestive system such as dyspepsia, constipation, or
organic disease.

14. A. H—, aet. 54, admitted 10th December, 1896, had always been
inclined to nervousness and depression, but had been fairly healthy until
about a year before admission, when he consulted a leading surgeon
about rectal ulceration and constipation of so obstinate a character as to
give rise to the belief that he was the subject of malignant disease of the
bowel. When he was admitted here, however, the rectal ulcers had
nearly healed. He had a right scrotal hernia which was not quite com¬
pletely reducible, and which some years previously had been strangu¬
lated, but reduced by taxis without operation. His attack of insanity
dated from two months before his admission, when he became depressed
and suicidal, expressing the belief that his soul was eternally lost. On
admission he refused food, and had to be fed through the oesophageal
tube. His bowels were very costive, but at first were regulated by
means of aperients and enemata. About a month after admission he
appeared to be somewhat improved both in mind and body, but on
16th January, 1897, the constipation had become obstinate. On 21st
January he was sick after food, and seemed very weak and ill. Vomiting

Digitized by VjOOQle

1900.]

BY G. J. CONFORD, B.A., M.B.

295

continued at frequent intervals, the patient rapidly grew weaker, and he
died on the following day. The question of operation was considered,
but rejected on the ground of the patients extremely feeble condi¬
tion.

At the post-mortem examination the rectum and descending colon
were almost empty, but the ascending and part of the transverse colon
were hugely distended. The transverse colon was dragged down so as
to form a sharp angle and constriction at its centre by several adhesive
bands, which appeared to form part of the great omentum, and these
passed into the internal abdominal ring. What had happened was
obvious: when the hernia had become strangulated some years before
the omentum had passed into the inguinal canal with the bowel, and
on the reduction of the hernia had not left the canal with the bowel,
but remained there exerting traction on the transverse colon, which was
permanently fixed by inflammatory adhesions. As time went on the
continuous traction thus exerted upon the transverse colon had dragged
down the latter, causing more and more difficulty in the passage of
faeces, and ultimately ending in complete obstruction.

15. X. X—, aet. 41, admitted 4th April, 1893, transferred from a
licensed house. Her mental illness dated from the birth of a child in
December, 1891, after which she had some septic trouble, probably
pelvic peritonitis. She became very depressed, her bowels being
obstinately constipated. It was not considered necessary to place her
in an asylum, and in April, 1892, she had apparently quite recovered. In
June of the same year, however, the depression recurred with a suicidal
tendency. She stated that she had told a lie, and that in consequence
two nurses had banged her head upon the floor until she was dead.
She heard a voice constantly whispering, “Crack-pot, your brain is
gone,” and imagined that she was about to be killed by poison. She
was then placed in an asylum, and was at first noisy and excitable, but
afterwards quiet, sullen, and depressed. She frequently refused food,
and would never take medicine unless it was given her by force or
stealth, although the state of her bowels demanded the constant adminis¬
tration of aperients. She was transferred to the Coppice in a condition
of resistive, silent melancholia, and frequently required forcible feeding
with aperients. She occasionally had attacks of sickness and abdominal
pain, and once or twice these were accompanied by jaundice. After a
residence of about a year she ceased to require feeding, but still
obstinately refused medicine, and unless carefully attended to would
pass urine and faeces into her clothes or bed, though the bowels fre¬
quently refused to act even in response to large enemata containing
castor oil or turpentine.

In July, 1895, she had an attack of pneumonia, which had a rapid
and satisfactory course, the temperature being normal at the end of
eight days. After this the case went on with occasional sickness and
abdominal pain until 10th March, 1898, when she had an attack at first
supposed to be similar to those described above, but more collapsed
than usual. She was put to bed, and her bowels acted well in response
to an enema. On the following day she vomited a little bile, but re¬
tained about two pints of milk which were given her. The temperature

XLVI. 21

Digitized by VjOOQle

296 BODILY DISEASE IN INSANITY, [April,

in the axilla at 10 a.m. was reported normal. In the evening, as the
patient seemed in pain, the abdomen was examined, and considerable
tenderness and resistance were found in the right iliac fossa, and the
temperature taken in the rectum was ioo*8°. The abdomen moved
fairly with respiration, and was not distended.

On 12th March the patient was obviously much worse, the abdomen
being almost rigid and very tender, while vomiting began to occur very
shortly after feeding. Her bowels did not act, and the rectal tempera¬
ture was 100*4°. General peritonitis was diagnosed and an operation
was suggested to the friends; but as they were unwilling and the measure
was not regarded hopefully by us, the matter was not pressed. The
patient rapidly grew worse, the vomiting becoming more and more
severe, while the pain was relieved by morphia injections. The tem¬
perature remained steadily at about the same level until the patient’s
death on 14th March, at 3 a.m. A post-mortem examination was un¬
fortunately refused. The severity of the chronic constipation was
probably due to some old inflammatory adhesions about the caecum, by
which peristalsis was considerable reduced, while the occasional pain
and sickness were due at times, perhaps, to gall stones, but, as a rule,
more probably to a temporary gastric catarrh or bilious attack. Her
last illness was doubtless due to appendicitis of the malignant or per¬
forative variety, which after causing temporary local peritonitis of
insufficient duration to protect the general peritoneal cavity by adhesions,
allowed the escape of faeces into the abdominal cavity, and so caused
the general septic peritonitis of which she died.

The insanity cannot be considered to have been due to the
disorder of the bowel from which the patient suffered, as the
attack originated after the puerperium, but the relapse and
obstinate character of the subsequent disease were not im¬
probably influenced very unfavourably by the severe chronic
constipation and gastric troubles which supervened.

The depression due to chronic gastritis and dyspepsia, with
the attendant malnutrition, is but too well known to need
remark, as also is the consequent danger to a person of neurotic
predisposition.

16. E. G—, set. 30, admitted 21st September, 1896. The patient’s
brother has since become melancholic. Before marriage the patient
was healthy, except for occasional attacks of sickness and dyspepsia,
but afterwards these became worse, though she never had haematemesis.
She had a miscarriage some months after marriage, and since then has
not menstruated regularly. Subsequently to admission the catamenia
never appeared. There are no abnormal signs in the abdominal or
pelvic organs. She was never markedly anaemic, but she began to lose
flesh, and her temper and spirits suffered; she became morbidly
sensitive about the distresses of her neighbours, and occasionally hinted
at suicide. About a fortnight before admission her self-control com¬
pletely gave way; she was found one night under her bed, and refused

Digitized by VjOOQle

1900.]

BY G. J. CON FORD, B.A., M.B.

29;

to move because she was not fit to live. When dragged out by force
she resisted violently and attacked her husband and her nurse. She
also attempted to injure herself with a knife, and bit and pricked her
fingers. Shortly after her admission here she refused her food and was
frequently fed with the oesophageal tube. She stated that she was
dead, and talked in a rambling, incoherent manner. On three occa¬
sions she made half-hearted attempts at suicide: firstly, by cutting her
pharynx from the inside, the wound being very slight and inflicted
most probably by a hair-pin; secondly, by dashing her head against a
wall, using, however, so little force that no injury was done; thirdly,
by swallowing a fungus which she picked up in the garden. She was
immediately sick and sorry, and readily swallowed an emetic of zinc
sulphate, which acted quickly and efficiently. Shortly afterwards the
patient vomited a considerable quantity of blood, and for three days
her stomach rejected everything swallowed, including a mixture con¬
taining bismuth subnitrate, which accordingly had to be discontinued
while the patient was fed every four hours by the rectum. The food
given in this way consisted of 1 oz. of beef tea, one egg, 1 oz. of milk,
| oz. of brandy, 10 grs. of sodium bicarbonate, and a drachm of Liquor
Pancreaticus each time the patient was fed ; and she did not appear to
lose flesh under this treatment. On one or two occasions in.x of
Tinct. Opii were given with the food to allay the irritability of the
rectum. Four days after she had swallowed the fungus she was given
two-minim doses of Liquor Morphinae Bimeconas every two hours, and
three days after this feeding by the mouth was cautiously recommenced,
though the rectal feeding was continued for ten days longer.

On nth May, 1897 (the fungus having been swallowed on 26th
April), the rectal feeding was discontinued, and the patient was fed
entirely by the mouth, but shortly afterwards began to refuse food
altogether. From 16th May till 2nd September she was fed four times
daily through the nasal tube, gaining flesh and colour during this time, but
maintained an obstinate silence, although rarely resisting the passage of
the tube. She occasionally vomited after receiving her food, but, as a
rule, retained it well, even if given, as was sometimes the case, imme¬
diately after an aperient. Her daily quantity of nourishment consisted
of four eggs and four pints of Benger’s food and milk.

Since September, 1897, the patient has taken her food voluntarily,
having only occasionally to be fed with the nasal tube. She has had
one or two attacks of sickness, and has recently been slightly jaundiced,
but otherwise her bodily health has been fairly good. Her mental
condition is, however, in no way improved; she is obstinately silent
and idle, and apparently to a considerable extent demented. There is
little doubt that in this case the gastric trouble played a very important
part among the causes of the insanity, and it is probable that had the
digestion been carefully attended to and the patient placed under a
cheerful, well-regulated regime at the commencement of her mental
symptoms, the power of self-control would have been retained.

17. M. D—, aet. 37, admitted 24th October, 1898. There is no record
of any serious hereditary neurosis, though her father was said to have been
passionate and irritable. For several years past she has had frequent

Digitized by VjOOQle

298

BODILY DISEASE IX INSANITY,

[April,

attacks of severe dyspepsia and constipation, has contracted influenza
three times, and has been rather depressed after each attack. The last
of these occurred less than twelve months before admission, and
shortly afterwards she began to have unreasonable suspicions of her
husband’s conduct towards her, and threatened him with an action for
cruelty, refusing to live in the same house with him. She then imagined
that everyone despised her, and that she was pointed at with contempt
in the street, so that it was at length decided to place her under treat¬
ment here. On admission she was quiet and depressed, her bowels
were very costive, her tongue foul, and her breath offensive. Since
admission she has had several attacks of dyspepsia and constipation,
and is still thin, having only gained two pounds on her previous weight.
She has been treated with chiretta, soda, and nux vomica before meals,
gentian and acid after meals, and every attempt has been made to improve
her nutrition, but with very little effect. Until a patient of this class
has been got into a good state of nutrition there is little hope of curing
the mental disease, and her liability to sickness and dyspepsia render
the former a very difficult task. Her bowels are obstinately constipated,
and she needs constant aperients and enemata. The catamenia have
not appeared since admission six months ago, but there are no signs of
pregnancy. She is more cheerful and contented than on admission,
and is wary in concealing her delusions, but they sometimes appear in
spite of herself.

The obstinate constipation and dyspepsia from which this
patient suffered seem to have been the main cause of the
mental alienation, though these were further complicated by a
uterine fibroid, which caused irregularity in the time and quantity
of the catamenial flow.

Consideration of cases like the two last described suggests an
analogy with examples of pregnancy in which all these sym¬
ptoms are frequently found, and in which mental disorders are
far from uncommon. The theory of auto-intoxication by the
products of a vitiated metabolism or retained excreta through
overtaxed excretory organs may be held to explain the mental
symptoms in these cases, just as it can be applied to the ex¬
planation of the polyneuritis, eclampsia, or other nerve phe¬
nomena of pregnancy.

Turney,( 6 ) in his paper on polyneuritis in relation to gesta¬
tion and the puerperium, states that among thirteen cases of
universal polyneuritis recorded by him, mental symptoms, from
acute mania downwards, were present in six.

There must, of course, be an individual predisposition or
undue excitability for these nerve phenomena to be produced
by the causes above mentioned, and this is present to some

Digitized by VjOOQle

BY G. J. CON FORD, B.A., M.B.

1900.]

299

extent no doubt in all cases of pregnancy, while the conditions
of hereditary or congenital defect may supply it in others.

V. Glycosuria and Insanity .

Diabetes appears to be a rare condition in insanity, and
Savage, in his paper on Alternation of Neuroses (1887), said that
cases of true diabetes among his patients were almost unknown,
and Clouston agrees with him as to its rarity. On the other
hand, Hubert Bond has collected a series of cases which show
a considerable prevalence, in the London asylums at least.

Considering the depressing influence of malnutrition, en¬
forced abstinence from most of the common luxuries of the
table, irritation of the skin, and general anxiety which almost
invariably accompany diabetes, it is remarkable that insanity
as a consequence of this disease is not more common.

Of the cases under care here, only one had glycosuria to any
considerable extent, and in this it occurred as a complication of
a spreading cellulitis, which unfortunately ended fatally, and is
of sufficient interest to be described at some length.

18. Y. Y—, aet. 41, admitted 13th December, 1888. Her disease was
attributed to intemperance, and had existed for about four months
before admission. She was at first obstinately morose and silent, and
there was a history of suicidal threats and attempts at home. She
refused food, and frequently required forcible feeding. A few months
after admission she became acutely maniacal, noisy, abusive, and erotic
for about six months; settling down ultimately into a condition of
chronic mania with delusions as to her own social importance and
personal attractions, with occasional outbursts of violent abuse directed
against her fellow patients and the nurses. During the last three years,
1896—1899, she has occasionally suffered from boils about her head
and face, but her urine, which was examined during the occurrence of
one of these, showed no albumen nor sugar. She was in the habit of
rubbing her hair off one side of her head, and stated that the nurses
caused this baldness by looking at her. While suffering from boils she
would never allow them to be examined if she could by any means pre¬
vent it, and on several occasions they burst of their own accord and got
well without surgical interference of any kind.

On 16th January, 1899, a swelling was noticed on the left side of her
lower lip, and attempts were made to treat it with hot applications, but
without avail. On 19th January the left cheek was involved in the swell¬
ing, but although an incision would have been desirable at this stage in a
sane patient, her resistance was so troublesome that it was considered
advisable to wait. The patient’s bowels were being kept well open, the
face was poulticed and the poultice held on. Tine. Ferri Perchlor. v\xx

Digitized by VjOOQle

300

BODILY DISEASE IN INSANITY

[April,

with glycerine was given thrice daily. The urine was examined and
found to contain io grs. per ounce of sugar with a trace of albumen,
and she passed 80 oz. in twenty-four hours. The cellulitis continued to
spread, and the whole of the left cheek and part of the forehead and
neck were involved, the eyelids being very oedematous. Quinine gr. v
was added to each dose of the medicine. In the meantime the sugar in
the urine continued to steadily increase, and on 26th January contained
25 grs. per ounce, 70 oz. of urine being passed in twenty-four hours.
On the same day the face was incised in three places, and the whole
thickness of the cheek was found to be involved in the cellulitic swelling,
the masseter fascia being reached before any definite abscess cavity was
found. The inflammation did not subside after the incisions, and the
patient gradually became weaker and semi-comatose, the smell of acetone
being obvious in the breath. The temperature during the whole illness
never rose above 102° F., generally keeping at about 99 0 in the morn¬
ing, and rising to a little above ioo° in the evening. There were no
signs of disease in the heart and lungs, and the pulse was very good
until the last three days of the illness. On 28th January the patient
became completely comatose, and died on the morning of 29th January
at 6 a.m. The rapidly increasing glycosuria of this case is certainly
unusual, and I do not remember seeing a similar instance in other
cases of cellulitis,in which I have examined the urine, but Dr. Hand-
ford states that he has not uncommonly seen glycosuria during the
occurrence of carbuncles, which has disappeared after the local disease
has been cured.

19. E. M—, set. 57, admitted 2nd May, 1898, suffering from melan¬
cholia with delusions of a conspiracy to poison him. He had sugar in
his urine to the amount of about 2 grs. per ounce, and this rapidly
increased in quantity, being present to the extent of 6 grs. per ounce on
19th May. He was given codeia, gr. £, with citric acid and Tinct.
Nucis Vom. twice daily, the sugar dropping to half its previous quantity.
The urine was not increased in quantity, and averaged about 30 oz. per
day. Notwithstanding this, however, he continued to lose flesh, and on
13th August he weighed only 10 st. 6 lbs., having lost 17 lbs. since his
admission. We have since come to the conclusion that his habit of
frequently masturbating, as well as his chronic state of anxiety, was the
cause of his loss in weight, for the following reason :—During September,
1898, he made a successful attempt to escape, and walked a distance
of forty miles. For some time after this he appeared to have resigned
himself to the inevitable, was comparatively calm and cheerful, and dis¬
continued his previous bad habit. He gained flesh, and the urine,
except for a mere trace, *8 gr. per ounce, became free from sugar. He
has now, after the lapse of some months, begun to show a renewal of
his former bad habit, anxiety and restlessness, and the sugar has
increased to 3 grs. per ounce of urine. This increase of glycosuria
coincidently with the excitement of anxiety and masturbation is an
interesting fact, of which he is the only instance that has come under
my notice. His mental state varies very much from time to time, being
occasionally moderately hopeful, and at others anxious, restless, intensely
depressed and lachrymose; and although he is better than when admitted,

Digitized by VjOOQle

BY G. J. CONFORD, B.A., M.B.

1900.]

301

it is obvious that his old suspicions and delusions have not dis¬
appeared.

20. J. H. D—, admitted 12th December, 1897, showed constant
slight glycosuria of about two 2 grs. per ounce, which, as it caused no
unpleasant symptoms, appeared to require no treatment beyond slight
modification of the diet. The patient, who was acutely melancholic
and demented on admission, recovered completely, and gained more
than a stone in weight, but the sugar in his urine remained practically
constant in quantity during the eight months of his residence at the
Coppice. In this case there was a history of insanity and diabetes in
his mother’s family.

Conclusions .

The foregoing cases constitute illustrations of the important
modifying influences exercised by mental and bodily diseases
upon each other. While bodily illness is assigned as the cause
of insanity, or at any rate as the sole cause, in comparatively
few instances, there are in a large number of instances well-
marked histories of chronic visceral maladies which had under¬
mined the vitality and diminished self-control. The depressing
influence of slight illnesses among the sane is but too well
known to need remark, and affords indication of what the
corresponding effect must be in persons whose will power and
judgment are inherently weak. Treatment must therefore
proceed in view of these considerations. It is in the beginning
of mental illness and before pronounced symptoms of insanity
have declared themselves, that care is necessary. Nothing is
more detrimental than conditions of malnutrition, and drugs are
of the greatest value when used to counteract some physical
evil which is undermining the general health.

In examining the causes of insanity we find that intemperance
in the use of alcohol is among the most frequently assigned
reasons for the attack, and unfortunately the prognosis in cases
of this kind is very bad. This might be expected from the
chronic congestion of the brain and the deterioration of its cells
which the long-continued abuse of alcohol invariably pro¬
duces ; but other physical evils follow in the train of alcoholic
excess, and play their part in preventing a favourable result.
The liver, so important in nitrogenous metabolism, and the
kidneys, which excrete the nitrogenous waste products, are
invariably affected by the poisonous influence of alcoholic excess ;

Digitized by VjOOQle

302

BODILY DISEASE IN INSANITY,

[April,

and in cases where this condition prevails, a state of auto¬
intoxication by perverted or retained metabolic products
necessarily becomes more or less chronic, and thus presents an
almost insuperable obstacle to successful treatment.

Among the twenty-nine cases in which intemperance is
mentioned as a cause of the attack, four recovered, one
was discharged unimproved, five died, and nineteen still
remain under treatment, only two of whom show any sen¬
sible improvement Of the other assigned causes, those
most frequently mentioned are hereditary predisposition,
business anxiety and pecuniary trouble, domestic trouble and
overwork. Business anxiety, of course, occurs most frequently
among the males, and domestic trouble among the female cases,
the latter holding a much higher place in the list than the
physiological epochs of childbirth and the menopause. The
assigned cause, however, is only one, and frequently not the
most important, of many existing causes all of which play their
part in disturbing the mental balance and lessening the power
of self-control.

The average age of the male patients when first attacked
was 38 years, and of the females 40’5. It may be noticed
that among the thirty-three chronic male cases which survive
from the admissions of thirty-four years all but seven are single
men and of these seven two are widowers. If any significance can
be attached to this fact, in view of the early disability of many
cases, it would tend to show that the unmarried state is less
favourable than the married to the mental health of those pre¬
disposed to neurosis, for the longevity of these patients appears
to justify the inference that their physical condition did not
per se account for their insanity, and moreover their proportion
is far in excess of that in the consecutive cases, who, it will be
seen, much more frequently succumb to some physical ailment
or are discharged recovered. Thus, of the chronic survivals
from 1859 to 1893, 7** per cent, were single men, 157 per
cent, married, and 67 percent, widowers ; while of the fifty-two
cases subsequently admitted only 16, or 30 per cent., were
single men, thirty, or 59 per cent., were married, and six, or
11 per cent., were widowers.

In the female cases the contrast is much less marked. Thus,
of the chronic survivals 60 per cent, were single, 23*3 were
married, and 16*6 widows ; while of the consecutive admissions

Digitized by VjOOQle

1900 .] BY G. J. CONFORD, B.A., M.B. 303

61 *6 per cent, were single, 30 per cent, were married, and 8*3
per cent, were widows.

As regards the incidence of bodily disease in the cases under
care, we find that only thirty-nine, or 22*34 per cent., were
returned as physically healthy, while in 134, or 77*66 per cent.,
there was some organic disease or abnormal physical condition
which occurred either antecedently to or as a complication of
the mental malady.

In ten instances there was organic disease of the heart, and
in twenty some functional disorder of the circulation. In
seventeen there was emaciation or weakness from malnutrition,
in seventeen constipation, in eight dyspepsia, in seven bronchitis,
in five phthisis, in two asthma, in two emphysema, and in one
malignant disease of the lung.

Chronic renal disease was present in six cases, glycosuria in
four, hemiplegia in four, old infantile paralysis in three, neu¬
ralgia in three, and epilepsy in three. In connection with this
last, however, it may be remarked that epileptic cases were
generally refused admission on account of their annoyance to
the other patients, so that their proportion is far smaller than
would be found in the total insane population. Uterine com¬
plaints such as menorrhagia, etc., were found in eleven cases,
and puerperal complications in three. Syphilis was definitely
ascertained to be present in only four of the cases, but it is
probable that it really existed in a far larger number.

Myxoedema caused a relapse in one instance, and gouty
meningitis appears to have been the sole cause of insanity in
another. A few examples give evidence of feeble circulation
by the presence of varicose veins, haemorrhoids, etc.

How far these various bodily diseases caused the mental
alienation it is impossible to say, but it is certain that in a con¬
siderable number they exercised a most unfavourable influence.
In insanity, as stated by Maudsley,( 7 ) “ It happens that the
morbid state of some internal organ becomes the basis of a
painful but formless feeling of profound depression which after¬
wards condenses into some definite delusion.” The truth of
this statement is proved by numbers of examples if their
physical and mental symptoms are compared. Thus we find,
as in the case of M. H—, that an attack of pleurisy may leave
traces giving rise to uneasy sensations, which lead to the de¬
lusion that the lungs are absent. The disordered state of the

Digitized by VjOOQle

304

BODILY DISEASE IN INSANITY,

[April,

stomach and liver in the alcoholic dyspeptic may become the
basis of the delusion that he is being poisoned, or that he has
lost his abdominal viscera ; the depression and suspicion which
not infrequently accompany deafness may develop into delusions
of conspiracy and persecution, while in some patients the
coenaesthesia or state of individual consciousness resulting from
the sum of the various sensory impressions may be so modified
as to lead to belief in a change of personality.

Of the part played by bodily illness as a complication of
insanity a considerable number of illustrations have been given.
The onset of acute diseases may be masked by the mental
symptoms or the abnormal nervous conditions which prevail in
insanity. Their course may be variable, and the symptoms
of the patient liable to mislead, so that prognosis is more
difficult.

J. A—, apparently in robust health, was seized with bronchitis—
probably a complication of influenza—on 30th March, and, notwith¬
standing every effort made to alleviate his condition and maintain his
strength, died on 4th April, 1899, after an illness of five days.

J. A— had appeared perfectly healthy until 5th April, when he was
found to be suffering from influenza, the first symptom being an attack
of syncope. The chest was carefully examined and no signs of cardiac
or pulmonary disease were found, so that the condition of the patient
was not regarded with anxiety. On ihe night of 7th April he was
seized with pleurisy of the left side, the pain and friction sounds being
most marked over the base of the lung and cardiac area, though no
signs of pericarditis could be detected. On the following day there
was slight effusion into the left pleural cavity, not sufficient, however, to
account for the weakness and irregularity of the pulse, which now
became very marked, while the pleural friction-sounds were still audible
over the cardiac area. Injections of morphia and strychnine (gr. £ and
aV, respectively) were given to alleviate the pain and stimulate the
heart, and local applications were also employed, but with only slight
and temporary relief. The patient died on the following morning—9th
April.

The frequency of phthisis or rather of tubercular lesions in
the insane has been already alluded to, the first evidence of
even extensive disease being not uncommonly found in the
post-mortem room. The case of M. E— affords a further
example both of the latency and rapidly fatal effect of phthisis
during general paralysis.

This patient was admitted with the mental symptoms of the latter
disease, but in robust bodily health, in May, 1898. His thoracic and

Digitized by VjOOQle

i goo.]

BY G. J. CONFORD, B.A., M.B.

305

abdominal viscera showed no signs of disease. His nutrition appeared
to be quite good until February, 1899, when he was noticed to be
losing flesh ; but as he had no cough or any other symptom of purely
physical disease, the loss of flesh was attributed to his constant restless¬
ness.

On 10th April the patient’s chest was examined, and he was found to
be the subject of extensive phthisical disease, although he had never
suffered from any symptom to draw attention to the condition of his
lungs. He was found to be intensely emaciated, and died on 14th
April, 1899.

The number of recorded deaths among the above cases is too
small for the induction of any trustworthy conclusions, but it is a
somewhat remarkable fact that 9 out of a total of 26 were due
to inflammation of the lungs and bronchi. Of the others, general
paralysis was the cause of death in 5, cerebral haemorrhage in 2>
cardiac disease in 2,(?) pulmonary embolism in 1, phthisis in 2 >
pleurisy in 1, appendicitis in 1, intestinal obstruction in i>
exhaustion from mania in 1, and senile decay in 1.

In considering the part played by bodily disease in causing
insanity, it must not be forgotten that in every case where
mental alienation occurs there is some individual predisposition*
and this in by far the greater number is accounted for by
hereditary influence, a factor which is present, no doubt, much
more frequently than can be definitely ascertained.

In the whole number of cases under consideration there
were 44 males and 49 females with evidence of neurosis
in the family history, making a total percentage of 53*14.
In 15 members of each sex, i. e. in 17*14 per cent, of the
whole number, there was insanity in previous generations.
In 13 males and 17 females, 17*14 per cent., there were
other instances of insanity—brothers, sisters, or cousins,—
in the same generation. In 4 males and 6 females, 5*714
per cent., there was insanity both in the previous and in
other members of the same generation. In 11 instances of
both females and males, or 18*28 per cent., there was a family
history of neurosis or intemperance without actual insanity,
while in 4 males and 3 females there was a family history of
phthisis.

In 41 members of each sex, or 46*86 per cent., there was no
ascertainable hereditary influence, though without doubt it was,
in many of these, intentionally or unintentionally concealed.
How the neurotic taint originates it is difficult to say, but once

Digitized by

Google

306

BODILY DISEASE IN INSANITY.

[April,

having arisen it is certainly fostered by the intermarriage of
members of neurotic families, and anything which throws undue
strain upon the nervous centres, such as over-fatigue of mind
and body, emotional strain, or the habitual abuse of stimulants,
will tax the individual capital of nervous energy beyond those
safe limits of which the sensations of healthy fatigue are an
index.

Physical disease, by impairing the healthy action of the
various organs, puts a greater strain upon the nerve centres
which regulate organic activity, and may thus prove the starting
point of a mental defect which only disappears with the exter¬
mination of the stock in which it has arisen. How far the
mental symptoms of the individual are determined by his
bodily illness is a matter of great uncertainty, but there is
probably no organic disease without its accompanying psychical
changes, though these will vary with the susceptibility of the
patient.

Some brains are much more sensitive than others and
respond with greater readiness to afferent impulses, so that a
whole series of psychic changes may result from that which in
more phlegmatic subjects would be followed by a mere reflex
or some slight subconscious mental phenomena. Considerations
of this kind suggest many subtle ways in which mental and
bodily disease can affect each other, but their discussion belongs
rather to the domain of physiological psychology, and scarcely
•comes within the scope of an essay which is merely concerned
with the practical points of mental and physical relationships.

( x ) See Journ. of Mental Science , vol. xxxvi p. 560. —( a ) See Journ. of Mental
Science , vol. xxi.—( 3 ) “A Contribution to the Study of the Circulatory System in
the Insane,” by T. Duncan Greenlees, M.B., Edinburgh, Journ. of Mental Science ,
vol. xxxi.—( 4 ) Dr. T. S. Clouston, “The Connection between Tuberculosis and
Insanity,” Journ. of Mental Science , 1863 et seq. —( s ) “ Polyneuritis in Relation to
Gestation and the Puerperium,” by H. G. Turney, M.D.Oxon., St. Thomas's Hos¬
pital Reports, vol. xxv.—(•) “ Alternation of Neuroses,” G. H. Savage, Journ. of
Mental Science , Jan., 1887.—( T ) Maudsley, “ Physiology and Pathology of Mind,”
London, 1867.

[The elaborate tables prepared by Dr. Conford in connection with this article
have been presented to the Library of the Association.— Ed.]

Digitized by VjOOQle

1900.]

CLINICAL NOTES AND CASES.

307

Clinical Notes and Cases.

A Case of Syphilitic Insanity . By R. D. Hotchkis, M.D.,.

Assistant Medical Officer, Glasgow Royal Asylum.

The following case is one in which insanity supervened
after an operation for a tertiary syphilitic lesion, followed by
recovery ; then cerebral haemorrhage a year later producing a
second attack.

R. M. B—, jet. 52, widower, a clerk, admitted to the Glasgow
Royal Asylum on July 19th, 1897.

History .—He was admitted into the Western Infirmary on June 2nd,.
1897, suffering from extensive cario-necrosis of the left tibia, which was
chronic in its onset and course, and had been operated on some seven
times. He admits having had gonorrhoea thirty years ago, and this was
followed by some symptoms pointing to syphilis; otherwise he has
been healthy. There is no hereditary predisposition. On June 8th
the tibia was extensively opened by Dr. Macewen, and found to be
much eburnated and thickened, and with necrotic scales in the interior.
Mental symptoms came on shortly afterwards, and he was transferred
here.

State on admission .—He is a stout man in good muscular condition,
but very pale and sallow, suggestive of cachexia from syphilis or other
organic disease. The only other physical sign is a greatly thickened
left tibia with a discharging wound.

His chief mental symptoms are defective memory, incoherence, and
delusions of suspicion. He also has hallucinations and illusions of
sight, e. g. sees pictures floating before him, and thinks that everything
has a dirty blue tint. Occasionally he is noisy, and seems to fear
injury from those about him.

The acuteness of the above symptoms passed away after a few days,
but he remained in a confused and somewhat variable state of mind for
some months. His memory continued very defective, and he often
made foolish and irrelevant remarks, e. g. gravely said one day that he
had had three children bom within two months of one another. In
addition he was often despondent, and had little self-reliance, asking
guidance in everything. At first he slept badly, but afterwards both
slept and took his food well.

On August 27th Dr. Dalziel removed nearly the whole of the left
tibia, which was of ivory hardness and whiteness. The patient took
the chloroform badly, but his mental condition after the operation was
quite unaffected.

October 13th.—There were no complications after the operation,
and now the wound is nearly closed, and is looking healthy. Mentally
his condition is one of slight depression, facility, and weak-mindedness.

Digitized by VjOOQle

308

CLINICAL NOTES AND CASES.

[April,

He is getting mercury and potassium iodide. By the end of the year
the wound had closed, but his mental condition showed no change.
He remained for nine months longer in the asylum, during which time
his bodily health steadily improved, and latterly he was able to walk with
the aid of two sticks. His mental symptoms slowly disappeared; he
became bright and cheerful, more self-reliant, and though he never
became quite as well as formerly he improved sufficiently to be dis¬
charged as recovered on October 7 th, 1898.

He kept well for a little over a year, when he had an attack of
cerebral haemorrhage producing right hemiplegia, and he was taken to
the Victoria Infirmary. Mental symptoms soon developed,—inco¬
herence, excitement with much noise and violence, defective memory,
so that he was readmitted here on January 26th, 1900.

State on admission .—He is hemiplegic (right) and partially aphasic,
but seems to understand what is said to him. He is also subject to
recurrent attacks of excitement, in which he speaks much more dis¬
tinctly ; but his vocabulary consists chiefly of abusive and profane
words, and he would readily strike if he got the chance. His left leg
remains healed, and before this attack he could walk fairly well.

Up to the present date, March 2nd, his condition is slowly im¬
proving ; he can speak much better, and has some power in his right
arm and leg. His attacks of excitement are less in number and not so
acute, but there is left considerable mental weakening, with very defec¬
tive memory. The probability is that these latter symptoms will be
permanent.

Remarks .—The effects of the syphilitic poison on the nervous
system are well known, the chief characteristic being its univer¬
sality. Any nerve may be affected, also some tracts of the
spinal cord, and the brain with its surrounding membranes and
bone. In fact, if there be irregular paralysis, especially in the
cranial nerves, not pointing to one definite lesion, the cause is
most probably syphilitic. The subject of syphilis as a cause of
insanity is a complex and obscure one, and this is best shown
by the diversity of opinion among authors, who vary much in
their descriptions. Diverse mental symptoms are produced not
only by syphilis, but by other poisons, e. g. alcohol, and the
modus opcrandi has not yet been fully solved. The influence
of the syphilitic poison in the present case seems to be fully if
not absolutely paramount. It might be claimed to be post¬
operative insanity ; but the symptoms are different, and a much
severer operation was performed in the asylum with no mental
effect. Further, the cerebral haemorrhage two years later
points strongly to syphilitic disease of the arteries, and it is
instructive to note the brain instability in a man whose con¬
stitution is undermined through syphilis. There was no other

Digitized by VjOOQle

1900.]

CLINICAL NOTES AND CASES.

309

apparent cause—no hereditary predisposition and no alcoholic
excess, but he had been a hard-working, fairly intelligent clerk
in a large warehouse. Though he was discharged recovered
on the first occasion, he never seemed quite to get back his
former mental tone or energy, and took things very easily
afterwards. The prognosis now is much graver, for even if he
survive the present shock he will always be liable to other
haemorrhagic attacks, and the mental enfeeblement, which was a
symptom in his former attack, is now very marked and will be
permanent. There are described several forms of syphilitic
insanity, and this one corresponds, though not in every respect,
to the delusional form found in the third stage of the disease,
and in these cases the delusions are so various that they have
no common features except that of suspicion. The treatment
adopted was of the usual antisyphilitic kind, but whether the
improvement on the first occasion was due to that or not is a
matter of doubt.

A Case of Remarkable Chloral Idiosyncrasy . By Arthur
W. Wilcox, M.B., C.M.(Edin.), Senior Assistant Medical
Officer, Warwick County Asylum.

A female patient, A. H—, unmarried, set. 44 years, was admitted to
the Warwick County Asylum on 18th August, 1899. She was a pale
and somewhat anaemic woman, suffering from acute mania. She was
stated to be not suicidal, epileptic, nor dangerous to others. There was
no family history of insanity nor phthisis. On admission she was ex¬
cited and delusional, and appeared frightened, thinking that people
wished to injure her. She mistook the identity of those around her, and
shouted murder when anyone approached her. On the following day
she was no calmer, so a sedative mixture containing Pot. Bromid. gr.
30, Tr. Valerian. Am. 1^15, Chi. Hyd. gr. 10 three times a day was pre¬
scribed. There was no material change in the patient’s condition,
mental or bodily, during the next three weeks.

On September 12th she was noticed to be covered with a scarlatinal
rash, particularly marked on the face, chest, and forearms, but present
all over her body. Her face was swollen and her eyelids oedematous,
while the glands of her neck were enlarged and tender to the touch.
She complained of sore throat, and her tongue was somewhat white.
Her temperature was found to be 104° and her pulse 100 per minute.
Mentally she was irritable and fretful, but could converse fairly rationally

As at the time we had a patient suffering from scarlatina (in whose

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

310

[April,

case a clear history of infection had been made out) this fever was dia¬
gnosed, and patient accordingly isolated.

On the next morning her temperature was 103°, rising to 104*8° in
the evening. On the third morning after the appearance of the rash it
was again 103°, rising to 104*2° on the evening of the same day. On
the fourth morning it was 101*2°, and 102*4° in the evening. The
temperature then began to fall gradually, showing slight evening rises
and morning remissions until it became normal on the eleventh day after
the appearance of the rash. There were no complications, and the urine
at no time contained any albumen. Mentally patient was simple and
childish in her manner, irritable, querulous and exacting, and often mis¬
took the identity of those near her. The sedative medicine was discon¬
tinued on the first day of the appearance of the rash. She was isolated
for two months. She desquamated very freely, the skin leaving her
hands in a glove-like manner, and pieces an inch long peeling from the
soles of her feet; her body giving off a shower of epidermic scales on
any movement.

Patient continued quiet, tractable, and well conducted (but still
delusional) until 2nd January, 1900. On the evening of that clay I saw
the patient about 6 p.m. She was then sitting before the fire quietly
sewing. At 12 p.m. I was called to visit her, and found her being held
down in bed by three nurses. She had become acutely maniacal and
actively suicidal. She was struggling and shouting, had tried to strangle
herself, and was endeavouring to dash her head against the wall. It
was necessary to remove her to another part of the asylum and place
her in a padded room with a special nurse to watch her to prevent her
from injuring herself. It required the services of four nurses to remove
her, and of several more to undress her, as she was very resistive and
fought and bit in a determined manner. She was given v\ v of a £ per
cent, solution of hydrobromate of hyoscine without benefit, as she was
very violent and noisy, and made many attempts to injure herself during
the rest of the night. The next day she was quieter, but informed me
that she could not control herself, and did not know what she might do
next. She was given a mixture containing Pot. Bromid. gr. 30, Chi.
Hyd. gr. 10, of which she had two doses only. On the followir^-
morning, 4th January, she was found to be covered with a red rash,
markedly scarlatinal in character. Her eyelids and ears w ere cedematous,
and her tongue was covered with a slight white fur. Her temperature
was 102*4° and her pulse rate 85 per minute. She conversed rationally
and complained of great thirst, slight sore throat, and intense headache.
Her urine was loaded with urates, but no albumen was present. The
next day the rash was even more pronounced, particularly on the face,
which w*as somewhat swollen and oedematous. Her tongue had assumed
a strawberry-like appearance, and she complained of difficulty in
swallowing and severe sore throat, which on examination w r as found to
be much congested. Her temperature was 103° and her pulse 85. On
6th January her temperature fell to 100° and her pulse to 80. The rash was
less marked, and her tongue comparatively clean. On January 7th her
temperature became normal, and she was allowed to leave her bed on the
16th, having desquamated slightly about the face and chest. Two days

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

1900 .]

311

later her hands and feet were peeling freely, some of the flakes of skin
being one eighth of an inch in length. She still complained of only being
able to control her actions by the greatest effort of her will. On February
2nd her mental condition required that a sedative should again be ad¬
ministered, and she was given one dose of a mixture similar to the last,
e.g. containing Pot. Bromid. gr. 30, Chi. Hyd. gr. 10. About seven
hours afterwards the nurse who had charge of her case (and who had
been told to watch carefully for such a possibility) reported that she was
again covered with a red rash, and her temperature was found to have
risen to 101*4°. The following morning her temperature was still the
same, and continued so until the medicine was discontinued on Febru¬
ary 5 th, when it again fell to normal. On this occasion patient had not
become acutely maniacal, but complained of great nervousness and a
fear that she should be unable to control herself.

A week later she was given a draught containing v\ 15 of Tinct.
Valerian. Am., and a few days later one containing Pot. Br. gr. 30 with¬
out any abnormal therapeutical effect. After a few days a draught
containing Chi. Hyd. gr. 5 was administered. This caused marked
flushing of the face and irritation of the skin of the whole body within a
few hours. The temperature remained normal. The tongue also
became rapidly covered with a white fur. The patient became more
irritable and peevish, and asked that the medicine might be discontinued,
as she could feel that it did not suit her.

This case, I think, presents several points of interest.
Various writers have described a scarlatina-like rash, with con¬
siderable irritation of the skin, and followed by desquamation,
after large doses of this drug, or when administered for a long
time. Dr. Garrod thinks that the rash more often resembles
that of urticaria.

Dr. Fowler states that albumen may be found to be present
in the urine, which occurring in a patient with signs and sym¬
ptoms like these described in this case would make yet another
difficulty in arriving at a diagnosis.

A rise of temperature is, I think, quite exceptional, as Chi.
Hyd. has been found, both by experiments on animals and in
practice, to lower the heat of the body.

It will be noted that on one occasion a single dose of 10 gr.
caused a rise of temperature of 3 0 within a few hours.

The glandular enlargement, oedema of the face, sore throat,
and the rapidity with which the tongue became furred are also
worthy of remark.

It has been observed in the case of sane persons who have
contracted the chloral habit and indulged it for any length of
time that they become irritable, peevish, and querulous. A

XLVI. 2 2

Digitized by VjOOQle

OCCASIONAL NOTES.

312

[April,

single dose of 5 gr. was sufficient in this case to produce these
symptoms to a marked degree.

Occasional Notes.

The Lunacy Bill .

The Lunacy Bill of 1900 has passed through the House of
Lords, and it may be that it will become law in the course of
this session. The Bill has been so fully discussed in previous
numbers of this JOURNAL that we need not revert to provisions
which now reappear unchanged, or to points of comparatively
little importance.

There are, however, certain clauses which cannot meet with
our approval, and certain notable omissions which we must
deeply regret.

First, with regard to the reduction of the valid duration of
urgency orders from seven to four days. Experience has
shown that this will be attended by difficulties and dangers
which will not fail to leave their mark, unless there is a con¬
comitant alteration in the powers of the Justices. Of course it
is well known that the emergency certificate in Scotland is
limited in operation to three days, but the circumstances are
altogether different from those which have to be considered in
England. The sheriff of a county or his substitutes are always
accessible through the sheriff clerk’s office, which is open for the
transaction of business every lawful day. Dr. Percy Smith and
others have graphically described the difficulties of finding a quali¬
fied Justice, when circumstances of urgency required orders for
the detention of insane persons within the narrow limits of time
available. No one has been found to say a word in vindication
of a system which imposes such delays and distractions in view
of dangers to insane persons and to £he lieges. The experi¬
ence of those placed in responsible positions should be con¬
sidered, and their condemnation of this hazardous proposal
should have due weight in the House of Commons. It should
be plainly stated that the present duration of the urgency order

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

313

sometimes barely suffices to obtain the permanent order, and
the failure to obtain that order means the release of the patient
however dangerous he may be—unless it be made an affair of
police, which cannot be too strongly deprecated. Ireland has
suffered in this way, and has made its well-grounded complaint
times without number. This is, indeed, a proposal which may
in any case be a source of possible pain and needless worry to
the relatives of insane persons. The curious point is, that after
all the talk of illegal detention to which we have been treated,
it is almost impossible to get the friends of patients to under¬
stand that the law must be observed in detail; and it is only
when the rigors of legal procedure are brought home to
individuals that they begin to realise what has been imposed
upon them.

This further restriction on the medical treatment of the
insane, it has been said, has been found necessary because the
present law has been abused. But no details have reached the
public ear. Surely the difference between seven days and four
days can have no effect in the prevention of possible wrong¬
doing. Why four days ? Why not one day ? For by thus
minimising the duration of villainy, the girl’s excuse for the
production of her illegitimate infant would be proportionally
lessened—it would be such a very small one! If the pro¬
cedure is right in principle, then it should be of sufficient
duration to be effective. In reducing the time the principle
remains, whether right or wrong, but the procedure is rendered
ineffective. We trust that our Parliamentary Committee will
not fail to make adequate representations to the medical
members of the House of Commons in regard to this important
alteration in the law. Either the present procedure should
remain unaltered, or the permanent order should be obtainable
without delay and inconvenience.

For the first time in its history the Bill has been introduced
without clauses ensuring the granting of pensions to officials in
pauper asylums. This omission has been very fully considered by
the Parliamentary Committee of the Association, and we may
safely leave it to them to press for a substantial measure of
justice. We are all aware of the vast amount of work which
has been done by Dr. Hayes Newington as chairman of that
Committee, and it is now late in the day to press upon our
colleagues the importance of fully informing their representatives

Digitized by

Google

314

OCCASIONAL NOTES.

[April,

in the House of Commons in regard to the actual state of
matters, and the urgent need for a compulsory system of
assured pensions. The literature of the subject is now so
voluminous that every conceivable argument has been brought
into play. On the one hand, we have heard how the West
Riding asylums have been deprived of pensions in consideration
of an increase in pay—an increase totally inadequate to make
provision for old age. On the other hand we have heard how
other similar services have been dealt with, and equal claims on
consideration made for asylum officials. We cannot but feel,
let the result be what it may, that the Parliamentary Committee
has done its best throughout this protracted struggle.

Turning to more satisfactory phases, we are glad to observe
that the clauses relating to the private care of cases of incipient
insanity have been retained, and that a new clause for the
establishment of pathological laboratories has been inserted.
This last alteration will give an impetus to the plans formulated
by certain medical superintendents in the Midlands, and will,
we trust, remove the last obstacle to the fruition of their
hopes.

A clause, which is more important from a political than from
a scientific point of view, has been added to give power to a
local authority to appoint not more than one third of the
visiting committee of its asylums from persons not members of
the local authority. It is by no means clear how such a pro¬
vision was thought to be necessary, and it is unlikely that the
House of Commons will pass a clause so directly antagonistic
to the system of local government built up of late years.

It may be, indeed, that the introduction of such contentious
matter will affect the fortunes of the Bill, and that we shall yet
see it re-introduced in coming years. At any rate, the dis¬
cussion sure to be awakened by this clause may incite to a
fuller consideration of the whole measure than it might other¬
wise have had.

Laboratory of the Scottish Asylums .

The third annual report of the Pathologist has been pub¬
lished. It relates to the year 1899, and gives evidence of a
success which has been well deserved by the indefatigable

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

3 1 5

industry of Dr. Ford Robertson. He states that nine
gentlemen have been given a laboratory course of instruction.
Four were assistant medical officers of the associated asylums,
two were from English asylums, and three were not officially
connected with such institutions. After a reference to the
library which is being gradually formed, Dr. Ford Robertson
goes on to show what reports have been made and consultations
given ; work accomplished, in progress, and contemplated. He
enters fully into a consideration of the aims and methods
adopted at the Laboratory. We hope that this Report will be
widely circulated, as it cannot but be most helpful to those con¬
templating development of pathological work and scientific
research.

The experience gained at the Laboratory of the Scottish
Asylums is not of merely parochial importance. It has
demonstrated that a practical scheme has been worked out at
inconsiderable cost to the institutions. It has afforded a
reasonably remunerative position to a physician engaged in
research. It has given an impetus to scientific work, aid to
scattered observers, and has already done much to remove the
opprobrium of the loss of important material to psychological
medicine. While fully recognising the pioneer work done at
Wakefield and other large asylums, we cannot but commend
this firmly established, amply justified institution as an example
to other districts. The tedious and delicate processes of modern
pathology require the uninterrupted attention of men skilled in
observation and research. No doubt the greater asylums may
and do command the services of competent pathologists, and
provide them with the necessary apparatus ; but the smaller
asylums should combine to obtain similar advantages. If the
Lunacy Bill becomes law, and is not shorn of the recently
introduced clause which will remove the only real difficulty, we
shall expect to see several pathological laboratories founded in
England at no distant date. We would fain hope that patho¬
logy will not be the only subject of study in these institutions,
but that allied sciences will have equal attention. In a recent
volume of this JOURNAL Dr. Van Gieson put forth an irre¬
sistible plea for this wider scope of research as the foundation
of a newer psychiatry, and Dr. Ford Robertson endorses his
arguments. It is, indeed, on such a foundation only that the
art of healing can be perfected.

Digitized by

Google

OCCASIONAL NOTES.

[April,

316

The Metropolitan Asylums Board and its Medical Officers .

A letter in the British Medical Journal of January 13th,
1900, is well worthy the perusal of all members of the profes¬
sion who might think of taking service in these asylums.

The writer, a former assistant medical officer, points out that
the assistant medical officers are classed by this Board with the
kitchenmaids, laundrymaids, etc., as subordinate, to distinguish
them from the principal officers, viz. the matron, steward, etc.
The kitchenmaids, he asserts, are better lodged, he (and his
successor) having to use his bedroom as an office and general
living room.

That medical officers thus treated should be put under regu¬
lations tending to prevent promotion under the Board, and
rendering advancement elsewhere next to impossible, is not a
subject of surprise, and the writer of the letter shows how this
result is brought about.

The social standing of the medical officers from the point of
view of the Board is perhaps most forcibly and comically illus¬
trated by the presentation to each of its assistant medical
officers of the magnificent sum of two shillings as a Christmas
box.

This Board, it is well to remember, recently dismissed one of
its superintendents after sixteen years* service on grounds that
would not bear investigation. The facts as reported to us at
the time seemed to indicate the commission of a most atrocious
injustice, resulting from the indescribable stupidity, or worse,
of the investigating committee, which was afterwards severely
censured by the general Board.

The service of the Board would appear, therefore, not only to
be attended by extreme physical discomfort and social degrada¬
tion, but by the absolute loss of all hope of advancement and
the risk of unjust treatment, resulting in the destruction of
professional reputation.

Medical men entering the service of the Metropolitan
Asylums Board, after such a warning, must not look to this
Journal for defence or assistance in the event of their being
maltreated.

A professional man who is content to be classed with scullery-
maids, will certainly be ranked by his brethren in a still lower
grade; but we must still hope that the Metropolitan Asylums

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

317

Board, which has shown considerable capacity in some respects,
may have the good sense to see that their own dignity and
importance is not enhanced by degrading their officers, and that
good pay and good treatment are conducive to efficiency,—that
the Board is indeed a modem governing body, and not a sur¬
vival, as its dealings with its medical officers would suggest, of
an obsolete Bumbledom.

The Publican's Responsibility in Criminal Drunkenness .

If drunkenness be a crime, as the latest legislation indicates,
any person helping to produce it becomes of necessity an
accessory, both to the crime and any criminal consequence.

That publicans are responsible, on this contention, for much
of the crime in this country appears very probable. Within the
few months last past, three judges of assize, Justices Kennedy,
Matthew, and Grantham, in charging grand juries, drew atten¬
tion to the large proportion of drunken crime, and its association
with public-house drinking. Justice Grantham, at Durham,
went so far as to assert “ that every publican from whose house
a drunken person went out should be put in the dock and
punished

Public-house drinking is associated with a very large propor¬
tion of the crimes reported in the daily press, and the least
observant person must have noted the Invariable appearance of
drunkards in the streets at the hour of closure of the drink-
shops.

The evidence, indeed, is overwhelming that publicans do not
limit themselves to their function of licensed victuallers, but do
their utmost to pander to and cultivate the drink crave in the
weak and depraved. It is astonishing that society at large has
been for so long morally blind to the iniquitous conditions of
the drink traffic.

Every drunken crime, if Mr. Justice Grantham is right,
should entail an investigation in regard to the persons who were
accessory to the drunkenness : but before this can be efficiently
done, the police and local magistrates must be brought to
regard their duties in this respect from a very different stand¬
point from that which now obtains.

The limitation of drink-supply to individuals—a very difficult

Digitized by VjOOQle

OCCASIONAL NOTES.

318

[April,

question—will have to be considered, and possibly guidance or
control might be given to the publican.

The publican, however, is licensed to supply the reasonable
needs of his customers, and it would seem right that on the
publican should rest the burden of disproof of having aided in
producing drunkenness and any resultant crime. If, for example,
a drunkard or drunken criminal is proved to have come from a
public-house, the licensee of that public-house should be held
responsible for the drunkenness, unless he can prove the con¬
trary.

The publican’s responsibility must be recognised in the most
definite and legal manner, as a necessary antecedent to any real
reduction in the amount of the drunkenness and resultant crime
in this country. The continuance of the existing licensed pro¬
duction of crime cannot but be considered as a disgrace to our
age and civilisation.

The Correlation between Sexual Function and Insanity and

Crime .

From the earliest period of medicine a connection has been
supposed to exist between the generative activitives and the
processes of thought. Perhaps to some degree the perception of
this connection was in early times due less to observation than to
a fanciful association in the mind of the thinker between the
two great functions which seemed the most mysterious belonging
to our organisation, and which seemed to have in common a
certain portion of the divine attribute of creation. And so we
find the Egyptians worshipping the generative impulse under
various forms, while the Greeks believed that the nymph
Memory was the mother of the Muses (various types of mental
activity) by Zeus himself.

In later days more substantial reasons have been found for
associating disturbances of the generative organs, particularly
in women, with abnormal states of cerebral action. The
accomplished outgoing president of the British Gynaecological
Society, Dr. Macnaughton Jones, dwelt upon this subject
in his valedictory address delivered on January 11th. Dr.
Macnaughton Jones has been for some time collecting statistics

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

319

in relation to the connection of insanity with diseases of women,
and has brought to the investigation a very extensive experi¬
ence as a gynaecologist and as a general physician. Dr. Jones
appears to have gone into the question with care, considering
how morbid impulses originating through the process of men¬
struation in the various groups of a woman’s pelvic nerves can
find their response in reflected neuroses in other organs, and thus
influence the coherence and stability of her nervous acts ; con¬
sidering also “ how the normal fulfilment of ovulation with men¬
struation developed for the time being erotic impulses,” and led
eventually to “ distorted mental visions and erratic moral acts,
vulgarly called crimes, which the woman was helpless to evade
or subdue.” Having discussed these and kindred topics, and
reviewed at some length the correlation of disease of the sexual
organs in women with varying degrees of mental alienation,
Dr. Macnaughton Jones concludes that this correlation is a
point to be taken into serious consideration in dealing with the
insane, that careful physical examination should be made when
there is any reason to suspect disease of the uterus or adnexa,
and that full weight should be given in considering criminal
acts committed by women to the condition of the menstrual
functions, or to the coincidence of such acts with the meno¬
pause. The greatest care is required to anticipate insane im¬
pulse and to prevent suicide and crime in the case of women
who manifest symptoms that are due to a correlation between
disorders of sexual organs and mental instability.

The views of so experienced a writer as Dr. Jones are always
worthy of respect, and we are always glad when an earnest
worker in another branch of medicine deals with those difficult
subjects that form the boundaries of our specialty. The
obstetric physician must often have opportunities for seeing
slight mental disturbances which do not come under the eye of
the alienist, and he very often has chances of studying incipient
insanity which are denied to the man whose work is chiefly
within asylum walls.

Nevertheless we are a little disappointed with the result of
Dr. Jones’s studies. If we are to judge from the abstract of
his address which has appeared in the British Medical Journal\
it cannot be said that he has done more than add his own
valuable observations to those of many others as to the correla¬
tion which he dwells upon, and which undoubtedly exists. He

Digitized by VjOOQle

320

OCCASIONAL NOTES.

[April,

does not seem to aid us in comprehending the connection. As
to questions of operative interference, we hold that the same
rules guide gynaecological operations in the sane and in the
insane. Many alienists have entertained the highest hopes of
obstetric aid in the mental diseases of women, and have in the
great majority of individual cases been much disappointed.
We are bound to put our patients in the best circumstances
(gynaecological and other) for recovery, but we have to remem¬
ber that we are not dealing with a disease which runs its course
like a fever, but with an affection which, whatever its origin, is
often essentially degenerative in its course. Again, there is
another matter to consider. Affections of the female sexual
organs are of such enormous frequency that it is difficult to
understand how they can alone produce insanity in many cases.
There must surely be in the majority of instances a tertium quid.
Akin to this consideration is the reflection that affections of the
sexual organs often seem to produce their effect upon the brain
indirectly, that is through the mind. Thus the distress pro¬
duced by sterility may be of a very complex nature, and may
even lead to insanity (it is, by the way, a common cause of
suicide among Oriental women), which we would no doubt be
wrong to attribute solely to a reflex from trouble of the nerves
of generation. Similarly mere vexation at the well-marked
entry upon old age which the menopause is held to connote is
sometimes a factor in producing depression at the climacteric
period.

Aphasia and Will-making.

The difficulties which attend the making of a valid disposition
of property by an aphasic are well known, and have attracted
much attention. At the meeting of the British Medical As¬
sociation in Edinburgh in 1898 the subject was very carefully
discussed. Dr. Byrom Bramwell dealt exhaustively with it.
Dr. Clouston proposed as a test that in every case where there
was agraphia “ the contrary case ” or another disposition from
the one apparently desired should be put, so as to secure not
only an affirmative assent, but a negative dissent by the testator.

Digitized by VjOOQle

1900 .]

OCCASIONAL NOTES.

321

In the month of February the validity of the will of an aphasic
was tried by Sir Francis Jeune, and a new and ingenious test
as to whether a testator understood what she was doing, and
could make an intelligible choice, was applied. The case was
that of Miss Edith Marian Moore, who died in London on
August 26th, 1899.

In July, 1899, Miss Moore had a stroke of paralysis, after
which she suffered from aphasia and could not express her¬
self by words. She was attended by Dr. Edmunds, who sug¬
gested that she should make her will. Under his advice two
packs of large cards were printed, one pack containing the
names of Miss Moore’s relatives and the other pack the items of
her property. Mr. Garrett, her solicitor, was sent for, and, at
an interview, he dealt out the cards, one from each pack in turn.
The name of Arthur John Moore was turned up, and Miss Moore
intimated by signs that she wished him to have her Ballycohy
estate in Ireland. The next matter was the disposal of her
half-share under her father’s will, over which she had the power
of appointment, and the cards were again shuffled and the name
of the relative selected. The shuffling of cards went on in the
same manner until Miss Moore had disposed of all her property.
Then came the selection of the executor. The cards were
again shuffled, and as soon as her brother’s name was turned
up Miss Moore indicated by signs that he was her selection.
She wanted another executor to be appointed, and the names
of her other relations were shown her on the cards, but she did
not come across the name she desired. She attempted to write
it down, but what she wrote could not be read, and she then
agreed that her brother should be her sole executor. The will
was drawn up and afterwards carefully read over to Miss Moore,
who put her mark to it, and Dr. Edmunds and Mr. Garrett
witnessed the making of the mark.

Dr. James Edmunds, in the witness-box, said when the cards
were used Miss Moore sorted them out in a perfectly intelligent
and methodical way. She had the two packs spread out before
her, went through them, and at last put them together in the
way she wished. At the time she executed the will she
perfectly well knew what she was about. It was not unusual
for a person suffering from aphasia to put the wrong names to
things. Miss Moore could not put together sentences nor
write. The names of all her relatives were put on one of the

Digitized by VjOOQle

OCCASIONAL NOTES.

322

[April,

packs of cards. She could not give instructions on her own
initiative.

Sir Francis Jeune said the mode of arriving at the wishes of
the testatrix was novel, well intentioned, and most ingenious,
and on the whole satisfactory. Taking the matter as it stood,
nothing could have been more fair or more skilful, and he
pronounced for the will, the costs to come out of the estate.

Editorial Comment .

The development of the JOURNAL is a matter of interest to
all our members. It is published by the authority of the
Association, and should therefore form, as we hope it does form,
a fair index to the vital force of that body. The production of
such a periodical, maintaining the high standard at which the
Journal of Mental Science has always aimed, is nowadays not
an easy task. There is immense activity in the field of
psychiatry, and great efforts are being made everywhere to
enable our science to keep pace with the general progress of
medicine and with the rapid advance of some other and younger
specialities.

Every year sees the establishment on the Continent and in
America of new periodicals dealing with medico-psychology in
its scientific aspects and as an art. Reference to our quarterly
exchange list of journals will show a few of those which seem
most representative and most valuable; but in addition to
special journals we receive numerous reprints of articles from
general medical journals dealing with our subject, as well as
monographs, detached papers from works by several authors,
etc. Surveying the vast and rapidly increasing volume of
work which is being accomplished on all sides, there devolves
upon us the arduous endeavour to keep pace with the entire
progress of psychiatry, and to present to our busy readers well-
sifted and thoroughly modern summaries of results.

It has for some time been evident that re-organisation is
necessary in that department which deals with the current
literature of insanity. The rearrangement of the Psychological
Retrospects which have been prepared year by year at the
cost of no little time and energy has been undertaken by

Digitized by VjOOQle

1900 .]

OCCASIONAL NOTES.

323

Dr. Lord, with the active co-operation of those who have
already done much for the JOURNAL, and of those who
willingly promise their services in the future. The preparation
of these retrospects represents much reading and sustained
effort on the part of skilled and competent specialists, and we
doubt if the labours of these workers have been adequately
recognised by the Association.

We cannot revert to former volumes without rendering a
tribute of hearty thanks to the earlier workers in this field,
among whom may be mentioned veterans like Dr. Ireland
and Dr. T. W. McDowall.

It will be observed that the abstracts are now classified and
generally signed by those responsible for them, and it would
appear that the time has come when reviews of more important
works should also, as a rule, be signed by individual re¬
viewers.

It is also designed that critical digests of important subjects
shall be published from time to time, thus resuming a method
which this Journal was among the earliest to adopt, and
which, as developed by other periodicals, has seemed to us most
serviceable.

The progress of knowledge makes readers more critical, the
advance of science calls for greater exactitude ; but, apart
from the literary and scientific aspects of our task, its business
side does not grow easier. The production of plates and dia¬
grams, for instance, almost indispensable nowadays f is costly
and troublesome to every one concerned. It is pleasant, on the
other hand, to note that the sale of the JOURNAL is increasing,
until 1000 copies are hardly sufficient to meet the demand,
notwithstanding that the price was materially raised some years
ago. Advertisers are beginning to recognise the advantages
which so widely read a journal offers them, and thus some
relief of the expenses of publication is obtained by the Asso¬
ciation.

We cannot forget that the Journal of Mental Science con¬
tinues to stand as the sole representative of Psychiatry in this
country. Nearly half a century has elapsed since the Associa¬
tion began to publish a journal. It has a long and honourable
record. We doubt if the founders of the JOURNAL were
sanguine enough to anticipate the success which has followed
upon their venture, but we are assured that they would not

Digitized by

Google

324

REVIEWS.

[April,

have been content to stop short while progress is possible.
We are mindful of the words in which Dr. Savage repudiates
self-satisfied science, and of Landor’s saying that those who are
not quite satisfied are the sole benefactors of the world.

We confidently appeal to the members, and especially to the
younger members of the Association, to increase their efforts to
keep the JOURNAL in the front rank by the only method
whereby that end can be attained, the contribution to its pages
of work of real importance. Only by a constant show of con¬
tinually improving work can any medical journal maintain a
foremost place in modem times.

Part II—Reviews.

A System of Medicine by Many Writers . Edited by Thomas Clifford

Allbutt. London : Macmillan and Co., 1899. Vol. viii, pp. 998.

Price 2 55.

The final volume of Professor Clifford AllbutPs System of Medicine ,
containing as it does the section on “ Mental Diseases,” is the one which
will prove of most interest to the readers of our Journal. The list of
the contributors is a sufficient guarantee that the quality of the section
is maintained at the same high standard which characterises the work
in its entirety. That nervous and mental diseases, taken together,
would seem to receive very full treatment is evidenced by the fact that
the sections devoted to these occupy nearly 1800 out of the total of
about 7800 pp., and yet we could have wished that more space had
been devoted to the latter, which are disposed of in only 315 pp., or
4 per cent, of the whole. From the point of view of the general prac¬
titioner, who is chiefly concerned with the treatment and difficulties
arising in cases of threatened outbreak of, or fully developed, mental
disorder among that class of society from which private patients are
drawn, the treatment is sufficiently full and adequate. In the case of
the poorer classes of the community, where no less than 90 per cent, of
the existing lunacy has its origin, the difficulties that present themselves
to the attending physician in a case of mental disorder are easily
resolved. In the ordinary run of cases it means relegation to the
asylum. In the case of the well-to-do the difficulties are enormously
increased, and, after perusal of the section, the general impression that
one gets is that the various contributors, in their recommendations as
to care and treatment, had this class specially in view.

In recent years the additions to our knowledge of disease have been
many and great, and these have always had as their consequence the

Digitized by C ' ogle

REVIEWS.

325

1900.]

benefiting of humanity. A steady diminution of the death rate during
the past half-century is equivalent to a diminishing occurrence of sick¬
ness and diminishing fatality of disease, but there is very little doubt
that this improved condition of affairs is to be connected not so much
with improved methods of treatment as with efforts which have been
directed to the prevention of disease. Certain diseases have been
clearly recognised as to a large extent preventable, and enlightened
public opinion has taken energetic steps to check their occurrence,
finding, with keen business instinct, that in the long run the expenditure
necessitated is in every way a paying investment. Mental diseases,
every one will admit, in no way differ, or ought not to differ, from any
of the other “ ills that flesh is heir to.” If anything they differ only in
their greater gravity and far-reaching consequences, social and economic.
Yet what, in this department of medicine, has been done ? Have any
real practical efforts been made either by the medical profession or the
public to grapple with this very grave aspect of social life, and if so,
what are the results ? Much has been done, and is being done, by
members of our own specialty, aided and encouraged by enlightened
public authorities, in the investigation of the pathological conditions of
mental affections, and much may be hoped for in the future; but so far
the result is not, to say the least, encouraging. Not only is there no
appreciable improvement in the recovery rate of these diseases, but
there is no evidence that there is any diminution in the occurrence of
fresh cases. In the opinion of one of our most eminent authorities,
Dr. Savage, it must be admitted that there is an increase, but not to
an alarming extent. If anything can be done to stem this increase,
it can only, or chiefly, to all appearance be in two directions : (1) pre¬
vention ; (2) the early recognition and prompt treatment of cases by
the practising physician under whose care all cases come in the first
instance.

As regards the latter, the whole section dealing with mental diseases
seems to us quite admirable. There is but little opportunity during
training for the clinical study of the early stages of mental disorder,
and a medical man usually begins to acquire real practical knowledge
only when he has begun the actual practice of his profession. In
every one of the contributions dealing with mental disorder the prime
necessity for early recognition is specially emphasised, and to that
end the premonitory symptoms of impending disease are very fully set
forth, and the treatment appropriate to this early stage as fully described.
That something can be done in this direction is proved by the fact that
the number of cases of puerperal insanity which require removal to an
asylum for treatment is steadily lessening, and that, too, notwithstanding
the fact that there is no diminution in the number of deaths from
puerperal fever and other accidents of childbirth. As a guide, there¬
fore, to the general practitioner, this section seems to us all that could
be desired.

In the all-important matter of prevention, however, we think it is
decidedly lacking, for the question receives but little consideration, and
we do think its value would have been enhanced by a clear and autho¬
ritative exposition of the subject. Such an addition would not have

Digitized by VjOOQle

REVIEWS.

326

[April,

increased the space given to the section so as to make it dispro¬
portionate.

The exclusion of general paralysis of the insane from this section,
and its relegation to that dealing with nervous diseases, is difficult to
understand. Only last year, for the first time, this affection received
the official recognition of the Commissioners as a distinct type of in¬
sanity, and its absence from this section and this volume is productive
of a distinct sense of incompleteness.

We have not dealt with the contributions which make up the section
individually. All are characterised by a high level of excellence. We
would point out, however, that the table of ages on p. 185 is of but
little value, giving as it does merely the absolute numbers of patients
in asylums at various age-periods without any reference to the popula¬
tion at corresponding ages. Nor is it the case that (in proportion to
population) “ the largest number of cases of insanity occurs between
the ages of twenty-five and fifty.” It is during the twenty years, thirty-
five to fifty-four, that the proportion attains the maximum ; and if
general paralysis, which alone, and not puerperal insanity, is responsible
for this occurrence, is left out of consideration, the liability to insanity,
judging from the age on admission, is one which increases by steady
progression with advancing age. The relationship to insanity of age,
sex, and condition as to marriage is by no means a simple one, and
no one of these can be considered by itself, but must be taken in con¬
junction with the other two. To say, for instance, as Dr. Savage does,
that “ over half the insane are married,” tells us really very little, and
taken by itself is positively misleading; for if the two conditions, celi¬
bate and married, are compared for ages over twenty, 1. e . the marriage¬
able age, the proportion of single to married among the admissions
in relation to the corresponding population is between two and three
to one. Table xviii, which gives the condition as to marriage, refers
to population, though that is not stated, and its place should have
been occupied by either Table xix or xx of the Commissioners’ Report,
though both of these are also misleading if only the totals for all ages
are given.

Apart from the few exceptions which have been mentioned, the
section on “ Mental Diseases ” is in every way excellent. To the general
practitioner, whose difficulties in dealing with these cases are often
trying in the extreme, it will prove a very present help. To the
specialist also is it likely to prove helpful, and some of the contribu¬
tions, such as those on dull, delicate, and nervous children (Dr. F.
Warner), vice, crime, and insanity (Dr. Mercier), and criminal lunacy
(Dr. Nicolson), are such as should appeal to that section of the
enlightened public which interests itself in the moral and mental
welfare of the community.

Diseases of the Nervous System. By Campbell Thomson. Bailliere,
Tindall, and Cox, London, 1899, PP* I2 3* Price 4*.

The author in his preface tells us that the object of his book is to
serve as an introduction to the study of diseases of the nervous system,

Digitized by VjOOQle

REVIEWS.

327

1900.]

and that the arrangement he has adopted is that which he has found in
his experience as a teacher to be useful to students. Of the thirteen
chapters into which the book is divided eight are devoted to the
description of the motor system and the actions and nerve-supply of the
muscles, and the remaining five deal with the general structure of the
nervous system, the sensory system, reflexes, localisation of spinal
diseases, and disorders of gait. In the description of the architecture
of the nervous system the results of the more recent microscopic
investigations appear to be taken into account, though we have not
found any reference to Waldeyer's conception of nerve structure, which
involves the existence of neurons of association as a link connecting
the sensory with the motor neurons, the whole forming the reflex arc.
The chapters on the ocular muscles and the reflexes are particularly
good, and the descriptions throughout are freely illustrated by photo¬
graphic reproductions and diagrammatic sketches. There is nothing
strikingly original in the work, but the manner of dealing with the
principles of the subject is so lucid that the result is a very readable
book, and one which fulfils very well the author's intention.

Clinical Studies in Vice and in Insanity . By G. R. Wilson, M.D.

Edinburgh: W. F. Clay, 1899, 8vo. Price 7 s. 6 d. net.

In this work Dr. Wilson has brought together a number of clinical
records illustrating certain aspects of mental disease which are in some
degree related, whether in origin or in symptomatic expression, to what
we rather vaguely term vice.

The standpoint throughout is clinical, but the observations are
preceded by and interspersed with very interesting considerations on
pathology and treatment.

The vice disease specially dealt with is inebriety; and the first
portion of the book is devoted to “an account of alcoholism intended
to convey an idea of a progressive alcoholfc lesion in drunkenness, with
a provisional suggestion of the nature of the vehicles and modes of
nerve-motion in health and in disease.”

The author comments at the outset on the present confusion in the
nomenclature of alcoholism, and suggests some emendations. We
could wish that he had been even a little more drastic in his proposals :
such secondary conditions, for instance, as paraplegia and hemiplegia
in a drunkard are hardly entitled to rank as special alcoholic disease
forms either separately or as constituents of “ alcoholic paralysis; ”
and “ alcoholic epilepsy ” or “ epileptoid alcoholism ” is a term which,
perhaps, asserts too much.

The chief interest of this section of the work centres in the very
ingenious, if somewhat speculative, theories which Dr. Wilson advances
in explanation of the pathology of alcoholism. His view is that the
morbid condition consists essentially in a lesion of the dendritic
system, whereby there results a reduction of mental function : new
paths are not developed, new connections are not made, hence the loss
XLVI. 23

Digitized by VjOOQle

328

REVIEWS.

[April,

of the function of “ initiative; ” the latest evolved, highest, and most
complex mechanisms are disorganised and impeded, hence the failure
in the function of “discipline.” The author regards the lesion as a
tonic depression in the dendritic system; the normal circulation of
nervous energy is obstructed in its highest levels, and this obstruction
entails a deprivation of trophic influence throughout the nervous
system.

This loss of tonicity is regarded by the author as adequate to account
for all the psychic symptoms of chronic alcoholism. Exempli gratis
the application of the theory is presented in detail in the case of two
typical disorders—aphasia and hallucination. In regard of the latter
symptom this view appears to us to be somewhat too exclusive. To
explain the remarkable prominence of hallucinations in the alcoholic
and their characteristic emotional tone—as compared, for instance,
with the relatively lower degree of importance of this symptom in
general paralysis—it would seem necessary to give more weight than
the author does to the influence of primary peripheral lesions.

The clinical reports, both of alcoholic and of non-alcoholic cases,
which form the remainder of the volume, are lucid, and the writer is
to be congratulated on his avoidance of tedious and immaterial detail.

In connection with several of the cases Dr. Wilson takes occasion
to reiterate his opinion—of decided authority coming from so keen an
observer—that in the production of the drunkard environment is, in
the majority of instances, more important than innate disposition.

The hints on treatment scattered through the clinical records are
original and practical, both as regards the exhibition of drugs and the
use of moral stimulation, the latter being a therapeutic agent deserving,
in the author’s opinion, more attention than it usually receives.

Specie e Varietd Umane [Human Species and Varieties ]. By G. Sergi.

Turin : Bocca, 1900. Pp. 224, large 8vo. Price 6 lire.

Prof. Sergi, of the University of Rome, is one of the most brilliant
and accomplished of Italian anthropologists and psychologists. His
interests are wide, and he has made his mark in many fields, but he is
best known for his contributions to two questions, in each of which he
has influenced the current of international work and speculation. One
of these is the Aryan question and the origin of the races which have
peopled Europe, the other is the problem of craniological method.
The two questions are allied, for, as Sergi insists, without a sound
anthropological method the Aryan problem cannot be settled. In the
present volume he has not dealt (except in an appendix) with the
peopling of Europe: he is working up his separate studies on that
subject for publication as a complete work later. He has here pre¬
sented a full exposition of his craniological methods, and these have
attracted such wide attention and discussion that a brief account of
them may not be out of place.

Sergi believes that the study of the skull form (and secondarily of the

Digitized by VjOOQle

REVIEWS.

329

1900.]

form of the face) is of the first importance in anthropology; the pig¬
mentation of skin, hair, and eyes, while not without significance,
furnishes, he believes, a very inferior criterion of race, for he considers
that it is very largely modified by climate and other environmental con¬
ditions. The same may be said of stature. Head form, however, he
finds to be persistent in a race through enormous periods of time.

While he thus attempts to demonstrate the great importance of head
form he severely criticises the cephalic index (the length-breadth index)
which until recent years has been regarded as the best, if not indeed the
only available, method of registering and comparing head forms. He
has little difficulty in showing (with the aid of a few ingenious dia¬
grams) that the most unlike shaped heads may still have exactly the
same cephalic index. And as a matter of fact the most dissimilar
races, from opposite parts of the world, will sometimes yield identical
indices. This scepticism as to the value of the cephalic index has,
indeed, of late become widely prevalent among anthropologists, and the
way has thus been opened for the sympathetic consideration of Sergi’s
method, a method which he regards as natural, and not different from
the methods employed in other biological sciences, such as botany and
zoology.

Sergi starts, as stated above, with the assumption that cranial types
are persistent. He hesitates even to admit that mesaticephalic skulls
are produced by the mingling of dolichocephalic and brachycephalic
races, as is usually assumed by French anthropologists ; he believes, on
the contrary, that in such minglings it is the rule for one or the other
head shape to be transmitted unchanged, and seems to regard the
mesaticephalic skulls as belonging—if we retain the old cephalic basis
of classification—either to the long-headed or the broad-headed group.
He has found that at Rome in the earliest ages there were two types of
skull—one native, the other foreign; and that though the proportions have
varied, the same two types are still found. In Etruria, likewise, from the
most ancient times there have been two types, never destroying each
other. Moreover he regards it as an error to believe that cranial
capacity has increased, as a result of greater intellectual activity, in the
course of social evolution from prehistoric times to the present. He
believes that the average cranial capacity of the various skull types has
remained invariable, like the shapes themselves, and he gives measure¬
ments in proof.

Sergi’s classification is mainly founded on the view of the skull from
above (norma verticalis). He makes nine divisions, which are as
follows (the names fairly indicating the shapes):—Ellipsoid, pentagonoid,
ovoid, beloid, rhomboid, cuboid, sphenoid, spheroid, platycephalic.
Most of these great groups are divided into several varieties (the
ellipsoid into not less than eleven), so that there are about forty-
five different varieties with separate names, some of these varieties
being still further subdivided; on the whole, however, the classifica¬
tion is fairly clear and simple in its main outlines, as here fully
illustrated. Sergi points out that the resemblances between the skulls
of the first four divisions are sufficiently marked to indicate that they all
belong to the same race, and that there is a similar resemblance between

Digitized by VjOOQle

33 °

REVIEWS.

[April,

the skulls of the last four divisions. The first race is the Eurafrican, the
second the Eurasiatic; and these two races, according to Sergi, have
peopled Europe.

There can be no doubt that Sergi’s method is one of great value, and
that familiarity with it must lead to great sureness of judgment in obtain¬
ing a really natural classification of skulls and in ascertaining their
relationships. It tells us far more about a skull than we can learn from
an index which merely shows the relationship of two variables. There
are certain obvious criticisms. In the case of so complex a body as the
skull it would often be extremely difficult to decide into which group we
should place an individual skull; the changes which Sergi’s classification
has undergone in the course of years alone shows this difficulty. One
is tempted to say that, valuable as the method is as an instrument of
research, it remains a somewhat individual method, and that we could
never be quite sure how far the results of two workers were comparable.
It might almost be said to be an art rather than a science; also as a
mere question of method, it may be pointed out that whereas the
classification as a whole is founded on inspection of the norma verticalis ,
one of the nine divisions, the platycephalic, is decided by the norma
lateralis (it may be noted in passing that Sergi regards the flat or platy¬
cephalic head as a racial and not a merely individual or abnormal
character). On the whole, however, it must be admitted that the wide
interest which this method has evoked is fully justified.

A somewhat similar but less extended classification is presented for
the face, and it is incidentally pointed out that the somewhat general
belief that a relatively large face characterises the lower human races
(as it does animals) is by no means founded on fact. A classification
of the palate is also brought forward : epsiloid, paraboloid, and ellipsoid.

The volume is furnished with appendices which are by no means its
least interesting portion, and are both well illustrated. The first deals
with certain anomalies of the skull. In the course of this a clear
account is given of the interparietal and pre-interparietal bones,
formerly called os incce> or, vaguely, Wormian bones ; they indicate an
arrest of development, and morphologically represent a character of
lower Vertebrates. The term “Wormian bones” should be reserved
for the small intercalary bones which have no morphological signifi¬
cance, and merely serve to compensate for incomplete ossification at
the marginal sutures of the parietal bones. Sergi is among those
who consider that the frontal or metopic suture has no significance as
an indication of great frontal development, but is merely due to arrest
of development.

The second appendix is “an application of the method.” Here
Sergi gives a brief but luminous account of his investigations and con¬
clusions concerning the first inhabitants of Europe. The first recog¬
nisable inhabitant of Europe is the man of Neanderthal, in Sergi’s
opinion a type still persisting on the shores of the Baltic, and especially
in Friesland. With the Neolithic epoch came the long-headed man of
finer and higher type from his original home on all the shores of the
Mediterranean. This is Sergi’s Hoiho Eurafricanus y to whom is chiefly
due the Egyptian, Greek, and Roman civilisations; this race came up by

Digitized by VjOOQle

1900.]

REVIEWS.

3 31

Spain as far as the British Islands, and under Northern influence
emerged afresh as the tall, fair, long-headed Scandinavian. Then
towards the end of the Neolithic period came, together with the intro¬
duction of metals, the dark broad-headed man from the East, Homo
Eurasiaticus . He is Mongolian in type, and radiates from Central Europe
in many directions ; so far as there are any “ Aryans ” at all, that name,
Sergi concludes, can only be given to this race. (Sergi notes in passing
that to Prichard probably belongs the honour of first recognising the
Mongolian element in the “ Celtic ” skull.) This is, in brief, the theory
—now gradually gaining distinguished adherents—with which Sergi’s
name is chiefly identified, and in his next work he purposes to give a
full and elaborate demonstration of it.

The Races of Europe: a Sociological Study . By William Z. Ripley,
Ph.D. London: Kegan Paul, 1900. Pp. 624, with bibliography
(paged separately), pp. 160. Price 1 8s.

For many years anthropologists, psychologists, and sociologists have
been working at the detailed elucidation of the numerous and impor¬
tant problems connected with the races of Europe. An immense
amount of material has thus been accumulated by specialists whose
contributions were mostly hidden away in the Transactions of the
learned societies published in every European language, the huge
bibliography, drawn up by the author in conjunction with the officials
of the Boston Public Library and appended to this volume, testifying
to the enthusiasm with which they have worked. So complex, however,
are the problems that even this vast mass of material was scarcely suffi¬
cient to settle more than their main outlines. Yet the time had cer¬
tainly gome for the results of the specialists to be woven together into
some kind of harmonious whole by a competent hand. This has been
done in the most admirable manner by the author of the present work.

Dr. Ripley is Assistant Professor of Sociology at the Massachusetts
Institute of Technology, and Lecturer in Anthropology at Columbia
University. He possesses the initial advantage of being an American,
and thus devoid of those racial prejudices which have had a subtly
pernicious influence on so many European anthropologists who have
sought to discover the wider bearings of their work. Professor Ripley
has also fully realised the magnitude of the task he has undertaken;
this is shown not only by the attention given to bibliographical details,
but also by the manner in which he has sought the aid and counsel of
the most distinguished experts throughout Europe, and the anxiety
which he has shown to obtain really typical photographs of the various
European people. There are not less than 222 such photographs, all
admirably reproduced and clearly printed as plates, and in such a work
they are of the greatest assistance. Moreover there are eighty-six maps
and diagrams, all constructed, so far as possible, on a uniform method of
gradation, and exhibiting at a glance the various characteristics of each

Digitized by

Google

REVIEWS.

332

[April,

separate country. It will thus be seen that the author has fortified his
position with the most elaborate precautions.

Such care would be useless, however, without the special personal
qualifications which alone enable a writer to grapple with complicated prob¬
lems. These qualifications the author in the main clearly possesses. He
can range facts in order with ease and skill; he shows good judgment
in finding his way among conflicting theories, and in avoiding extreme
positions; and although it can scarcely be said that he has mastered the
art of writing, he always presents his results in a clear and readable
fashion. It was not his business to contribute new material, or even to
invent new theories, but the task was still one that called for, and has
found in Dr. Ripley, a special combination of intellectual qualities.

It seems well to dwell on these preliminary considerations, for the
value of a work of this kind depends very largely on the confidence
we can place in the skill and competence of the author, and it is more
important to feel assured that we have a reliable guide than to know
exactly whither he will take us.

The exact conclusions reached by Dr. Ripley cannot be summarised
within the limits of a short review, but we may touch on two or three
of the most important and significant After a preliminary sketch of
the development of the questions concerned and of the factors involved
—language, nationality, race, etc.—the author turns to the discussion
of methods, devoting a chapter to head form. In accordance with a
growing tendency the cranium is put in the first place as the criterion
of race ; the size is unimportant, and the form is no indication of
intelligence, but no other easily measurable character is so persistent
or so little influenced by selection. Pigmentation (which Huxley took
as the basis of racial classification) and stature are useful as secondary
criteria, but they are more modifiable through environment, nutrition,
urban life, and other influences, and cannot be placed on a line with
the head form. In this statement Prof. Ripley is at one with the
distinguished Italian anthropologist, Prof. Sergi, but he differs from
Sergi in accepting the validity of the length-breadth or cephalic index.
In this he is certainly wise. While Sergi has convincingly shown that
there are distinct limits to the reliability of the cephalic index, so long
as we confine ourselves to Europe it serves us fairly well; and since
nearly the whole of the available cranial data are expressed in terms of
the cephalic index, we should indeed be helpless if we threw it aside.

In a subsequent chapter the author deals with the great central
problem of European anthropology: How many European races are
there ? Up to within the last ten years it was generally held that there
was only one really important race in Europe, the bearer of all its
civilisation—the so-called “ Aryan ” race,—and the problem was to find
who were the closest representatives of that primitive race. Even when
the Eastern origin of the “ Aryans ” was discredited, the “ Aryans ” had
still to be placed in Europe. This was the state of the question when
Canon Taylor wrote his brilliant little book, The Origin of the Aryans.
It is now generally agreed that there is no “ Aryan ” race at all, though
we may still retain the name for a group of languages. The problem
remains to determine the number, nature, and origin of the European

Digitized by VjOOQle

REVIEWS.

333

1900.]

races. Deniker holds that there are six races, a statement which
Ripley qualifies by the remark that by “ races ” Deniker really means
“varieties.” Sergi, on the other hand, holds that there are two—the
African, long-headed race, and the Asiatic, broad-headed race. Prof.
Ripley steers a judicious middle course by accepting three races,—a
long-headed race of African origin, a long-headed of Northern origin,
and a broad-headed race which he terms Alpine, probably of Asiatic
origin. At the same time he conciliates the upholders of the two-race
theory by reaching the conclusion that the Northern long-headed people
are probably derived from the southern long-heads. It seems probable
that, as far as our knowledge goes at present, this is the most satisfactory
solution of the problem.

The bulk of the work is necessarily taken up by chapters devoted to
the separate countries of Europe; there is also a chapter on the Jews
and one on Western Asia. Finally, there are chapters on social
problems, environment versus race, culture, urban selection, and accli¬
matisation. Although these latter chapters are always interesting they
are not always so satisfactory as some of the early chapters, owing to
the data, in many cases, still being very imperfect, and also, perhaps,
because the author has endeavoured to deal with a great many impor¬
tant questions in a short space. In a chapter on urban selection the
tendency for modern European cities to be nearly everywhere mainly
populated by brunette long heads is clearly brought out. On the
question of environment versus race the author is inclined to emphasise
the influence of the former factor in the belief that the latter factor has
been unduly favoured by some writers; there can be little doubt that
we must attach great weight to both factors. On the question of
acclimatisation Dr. Ripley reaches the conclusion that the Teutonic
peoples, including the English, have a very limited power of adapting
themselves to a new climatic environment. He notes that the Dutch in
Africa are the most notable exception to this rule; as to this it may be
remarked that the South African Dutch have a large infusion of French
blood, and as this element was Huguenot we very reasonably conclude
that it came mainly from the south of France, and therefore belonged
precisely to that race which, as Dr. Ripley points out, has a special
aptitude for acclimatisation. “A popular opinion is abroad,” the
author remarks, “ that Africa is to be dominated by the English and
German nations. If there be any virtue in prediction it would rather
appear that their activities will be less successful as soon as the pioneer¬
ing stage gives way to the necessity for actual colonists, who with their
families are to live, labour, and propagate in the new lands.”

We have probably said enough to show the great value and interest
of Prof. Ripley’s work. For all practical purposes it will doubtless be
the standard work on this subject for many years to come.

Digitized by VjOOQle

334

REVIEWS.

[April,

After-images . (Motto graph Supplement , Psychological Revmv.) By

Shepherd Ivory Franz. London and New York: Macmillan,
1899, pp. 61, large 8vo.

After-images were first described by Aristotle, who seems to speak of
them as familiar phenomena, and apparently regarded them as a
continuation of the stimulus of vision, and at the same time as closely
allied to the images of the dream state; they were re-discovered by
St. Augustine, and in the eleventh century again discovered by the
Arab Alhazan ; in the seventeenth century the great humanist, Peiresc,
regarded himself as their original discoverer, and made many observa¬
tions on them. Since then they have been studied by a number of
distinguished investigators—Boyle, Newton, Buffon, Goethe, R. W.
Darwin, Fechner (who lost his eyesight mainly through long-continued
experiments with the after-images of bright lights), etc.

Yet, although after-images have received so much attention, we are
still very much in the dark about them. At the present day a number
of widely divergent theories (duly set forth in the present monograph)
are held regarding their nature. There is not even conformity with
regard to the exact definition of positive and negative after-images.
Dr. Franz decides that the positive after-image may best be defined as
“ an after-image in which the image and its background bear the same
intensity relation as in the stimulus,” and the negative image as “ one
in which the relation of intensity is reversed.”

The interest of after-images is largely due to their seemingly two¬
fold character (indicated from the first by Aristotle), since they are
allied both to sensation, and to memory images and imagination images.
In the history of after-images, the author here remarks, “ we seem to
have an epitome of the interrelation of physics, physiology, and
psychology, and probably no other single phenomenon is so good an
example of the growth of experiment and measurement in psychology.”

Dr. Franz has not attempted to settle the ultimate question con¬
cerning the nature of after-images, but to give an experimental analysis
of the conditions affecting the production, duration, latent period, space
relation, etc., of the after-image, and he also considers their relation to
sensation, memory, and imagination. The chief subjects were eleven
advanced students in psychology at Columbia University, New York,
and the apparatus used was adapted from that devised by Fullerton
and Cattell. The results are fully illustrated by tables and diagrams.
During three series of 3000 experiments, only five times were negative
after-images seen under the conditions of the experiments; these were
noted only with the longest time, largest area, and greatest intensity,
towards the end of the experiments, and indicate that the negative
after-image is due to eye-exhaustion. The image, especially as regards
duration, was found to be affected by many mental and physical con¬
ditions, especially the mental attitude of the subject. It is much
affected by attention. The author finds reason to believe, in opposition
to some other observers, that the peripheral seat of the image is only
in the stimulated eye, and is not transferred. The monograph is
accompanied by a bibliography.

Digitized by VjOOQle

1900.]

REVIEWS.

335

Psychologische Arbeiten. Herausgegeben von Emil Kraepelin.

Bd. II, Heft 4; Bd. Ill, Heft 1. Leipzig: Engelmann, 1899.

Price 5 marks each.

Professor Kraepelin’s students and fellow-workers are still vigorously
prosecuting the laborious investigations which have done so much to
further the scientific study of insanity in many parts of the world.
Kraepelin’s aim, as expressed in one of the studies before us, is so to
adapt the methods of experimental psychology as carried on in modern
laboratories that they may yield useful methods of diagnosis in the
investigation of pathological mental conditions, and aid in the recogni¬
tion and definition of mental diseases. The elementary and funda¬
mental nature of many of the questions investigated—the fact that
many of the results obtained merely enable us to give precision to
undemonstrated truisms—render it sometimes difficult or unprofitable
to summarise these investigations, and in many cases indeed the
experiments are merely partial and preliminary attempts to deal with
the subjects under examination. But it is impossible not to feel that
the methods here adopted are sound, and that their development in
years to come will render the study of the sane and insane minds a
comparatively exact science. *

Among the studies contained in these two parts we find Adolf Gross
on the psychology of traumatic psychosis, a preliminary study of a
single patient which is to lead up to an investigation of a large number
of normal persons, with the object of establishing a sort of “ psychic
status ” for comparison with minor degrees of psychic disturbance. In
a somewhat lengthy paper Joseph Reis presents a series of simple
psychological experiments on the sane and insane: the latter were
cases of hebephrenia and general paralysis ; the former were students
and attendants. It was found that the patients at their best efforts
equalled the sane at their best, but the inferiority of the former was
well marked when they were considered in groups; the general paralytic
in every respect showed more intellectual activity than the hebephrenic.
A short and preliminary study deals with the relation of meals to
mental capacity, as attested by Kraepelin’s favourite method of ability
in adding. The advantageous effects of eating were found to be very
rapidly produced, and the importance of a good breakfast for school
children is emphasised. Ragnar Vogt deals with the influence of
distraction on simple mental processes. One of the most interesting
studies is that by August Diehl, who, following up a previous investi¬
gation by Adolf Gross, has inquired on simple and scientific lines into
the characteristics of the handwriting of the sane. Diehl points out
the special significance of handwriting for the alienist. Disturbances of
the will, though playing a large part in mental disease, are much less
easy to investigate precisely than disturbances of attention or memory,
and handwriting seems especially adapted to lead to a more exact
knowledge of such disturbances. The experiments were made on
eight asylum attendants (four of each sex) with a writing apparatus in
connection with a kymograph, and the experiments consisted mainly in
writing the figures 1 to 10 at various degrees of speed and under

Digitized by VjOOQle

336

REVIEWS.

[April,

various conditions. A certain number of interesting results were
obtained, and notable sexual differences were observed: thus the women
wrote larger, more rapidly, and with less pressure; and when the diffi¬
culties of the task were increased the men responded with a greater
effort of will, and the women by decreasing the difficulties, as by writing
smaller.

The Anatomy of the Central Nervous System of Man, and of Vertebrates
in General. By Prof. Ludwig Edinger, M.D. Translated from
the fifth German edition by VV. S. Hall, M.D., assisted by P. L.
Holland, M.D., and E. P. Carlton, B.S. The F. A. Davis Co.,
Philadelphia, and H. K. Lewis, London, 1899. Pp. 446, 8vo.
Illustrations 258. Price 15J. net.

A distinguished physician, who is also a brilliant physiologist, not
long ago remarked that the proper understanding and practice of
neurology requires a very little knowledge of physiology, but a great
deal of anatomy. At any rate, it is true that the logical processes by
which neurological diagnosis is accomplished invariably necessitate the
statement of certain anatomical facts.

And we can perhaps best convey a sense of the value and purpose of
the work before us by saying it is one in which these and other facts of
human anatomy are presented in philosophical relation to what is
known of the nervous anatomy of vertebrates in general. It is a work
—appropriately enough dedicated to Waldeyer—that has, in earlier
editions, by means of Prof. Rigg’s admirable translations, already com¬
manded the attention of British and American neurologists.

Prof. Hall, of Chicago, is responsible for the present translation, and
of the manner in which he and his subordinates have acquitted them¬
selves we shall presently speak. But for the moment it is sufficient to
notice, in Edinger’s last edition of his own work, that some increase of
scope and expansion of matter have not hindered a persistence of the
original plan and purpose. And we must generally praise the breadth
of conception and minuteness of detail with which the comparative
morphology of the nervous system of vertebrates is here presented to
the physician, zoologist, and psychologist alike.

The book is divided into three parts, of which the first is introductory,
and the first chapter, properly enough, historical. It is, though, perhaps
fortunate for the credit of Edinger’s work amongst Anglo-Saxons that
the historical matter is that alone, if any, from his pen that is tinctured
by Germanic exclusiveness—we had almost said parochialism.

In the succeeding chapters of this part, dealing as they do with
fundamental conceptions, the dry bones of anatomical precision are
clothed with morphological significance in the light of embryological
research. We may, it is true, regret that Edinger has found no place
for mention of GaskelFs famous theory of the origin of the nervous
system of vertebrates, although it is obvious from the text that he is
acquainted with much of this worker’s research.

Digitized by CjOOQle

igoo.]

REVIEWS.

337

Again, it is true that Edinger deals ostensibly with the central nervous
system; but since the currency of the newer neurological ideas it has
become hardly possible to maintain the old distinction between “ central ”
and “ peripheral ” organisations, and we therefore are the more surprised
that Edinger fails even to afford a hint that he appreciates the signifi¬
cance which many of late have become inclined to attach to the endings
of nerve in muscle.

Neither is the last chapter of this part free from fault. In it Edinger
develops a kind of “overflow” theory of ganglion-cell dynamics, and
we are assured that ganglion cells store up “irritation” till the “accumu¬
lated irritation” becomes “too great,” when they then “discharge.”
Something more than inadequate powers of expression is revealed by
the laxity of these phrases, which are, as they stand, a monument of
philosophical confusion. Unless it be—wffiich we doubt—that Edinger
desires to evade any show of adhesion to chemical, physical, or vitalistic
theories of cell dynamics, we are inclined to blame the translators for
these and other crudities.

The second division of the w'ork deals with the embryology and
comparative anatomy of the vertebrate brain, and is a comprehensive
and accurate digest, written with an abundance of morphological state¬
ment such as few but the author could supply; while the third and
last division, treating of the anatomy of the mammalian, and especially
the human brain, contains the author’s best work.

Ope chapter in particular, that on form-relations of the human brain,
is of interest to psychologists. In it the author develops the hypothesis
that the intellectual peculiarities of prominent men may be connoted
with increased development of single cortical regions, and this without
any expression in the general relations of the gyri or in the brain weight.
In other words, as many have long foreseen, we are drawm across the
threshold of a new phrenology. Incidentally it may be mentioned that
Edinger revives the old idea that some men of prominence have been
the subjects of retrogressive hydrocephalus. He mentions Cuvier and
Rubinstein, but omits the salient instance of Thackeray.

On the whole Edinger’s w r ork is a fine one, and deserves high praise.
Its renewed appearance in an English dress is sufficient proof of its
vitality, and of its usefulness to the practitioner and systematic teacher.
The diagrams are of a high standard of excellence, and many of them
are, in their w f ay, of more value than much letterpress.

But our praise of the translators’ efforts must be more qualified.

We suppose it hopeless to pray Transatlantic authors to spell the
language of Shakespeare and Milton with acceptance to Englishmen, but
surely w r e have a right to expect, in scientific w r orks, an absence of the
colloquialisms of the evening newspapers.

The translators* knowledge of English may be inferred when we say
they suffer “ knowledge ” to be divided thus: “ knowi-edge.” That
they have less Latin is obvious from the fact that they frequently write
“et al” without the least sign that they are aware that “al” is an
abbreviation of “alii.”

We find on one page such a remarkable statement as that certain
portions of protoplasm form the “ fundament ” of the central nervous

Digitized by VjOOQle

338

REVIEWS.

[April,

system, and on another such an absurdity as that ganglion cells
“ usually ” send out certain processes. In one line the noun singular
“ fascicle ” is used ; in the next the noun plural “ fasciculi.”

The pages are literally sprinkled with such monstrous phrases as
“ Gudden experiments ” and “ Purkinje cells,” while the reader’s task is
rendered difficult by the overweighting of cumbrously constructed clauses
with complex words imitated from the German.

But more than this, the translators have taken it on themselves to
restrict the use of the term “neuraxon” to axis-cylinders having an
efferent function, while those of afferent function they call dendrites.
In consequence of this, as appears from a foot-note, the reader is expected
to suffer the mental burden of two sets of symbols for one and the same
verity.

It is the great value of Edinger’s work that prompts us to point out
these, amongst others, of the translators’ shortcomings, and to express
the hope that in a new edition the translation will undergo revision at
the hands of some competent English scholar.

On the Relation of the Nervous System to Disease and Disorder in the
Viscera. By Alexander Morison, M.D.(Edin.), Edinburgh and
London. Young J. Pentland, 1899. Demy 8vo, pp. 132. Price
7 s. 6 d.

Dr. Morison here presents us with a reprint of the six Morison
Lectures given by him before the Edinburgh College of Physicians in
1897-8. “Some verbal corrections have been made, and a little
additional matter interpolated to make my meaning clear. Some illus¬
trations which were unsatisfactory have been omitted, and others added.”
In these words the form of issue of the present volume is explained.
The anatomy of visceral innervation is dealt with in the first two
chapters. Much of the work done of recent years by workers with the
Golgi silver methods is utilised in compiling these chapters, and the
account given is clear and concise. Dr. Morison has worked in¬
dependently at the histology of nerves in such viscera as the heart and
uterus, and an excellent account is given of this part of the work, the
value of which is enhanced by microphotographs. Here and there we
notice in the earlier chapters a tendency to fall into poetical quotations
and other digressions—perhaps as a flavouring towards aid in the diges¬
tion of a difficult subject. The pathology of visceral innervation
naturally succeeds the subject of the physiology of visceral innervation.
Some valuable observations on the nerves of the uterus during and after
pregnancy, and such topics as cardiac pain and Graves* disease, respira¬
tion and vaso-motor innervation, are briefly and fragmentarily dealt with,
but this portion of the subject lacks systematisation. Pulse tracings and
respiratory tracings are given in illustration of cardiac and pulmonary dis¬
turbances. The sixth and concluding lecture deals with the “brain
regarded as one of the viscera,” and with the subject, so dear to psycholo¬
gists and metaphysicians, of “ mind and body.” The exposition here, in its

Digitized by VjOOQle

REVIEWS.

339

1900.]

efforts to rise to the height of the great argument, becomes stilted and
pompous. Thus, speaking of cerebral memory, we are informed that it
“ may be impressional and conclusional; that is, the automatic record of
impressions received through the senses, or the record of the results of
that inward digestion of such impressions by the recepto-retento-motor
process we call thought or reasoning, in the exercise of which more
cerebral organules than one take part” (p. 118). Again, “ It seems feasi¬
ble to argue, or assume, or imagine, as you will, that the polymorphous
cell, with its universality of axonic direction and equal universality of
dendritic receptivity, is the type of that retentive and connective organule,
the repletion and utilisation of which is the mainstay of mental life, as
the greater or less storage of supplies—potential energy—is the necessary
condition for the increase of any power whatever,—or kinetic energy.”
“ There are, moreover, preponderant (nerve) centres for the evolution of
energy, otherwise direction could not be given to motion, and the
universe itself would have been a chaotic pyrotechnic display of short
duration, if it had existed at all, which, having flared imposingly into being
like the rocket, would, like the residual stick, have fallen into the abyss
of oblivion in a similarly ridiculous manner.” It would be ungracious
to criticise further, for the work is very unequal in its parts, and portions
of it exhibit decided ability and merit, especially where anatomical and
physiological facts are concerned, as already pointed out. The volume
is well got up, and the type and printing clear and easy to read.

Le Rire et les Exhilarants. By Dr. J. M. Raulin. Paris: Librairie
J. B. Bailliere et fils, 1900, pp. 292.

This monograph on laughter fairly sums up our recent knowledge on
its mechanism. In the first two of the three parts into which the book
is divided, the anatomy and physiology of laughter are considered.
While the zygomaticus major plays a leading part in its production, the
author shows that Duchenne attached an undue importance to it, neglect¬
ing the functions of other muscles—the risorius, orbicularis palpebrarum.
Stress is laid wisely on the rdle of the muscles of expression about the
eyes in laughter, and attention is drawn to the sound i (pronounced
English ee) found in different words relating to laughter in various
languages, thereby illustrating the analogy which exists between speech
and its primitive expression,—sounds seen corresponding to labial
gestures.

The evolution of laughter, its predisposing causes, are next con¬
sidered.

Laughter as a pure reflex is discussed in relation to tickling, and in
the chapter on exhilarants (nitrous acid, opium, Indian hemp) as a result
of central stimuli. The exhilaration arising from the inhalation of nitrous
oxide gas is closely related to that produced by tickling, and the sensa¬
tion of pleasure is especially localised around the mouth and lips. With
regard to haschisch (Indian hemp) Dr. Raulin says, “ Hitherto it has
been but little used therapeutically. But sooner or later this agent,

Digitized by VjOOQle

REVIEWS.

340

[April,

which exercises a considerable influence upon the nervous system, will
probably occupy an important place in therapeutics.”

Laughter, which is a marvellous stimulant in normal life, also fre¬
quently recalls mental disorganisation, and in certain pathological cases
is a most expressive sign ; hence in part iii we are given a good account of
the semeiology of laughter—its occurrence in facial palsy, progressive
muscular atrophy, glosso-labio-laryngeal palsy, general paralysis, etc., and
in the various psychoses.

With regard to the localisation of laughter, the commanding centre is
in the cortex (operculum of Arnold); that of co-ordination and inhibition
in the grey nuclei of the optic thalamus ; that of execution in the
medulla. So far as post-mortem evidence can enlighten us at present,
Raulin concludes with Brissaud that spasmodic laughter (e.g. in dissemi¬
nated sclerosis, tumor cerebri, etc.) is due to an irritative lesion of
the anterior segment of the internal capsule.

A full bibliography is included.

Die Geistesstorungen im burgerlichen Gesetzbuch und in der Civil -
Process-Ordnung (20 th May , 1899) [The Insanities in the Code of
Civil Law and in the Form of Civil Process ]. Von Dr. C.
Moeli, Prof, an der Univers. Berlin, Director der Anstalt Herz-
berge, etc. Berlin, 1889, 8vo, pp. 47.

In this pamphlet Dr. Moeli considers the changes introduced into the
law in May, 1899. He cites the provision that a person can be put
under curators who, in consequence of mental derangement (Geistess-
krankheit) or mental weakness (Geistesschwache), is unable to look
after his affairs. There is nothing new in this, but the professor per¬
tinently observes that there must always be a difficulty in distinguishing
between insanity and mental weakness, which may be congenital or the
sequel of insanity, or the two may alternate. He thinks that the
Prussian law is often too hard upon weak-minded persons, as it takes
from them all voice in their own affairs, whereas in some cases it would
be enough to reduce them to the status of pupils or minors.

For persons afflicted with dipsomania (Trunksucht), defined as an
irresistible craving for continued or periodically returning indulgence in
intoxicating drink, guardians may be appointed if their dissipation
threaten to end in destitution or be dangerous to the safety of others.
It does not appear that it is necessary for the judge to take the evidence
of a medical man to determine this condition.

Dr. Moeli observes that drunkenness may be the outcome of a
diseased state of the brain, or simply of vicious indulgence which might
be resisted by a vigorous exertion of the will, and it would require a
physician to distinguish between these two varieties.

We learn that in Prussia nullity of marriage may be declared if one of
the contracting parties be proved to have been in such a condition that
he had not recognised the nature of the engagement (this would cover
insanity); or if there were certain peculiarities concealed, apart from

Digitized by VjOOQle

1900 .]

REVIEWS.

341

deficiencies of means, unless this has been condoned or accepted by the
party aggrieved.

Divorce is permitted if one of the spouses has become insane and the
insanity has lasted at least three years during the time of marriage, and
has reached such a grade that rational intercourse between the married
persons was suspended, and any prospect of the renewal of such inter¬
course was excluded. Dr. Moeli’s remarks on the civil code are sensible
and well stated, but one would need to have the text of the code to
follow his criticisms. William VV. Ireland.

The Pathology of the Emotions: Physiological and Clinical Studies . By
Ch. F£r£, Physician at the Bicetre. (Translated by Robert
Park, M.D.) University Press, Limited, Watford, 1899, PP* 5 X 7 *
Price 15*.

This book is a translation by Dr. Robert Park of the work on the
pathology of the emotions by Ch. F 6 r 6 . As a translation it gives a
literal—too literal—presentation of the original; for frequently the French
terms are represented by their verbal equivalents in English, although
these may be conventionally used in totally different senses in the two
languages; e . g. the translator speaks of the author making experiments
on the personnel of his “services” at Bic£tre. Again, he frequently
speaks of the insane as aliens—a word conveying a totally different
meaning in English ; we shall have some one terming them “ outlanders ”
next. In one place, indeed, an insane individual is actually termed an
“ alienist.” The whole translation teems with ungainly additions to the
English language, such as “ icery,” “ peripherical,” “ odorating,”
“tonality,” and many hundred others. An amusing mistranslation is
that in which “membre,” a limb, is rendered penis (p. 16). Dr. Park
claims that this work has been “ rendered into English ” by him;
“rended from French” would, in our opinion, be a more accurate
description.

In his preface the translator advances views, though in somewhat
cryptic language, advocating the materialisation of the mind, but we do
not think any support will be found for them in the work of the author
himself. This work is in itself most interesting, both in subject and
treatment. Starting, in his preface, with Herbert Spencer’s definition of
the emotions as being states of consciousness proceeding from the
centre, as opposed to sensations, which are states of consciousness pro¬
ceeding from the periphery, the author in his work proceeds to enumerate
experiments on the sensations, which seem somewhat to invalidate the
definition, as tending to show that the emotions are really dependent on
the sensations. In showing how perverted sensations are responsible
for certain hysterical emotional states, we are struck by the well-known
fact that the French are in a more pathological condition with regard to
the latter than ourselves. We are next shown the influence of emotions,
of undoubtedly central origin, upon the bodily functions, circulation,
respiration, digestion, etc. In this connection is noted the incidence of

Digitized by VjOOQle

342

REVIEWS.

[April,

chorea after fright. From chapter ten onwards the matter will be found
especially interesting to the alienist, for here we are dealing with the
emotional value of the cardinal insane states—mania, melancholia,
dementia. The author points out how the various states shade into one
another, though he balances opinions so impartially that we are left in
doubt as to his own views ; for instance, it is not clear whether he regards
mania as an exaggerated state of exaltation or joy, or as a prolonged
anger. The influence of the insane states upon the bodily functions is
compared with that of the emotions, and the author notes, with apparent
surprise, the low tension pulse of mania, a point recently emphasised by
Dr. M. Craig. While pointing out the anomalies of phthisis in the
insane, he seems to think that the temperature will always rise, but this
need not be so. A striking paragraph runs, “ The harmony of movements
is especially affected in psychopathies; and the default makes itself
principally remarked in the physiognomy so easily altered. One may
say that madness is the enemy of beauty; beauty is rare amongst the
insane: when they regain harmony of expression one may prophesy a
speedy cure.”

In speaking of the hypersensitiveness of degenerates the author pro¬
pounds the theory that “ second sight ” may be due to such a degenerate
emotional state ; but surely this phenomenon, largely associated as it is
with such a typical non-degenerate race as the Highland peasantry, has
been more plausibly claimed as an embryo in the evolution of a new
faculty.

No one who has begun the perusal of this most interesting work is
likely to put it down until he has made himself master of its contents,
for, though not calculated to prove of any great practical value, as a
philosophical exposition of the subject of which it treats it cannot be
too highly praised.

The book contains ten psycho-physical diagrams, and is furnished
with a very full index.

Les Troubles mentaux de PEnfance. Par le Dr. Marcel Manheimer.

Paris: Soci£t£ d’ Editions Scientifiques, 4, Rue Antoine-Dubois.

Cr. 8vo, pp. 189. Price 5 fr.

In this little treatise on the mental disorders of childhood, Dr.
Manheimer, an old assistant of the clinical professor of mental medicine,
Dr. Joffroy (who writes an introductory preface), gives a “summary of
infantile psychiatry with its pedagogic and medico-legal applications.”
The divisions of the subject are set out, with the usual French precision,
under the headings of Etiology, Semeiology, Nosographic Description,
Legal Medicine, and Cure and Treatment. The book is to a consider¬
able extent a compilation giving the views of the leading French authori¬
ties on the psychological and psychopathic aspects of the period of child¬
hood. Legrain’s observations on “ degeneration and alcoholism ” -are
quoted to prove that in three generations the alcoholic family is practi¬
cally reduced to a progeny of imbeciles, idiots, insane, hysterics, or

Digitized by VjOOQle

1900 .]

REVIEWS.

343

epileptics. Psychical causes of mental trouble are less frequent in
juvenile than in adult life : physical play a more prominent part in the
young, especially in those with inherited predisposition to mental break¬
down ; unwholesome home surroundings and injudicious schooling are,
says our author, important factors in determining mental troubles, but
the latter is the more potent. Urban agglomeration (he thinks) and the
vices of city life have much to do with the increase of juvenile insanity.

The section on legal medicine is perhaps the most interesting and
original part of the book, and the part played by mental weakness in the
production of tramps, “larrikins and hoodlums,” of incendiaries, of
thieves, and of homicides is carefully considered. A judicious warning
is given as to the credibility of children as witnesses in courts of justice,
the influence of suggestion and imagination often leading them to
exaggerated statements. With regard to suicide in children, it is stated
that the proportion of such cases has increased by 50 per cent, in the
years 1881-95, and that the females of Paris under age furnish no less
than 40 per cent, of the whole number of suicides. Some judicial
remarks on care and treatment close the volume, which we may charac¬
terise as an interesting summary of the subjects with which it deals.

The Cerebrospinal Fluid: its Spontaneous Escape from the Nose . By
Dr. StClair Thomson. London : Cassell & Company, Limited,
1899. Royal i2mo, pp. 132.

It is more valuable to study one case thoroughly than thousands
casually. Dr. Thomson has had a case of cerebro-spinal rhinorrhoea
(escape of cerebro-spinal fluid through the nose not due to erosion of
bone), and he has studied it carefully and thoroughly, with the result
that he has added a valuable monograph to medical literature. This
monograph, which is of the nature of a critical digest, successfully accom¬
plishes its intended task of “ finally establishing a hitherto unrecognised
pathological possibility.”

Taking his own patient as a text, the author reviews all the published
cases of cerebro-spinal rhinorrhoea (nine certain and nineteen possible
cases).

It is demonstrated that the clinical picture usually, if not always, in¬
cludes cerebral symptoms premonitory to the flow, which are absent as
long as the flow continues. This indicates that the pathology of the
condition includes more than the presence of an accidental foramen in
the base of the skull through which the fluid escapes. Hydrocephalus
intemus is suggested.

There are several interesting chemical analyses of the fluid by Prof.
W. D. Halliburton.

The most successful treatment of the condition is one too often, alas !
neglected by us all in the treatment of disease, viz. non-interference.

XLVI.

Digitized by

Google

344

RETROSPECTS.

[April,

Diseases of the Nervous System . By C. E. Beevor, M.D., F.R.C.P.

London : H. K. Lewis, 1898. Cr. 8vo, pp. 432, Illustrations. Price

1 os. 6 d.

This introductory work on neurology forms one of the volumes
of “ Lewis’s Practical Series,” and will be found of real interest and dis¬
tinct value. The author has planned his work so as to begin with
anatomy and physiology, and, having laid a secure foundation, proceeds
to discuss the various diseases affecting the nervous system. The
limits of space at Dr. Beevor’s disposal do not permit of discussion of
points which are still in dispute; but perhaps that is fortunate, in render¬
ing his opinion clear-cut and lucid. Indeed, the book can be read from
cover to cover with ease and with profit. Although it is concise, brevity
has not caused any sacrifice of the author’s meaning; and his explana¬
tions of nervous phenomena are sure to meet with a grateful appreciation
on the part of those who are desirous of arriving at an understanding of
these difficult problems.

In dealing with localised diseases of the brain Dr. Beevor lays us
under special obligations in having avoided superfluous details while
conveying a vivid impression of his experience. In an introductory
handbook, of course, one cannot expect a full discussion of disorders
which, when dealt with at length, require monographs for each. Alcohol¬
ism is disposed of by the author in six pages, but these pages give the
impression of having been written by a physician who has determined, in
the fulness of his knowledge, that his words shall be few and well chosen.
We must also refer in terms of appreciation of the practical and scien¬
tific spirit which is made manifest in Dr. Beevor’s remarks on treatment,
and cordially commend this book to students and junior practitioners,
while indicating that a perusal of its pages will not come amiss to those
of wider knowledge.

Part III.—Retrospects.

1. Anthropology*

Anthropological Work in Asylums. (Lancet, July 15 th, 1899.) Goodall, E.

A clear and comprehensive statement of the raison <Tetre of
anthropological work, with its practical application in asylums. A list
of instruments required is given, together with a scheme of anthropo¬
metric and descriptive data, and in conclusion a comprehensive
bibliography. A valuable paper. J. R. Lord.

Pleasurable Emotions in Certain Animals \Des Emotions gais chez
quelques Animaux]. (Rev. de VHyp., Jan., 1900.) Coutaud, A.
This short essay raises the question of the possibility of laughter as
an emotional expression in animals. That animals can be gay and

Digitized by VjOOQle

RETROSPECTS.

345

1900.]

give gestural expression to this feeling all will admit; that the smile may
be the signature of this inner joy, and is possible anatomically for the
animal, we may grant; but that the sense of the comic, which laughter
generally conveys, is present even rudimentally is more than doubtful.
For our own sakes let us hope that the animal germ of humour, if
present, will never develop. The discussion is interesting if rather
academic. The author, M. Albert Coutaud, refers us with interest to
two precursors in this field of psychology—Laurent Joubert in the
sixteenth, Godenius in the seventeenth century.

Harrington Sainsbury.

2 . Neurology.

Structure of the Nerve-cells of the Spinal Ganglia [Di Nuovi sulla
Struttura delle Cellule Nervose dei Gangli Spinali ]. (Com. fatta
alia Soc. Med.-Chir . di Pavia nella seduta 20 Gen., 1899.) Golgi , C.

In this paper Professor Golgi gives an account of some further
observations upon the reticular figure revealed within the protoplasm
of certain nerve-cells by his silver method (see Journal of Mental
Science , 1899, p. 403). He set himself to investigate more minutely
the structural differences presented by it at different ages, in the hope
that they might throw some light upon its functional significance. He
has found that these differences are so pronounced as to make it
possible to say whether a spinal ganglion, upon which organ his
observations were carried out, is from a young animal or from an old
one. In the ganglia of a twenty-year-old horse the most characteristic
features of the endocellular reticulum were its peripheral disposition
(although there still remained a narrow outer zone unoccupied by it),
a tendency to be arranged in lobules of a globose or conical form with
the narrow ends directed towards the nucleus, and the absence of a
segment in correspondence with an accumulation of pigment in a
portion of the protoplasm. This endocellular figure was already well
developed in the bovine foetus of from two to three months. It pre¬
sented itself, however, only at one point in the cell, close to the nucleus,
which was often displaced to the opposite side of the cell. It did not
consist of a distinct reticulum, but rather of short filaments passing in
various directions and ending in little swellings of the form of a pin-head.
At a somewhat later stage of foetal life the figure, although still tending
to present the characters just described, occupied a larger portion of the
cell. In the ox, though not in the cat and rabbit, it now presented a
distinctly reticular character, and with greater frequency than at later
periods was placed in contact with the nucleus by means of short and
delicate processes, each of which terminated in a slight swelling. In
the newly born animal the figure had essentially the characters that it
presented in the adult, which were described in his earlier papers.
The reticular character was, however, not quite so pronounced, and
figures occupying an eccentric zone of the cell were still common.

He admits that, up to the present, his hope that the study of this
apparatus at different stages of its development would lead to some

Digitized by VjOOQle

346

RETROSPECTS.

[April,

definite knowledge as to its nature has not been justified. As no one
else seems as yet to have been any more successful in throwing light
upon the subject, the significance of this remarkable structural feature
of the nerve-cell must still be regarded as obscure.

W. Ford Robertson.

The Axial Nerve-fibres of the Brain [ Wander - Versammlung der
Neurologen und Irrencirzte, Baden-Baden ]. (Afonats.fi Psychiatrie
u. Neur ., April , 1899.).— Markfiasergehalt der Centralwindutigen
eines normalen tnannlichen Individuums. (Neur. Cbl., No. 6, 1899.)
Passow , A.

In the report which he delivered at Strassburg on the nerve-fibres of
the brain cortex, after reviewing the steps by which our present
knowledge of the histology of the brain has been reached, he quotes
Meynert’s division of the cortex into four layers : (1) Tangential fibres
(Tangential Fasern); (2) Superradial fibre-work (Superradiares Faser-
werk); (3) Interradial plaited work (Interradiares Flechtwerk, also
named the Bailiarger and Gennari layer) ; (4) Radiating axial fibres
(Markstrahlen). Kaes, to whom Passow gives the credit of making the
most progress in the study of the nerve-fibre, uses this division.
Tuczek made the important observation that there was a marked
wasting of the nerve-fibres in general paralysis. Zacher two years after
showed that there was a similar disappearance of fibres in other
varieties of insanity. Amongst the microscopists who have advanced
our knowledge of the minute structure of the nerve-fibres of the brain,
Passow especially signalises Righetti, Vulpius, Monakow, and Flechsig.
He explains in detail Wolter’s method of staining and preparing sections
under which the finest nerve-fibres are dyed a deep blue, and the nerve-
cells a yellowish brown; but he objects that it is scarcely possible to
mount thin sections with this process without injuring them. He pre¬
fers the method of Kaes, who cuts the whole brain in frontal slices, and
makes a segment of the central convolutions, and carefully notes the
parts from which the segments are taken. Kaes has already examined
ten brains, from a child of ten months old to a man fifty-three years of
age, and two brains of members of the lower races, Hindu and Chinese,
and a microcephalic and macrocephalic brain of subjects aged two
years and twenty-five years. Dr. Passow refers to plates which were
before the meeting, but which are not reproduced in the Monatsschrift;
this is one reason why his descriptions are difficult to follow. He
indicates the development in the first month of life of the projection
fibres towards the periphery of the cortex, of the fiibrice propria of
Meynert of the association system, and the formation of the different
layers of the cortex. Kaes has shown that there is a difference in the
texture of the nerve-fibres of the anterior and posterior central gyri, and
also a difference at various depths of sections of the same convolu¬
tions.

Dr. Passow above four years ago set himself to study the brain of a
man thirty-three years old, who died of phthisis in a normal mental
condition. He spent two years in making sections and mounting
them. He now possesses 1890 sections. He finds a difference in
the construction of the brain at different parts of the cortex. The

Digitized by VjOOQle

1900.]

RETROSPECTS.

347

change never begins abruptly. Dr. Passow shows (Neur. Cbl., No. 6)
by two woodcuts that the posterior median convolution has fewer fibres
than the anterior one. This was confirmed by careful measurements
with the micrometer. The parts richest in nerve-fibres seem to lie in
the motor area of the hand and finger. Dr. Passow examined the brain
of a man who suffered from epileptic convulsions from youth upwards.
He was treated with the bromides. He died of inflammation of the
lung at twenty-eight. Passow observes that although the patient was
ascertained to be not weak-minded, and even to possess some technical
capacity, the cortex was found to be very poor in nerve-fibres; even
in sections of the median convolution a type was found inferior to the
brain of a child under a year old. We ought, therefore, to be cautious
in coming to conclusions which are not controlled by comparative
observations, for examinations of the brains of epileptics who do not
suffer from mental alienation are seldom obtained by physicians in
asylums, who do most of the pathological microscopic examination of
the brain. W. W. Ireland.

The Heaviest Brain, {Neur, Cbl., No. 13, 1899.) Van IVa/sem.

In this paper is given a short description of the heaviest brain on
record. The possessor of this ponderous organ was an epileptic idiot,
who died at the age of twenty-one. There was a hereditary neurosis,
three brothers, having also large heads, dying in childhood. He began
to walk at four years of age, never attended school, and was received
into the institution at Meerenberg at his fourteenth year. He was an
idiot of low intelligence, and of changeable but good-humoured disposi¬
tion. He used but a few words, and only recognised the people who
were daily round him. He amused himself with a common toy.
Through care he was kept cleanly in his habits. The senses seemed good
and the muscular system well developed. He was 1 *40 metres in height.
The gait was jerky; the tendon-reflexes heightened. He suffered
from epilepsy, during an attack of which he died. The encephalon
with the membranes weighed 2850 grammes. It appeared to be a
general enlargement The brain was found to be larger in the trans¬
verse direction than in the fronto-occipital. The cerebellum was regular
in form. The spinal cord seemed slightly larger than usual, and the
spinal nerves bigger. The optic and motor nerves seemed also some¬
what bigger. On microscopic examination the ganglion cells of the
brain seemed rare, the layers indistinct, the pyramidal layer scanty, the
nerve-fibres everywhere distinct, and the tangential layer had wide
meshes. Neither the cerebral vessels nor the neuroglia seemed to be
altered. W. W. Ireland.

Lobulus Parietalis Inferior, {Arch,/, Psyche B, xxxi, H. 1, 2.)

Monakow.

This is a treatise on the anatomy and pathology of this lobule, filling
seventy-three pages, and illustrated with two large pages of lithographs
and four woodcuts. The commonest symptom in lesions of the gyrus
marginalis is disturbance of the muscular sense without injury to the
power of movement. Monakow adopts the view that in the gyrus

Digitized by VjOOQle

RETROSPECTS.

348

[April,

angularis is situated the area of feeling for the eyeball, and that its
removal is followed by loss of feeling in the conjunctiva.

Monakow’s work is based upon profound anatomical and pathological
researches. He has studied the inferior parietal lobule in all its con¬
nections, and at ail stages of development and degeneration. While
recognising the value of Flechsig’s new method of studying the develop¬
ment of the axial nerve-fibre, Monakow opposes the view that the
lower parietal lobule is not connected with the corona radiata, and that
it only sustains its connection with the other parts of the brain through
the association systems and the fibres of the corpus callosum. Flechsig
observed that the inferior parietal lobe, as well as the basal temporal
gyri and the frontal lobe, have no mature fibres up to the second month
of infancy, a period of development in which the fibres in the projec¬
tion system of the brain have long been clad with myelin up to the
inner capsule. This gave occasion to Flechsig to reject the connec¬
tion of the corona radiata with the said region of the brain surface.
This was, however, pushing to physiological conclusions far beyond
the anatomical data. Flechsig holds that only a third of the whole
superficies of the cerebrum is connected with the brain stem, while the
rest of the cortex, which is represented by three large insulated con¬
volution areas, is only connected by association bands of fibres, and by
commissures. These three association centres serve the higher mental
activities, and are only connected with one another and the sensory
spheres. The inferior parietal lobules he regards as belonging to the
great posterior association centres. Monakow then enters into an
argument as to the import of the degeneration of the tissues in a case
reported by himself, but which is interpreted in a different way by
Flechsig.

Monakow observes that Flechsig’s theory is based upon the fact
that, in the infant’s brain, the mature axial fibres connecting the
frontal parietal and temporal lobes with the corona radiata are not
seen up to the third month, although at that time the other nerve
tracts of the corona are fully formed. Is it, then, true that more than
two thirds of the superficies of the human brain is unconnected with
the corona radiata ? That this is not the case with rabbits and dogs
is certain. In these animals the connection of the parietal lobe with the
ventral nucleus of the thalamus and indirectly with the fillet has been
experimentally proved, but Flechsig argues that the human brain may
be in its development different from that of animals. For some
years past Monakow has studied these questions not only upon the
operated brains of dogs and monkeys and upon some new pathological
cases in men, but has also made embryonical researches on the develop¬
ment of the nerve-fibres.

Monakow examined the brain of an infant who died when three and
a half months old. He found connecting nerve-fibres between the
corona radiata and the inferior parietal lobule, as well as with the
central temporal gyrus.

In the course of his paper, Monakow keeps his attention upon
the Leipzig Professor as well as on the parietal lobule. He objects
to some of his statements in detail, and questions if the nerve-

Digitized by VjOOQle

RETROSPECTS.

349

1900.]

fibres always put on their medullary sheaths in the regular succes¬
sion assumed by Flechsig. Monakow strengthens his position by
detailing his experiments and observations of the brains of monkeys,
and by the report and an analysis of some instructive clinical cases.

We await with interest the continuation of this important treatise.

W. W. Ireland.

Brain Weight and the Peripheral Nerve-fibres v. Bodily Size [Das
Hirngewicht und die Zahl der peripherischeti Nervenfasem in ihrer
Beziehung zur Korpergrosse ]. {Biol. Cbl., No . 13, 1899, reported
in Zeit.fiir Psyche B. xx, H. 5.) Brandt

Professor Brandt, of Charkow, has for a long time paid attention to
this subject. Haller observed that smaller animals always had a larger
proportion of brain to the weight of the body than larger ones. These
small animals have a greater surface in proportion to their bodily weight,
and cool rapidly. In consequence of this they require a more active
metabolism and a greater power of assimilation, as well as a stronger
development of the trophic brain centres. The surface of their bodies
therefore requires (to give them the same amount of sensibility) more
sensory nerve-fibres in proportion, which fibres in their turn require a
greater representation in the brain.

The number of fibres in a muscle depends not upon its volume, but
upon its diameter. Thus, the smaller muscle possesses more nerve-
fibres than the larger one reckoned by volume, consequently more
leading nerve-fibres, and it is to be supposed a greater area of grey
substance in the brain.

It has been proved by numerous measurements that smaller animals
have relatively more peripheral nerve-fibres, sensory and motor, and
that the number of these fibres is proportionate to their relative brain
weight. For example, the rat has from ten to twenty times more bodily
weight than the mouse, while it only has three to five times more nerve-
fibres in its sciatic nerve, and about three to five times more brain
substance. W. W. Ireland.

Lesions of the Hippocampus in Epilepsy [Ammons horn befunde bei
Epileptischen ]. {Arch, f Psych., B. xxxi, H. 3.) Bratz.

This is an inquiry into the question of the alterations in the hippo¬
campus major said to accompany epilepsy. The frequency of this
lesion has been several times denied and reaffirmed. Dr. Ford
Robertson, the Scottish anatomist, has only observed degeneration of
the glia of the hippocampus in one case out of thirteen.

Dr. Bratz made his histological studies in seventy subjects, of whom
fifty were genuine epileptics. There were alterations of the cornu
ammonis in twenty-five of these cases; eleven times the lesion was on
the right side, thirteen times on the left, and only once on both sides.
The alteration w r as always of the same character—atrophy of the great
pyramidal cells with increase of the neuroglia. Bratz found the gyrus
hippocampi, and in several cases the parietal convolution, smaller on the
same side as the contracted hippocampus, the result of a general wasting.
In an epileptic boy, besides the contracted cornu, the whole left hemi¬
sphere was lesser in size. There is no adequate explanation of the

Digitized by VjOOQle

350

RETROSPECTS.

[April,

significance of this morbid process in the hippocampus, or why it
should be so often present in epilepsy, and absent in so many cases of
long-continued brain disease. It cannot be a necessary sequel of
continued epilepsy, for here are twenty-five instances in which the
alteration is wholly wanting. Nor can there be found any marked
difference in the aetiology or clinical symptoms of the epilepsy, whether
the lesion is present or absent. It was, however, observed that when
the convulsion began on one side of the body, this took place on the
side opposite to the alteration in the cornu Ammonis as afterwards
found. Bearing in view that the great pyramidal cells of the hippo¬
campus represent “ integrating stations ” for the perception of smell,
the author made a careful test of the perception of odours in a number
of epileptics without being able to find that the sense was injured either
on the one side or the other. The commissure, as described by
Edinger as connecting the two cornua through the psalterium leading
to the fornix, was found in Bratz’s dissections to be intact.

W. W. Ireland.

Paralysis Agitans and Sarcoma . (Amer. Journ. Med, Sc ., Nov., 1899.)

Dana, C. H,

A case of paralysis agitans, with comments on the pathology of the
disease, and |l histological examination of the condition of the nerves,
spinal cord, and brain, and of muscle-fibres (illustrated). The sarcoma
referred to consists of multiple malignant warts of the skin of the lower
extremities.

Acute Ascending Anterior Myelitis (Landry's Paralysis). (Arch, de
Neur., Nov., 1899.) Courmont and Bonne.

They record a case:—G. L—, set. 58 years, suffering from rapid
acute paralysis of the lower limbs extending to the upper limbs, to the
diaphragm, larynx, and tongue, with affection of sphincters, loss of
knee-jerks, and no sensory troubles, ending fatally after four days. At
the autopsy was found distension of spinal meninges with fluid;
microscopically the cells of the anterior cornua were markedly affected
in the lumbar enlargement of the cord, in the cervical enlargement
(less), and there were decided alterations in the nuclei of the hypoglossal
and vagus nerves.

A microbe related by certain characteristics to the pneumococcus,
and by others to the streptococcus pyogenes, was found in the meningeal
fluid (hence the infectious origin of the disease). No lesions of peri¬
pheral nerves were found.

The case seems to have been one of pure motor paralysis due
exclusively to lesions of cells, the centre of the peripheral motor
neurons.

Incidentally, the authors discuss the artificial alterations in ceils by
fixing agents (alcohol, etc.) in mounting, and the significance of
Landry’s syndroma (varying causation, etc.). H. J. Macevoy.

Cases of Hemiatrophy of the Tongue [Palle von Hemiatrophia lingua ].

(Neur. Cbl., No. 18, 1899.) Wiersma .

In this paper, Dr. Wiersma describes seven cases. He illustrates
how irregular atrophy of the tongue in its affected half, paralysis of one

Digitized by VjOOQle

RETROSPECTS.

351

1900.]

vocal cord with one half of the soft palate, and the absence of the
reaction of degeneration, indicate a bulbar origin ; while uniform atrophy
of the tongue, no paralysis of the vocal cord or soft palate, and the
presence of the reaction of degeneration indicate a peripheral origin.

W. F. Penfold.

The Pathology of Paralysis Agitans . (Amor. Journ. Med. Sc.,

Dec., 1899.) Gordinier, H. C.

A description of the pathological appearances found in a case of
paralysis agitans as—firstly, endarteritis and periarteritis with patches
of perivascular sclerosis; secondly, degeneration and atrophy of certain
nerve-cells; thirdly, a general increase of the neuroglia. These changes
chiefly affected the cord. From comparing these with those already
recorded the writer concludes they are characteristic of the disease.

VV. F. Penfold.

A Case qf Diffuse Sarcoma of the Whole of the Pia Mater of tht Brain
an 4 Cord [Ein Fall von diffuser Sarkomatose der gesamten Pia
Mater des Gehirns undRuckenmarks\ (Monats. f. Psych, u. Neur.,
Nov., 1899.) Schroder.

In this case, Dr. Schroder observed clinically head pain, advancing
blindness and deafness, tumbling to the left, ataxia, loss of left patellar
jerk, hallucinations of touch, difficulty in swallowing, and paralysis of
the left arm. He found post mortem sarcomatous infiltration of the
pia of the brain and cord, which was most marked over right hemi¬
sphere. The infiltration was mainly round the vessels, and dipped down
between the nerve elements. VV. F. Penfold.

Pineal Gland: its Normal Structure; some General Remarks on its
Pathology; a Case of Syphilitic Enlargement. (Trans. Path. Soc .,
1899.) Lord,J.R.

This paper forms one of a series of contributions on abnormalities of
the pineal body which were brought forward at the Society. These
included cases of tumour by J. W. P. Lawrence and C. Ogle, cystic
enlargement by A. E. Garrod and A. E. Russell, and “ Notes of two
cases of dilatation of the central cavity or ventricle of the pineal gland ”
by A. W. Campbell. Of these C. Ogle’s paper is the more important,
and enters into the literature of the subject.

Cerebellar Tumour, considered with Reference to its Localisation . (Scot.

Med. Surg. Journ., September, 1899.) Bruce, A.

A fibro-sarcoma, accurately diagnosed, from the symptoms produced
and verified after death, to have origin in the flocculus, to involve the
glosso-pharyngeal and auditory nerves, to compress the facial and fifth
nerves and the anterior pyramid, and to exert pressure on the nucleus
of Deiters, the nucleus of the vestibular nerve and tract. Illustrated by
photographs of the growth, and a diagram of the tracts involved. The
case is a sequel to experimental evidence published by the author in
Brit. Med. Journ., May 6th, 1899.

Digitized by VjOOQle

35 2 RETROSPECTS. [April

Tumour of the Pituitary Body. (Jour ft. Nero. Ment. Zto., August,
1899.) Walton, G. L., and Cheney.

An “ endothelioma ” (? adenoma) of the pituitary with the symptoms
produced. The patient had signs indicating early acromegaly.

Tumour of the Oblongata presenting Ataxia and Astereognosis as the
most Prominent Early Symptoms. (fount. Nero. Ment . Dis.,
August, 1899.) Dercum, F. X.

The tumour sprang from the occipital bone, and exerted pressure on
the pons, medulla, and cerebellar lobe. The cause of loss of muscular
sense and of the sense of position of the limb is discussed, and the
view expressed that these are due to pressure on the direct cerebellar
tract. The paper is illustrated, and references are given to other cases.

Acute Anterior Polio-myelitis. (Clin. Rev., October, 1899.)

Lyman, H. M.

In a lecture at the Rush Medical College, Dr. Lyman develops the
clinical and pathological aspects of this disease. Pathologically he
insists upon its infectious nature, though the microbe is still to find; but
whilst dwelling on the inflammatory nature of the affection, and the
changes which the cells and their prolongations undergo, he does not
mention the important part in the inflammation which is assigned to
the arteries supplying the anterior cornua, and upon which recent
observers insist. The statement is, however, very lucid, and well worth
reading. Harrington Sainsbury.

Jores’ Formalin Method of Mounting. (Scot. Med. Surg. Journ.,
March, 1899.) Shennan, T.

A short practical paper embodying writer s experience with Jores’
method. His best results were obtained by a more prolonged fixation
with the formalin, and an alteration in the final mounting fluid in
the direction of greater dilution of the glycerine, and the addition of
formalin as an antiseptic. J. R. Lord.

Platinum Method for Central Nen>ous System. (Scot. Med. Surg. Journ.,
Jan., 1899.) Ford Robertson, W.

In this new method the solution, provisionally recommended, is made
by the addition of a 5 per cent, solution of formalin to a 1 per cent,
solution of platinum bichloride. The tissue remains in this solution
until thoroughly blackened, usually taking from three to four months.
Sections are cut with the aid of dextrine and a freezing microtome, and
are dehydrated, cleared, and mounted in balsam. This is a mere rough
outline of the process. The facts revealed promise to be of great
importance. So far it has shown (1) the presence of fibres in the wall
of the cerebral and medullary vessels; (2) the primitive fibrils of the
protoplasm of the nerve-cell; (3) the presence of certain granules in the
nucleus of the nerve-Gell; and (4) the existence of special cell elements
in the brain. J. R. Lord.

Digitized by VjOOQle

1900.]

RETROSPECTS.

353

3. Physiological Psychology.

The Equipment of a Psychological Laboratory . (Afind, July, 1898.)

Titchener.

Prof. Titchener contributes a valuable article on this subject, founded
on his own experience at Cornell, which will be useful even to those
who contemplate the establishment of much more modest laboratories.
The laboratory at Cornell was opened in 1891, and includes ten rooms,
to which it is expected that two more will shortly be added. These
rooms comprise optics room, acoustics room, haptics room, dark room,
reaction room, taste and smell room, physiological process (pulse, respi¬
ration, etc.) room, etc., together with private rooms for directors and
assistants. The instruments fall into four groups: (1) apparatus needed
for research in experimental psychology, (2) for drill work in experi¬
mental psychology, (3) for class experiments in experimental psychology,
(4) for the study of individual psychology. The last group is probably
that of most interest outside university work. It requires apparatus
which should be strong, cheap, and simple. Many of the instruments
devised by Galton would be useful if they were less expensive. On the
whole Prof. Titchener recommends as the best the instruments devised
by Prof. Jastrow (and to which attention was called in these Retrospects
some years ago). A full set of such instruments would include the
ordinary sense tests (keenness of vision, audition, colour-blindness,
aesthesiometric discrimination, power of smell, etc.), instruments for
taking simple and associative reaction-times, tests of muscular strength,
steadiness, fatigue, etc., as well as tests of “ higher ” mental processes :
quickness of apprehension, ingenuity, accuracy, memory, co-ordination,
memory-type, control of attention, temperament, etc. A laboratory
can be equipped at any cost from £10 upwards. The expenditure
upon the equipment and maintenance of Cornell Laboratory since its
inception has been over ^1000; but, on the other hand, Titchener
quotes from Sanford “ a liminal list of apparatus—the amount that is
just noticeably better than nothing,” costing approximately only £5.
The paper is full of useful practical suggestions. Havelock Ellis.

Right-sidedness and Left-sidedness (Z’ Homme Droit et fHomme Gauche ).

(Rev. Phil 1 , February , March, April, 1899.) Van Biervliet,J.

Prof. J. van Biervliet, of Ghent, has lately completed a very elaborate
study of this question in its widest bearings. By bringing together the
observations of others and contributing many important new observa¬
tions of his own he seems to have shown that right-sidedness or left-
sidedness, anatomical and physiological, extends to the whole of the
organism, and that everyone belongs either to one or the other class.

That strict symmetry does not exist is a well-known fact, known even
to the ancients, for (as Hasse first showed) the head of the Venus of
Milo is anatomically correct by being slightly larger on the left side,
while her nasal septum also deviates slightly to the left. We have to
admit a priori that the vascular irrigation of the left hemisphere is more
abundant than the right, since the left carotid is larger than the right
and is also less curved, so that the left blood-stream is both larger and

Digitized by VjOOQle

354

RETROSPECTS.

[April,

quicker. This fact will not, however, account for all the phenomena.
In the right-sided, for instance, Biervliet has found the right nostril is
wider, and in the left-sided the left nostril.

This asymmetry extends to the whole osseous and muscular system.
The results of the measurements here brought together show that, while
in the right-sided the head is more developed on the left side, in the
left-sided it is more developed on the right side. The bones of the
right arm in the right-sided are superior in length and in diameter, in
volume and in weight, over the bones of the left arm. In women this
predominance of the right arm appears to be less frequent, or else the
asymmetry less pronounced. With regard to the leg it is not yet
possible to speak with certainty, and Biervliet does not consider that
one can yet accept the opinion of those who assert that in the lower
limbs the asymmetry is crossed, the left leg becoming predominant.
Observations on the muscles agree with those on the bones. On the
living subject, also, Biervliet’s own observations, conducted with great
care, have never resulted in the discovery of a symmetrical person,
either man or woman. As a further contribution to the subject he has
consulted shoe-makers, tailors, hatters, glovers, etc. The evidence
thus obtained, on the whole, confirmed that furnished by anthropo¬
logical methods. It was impossible to find a perfectly symmetrical
head, and one hatter stated that the proportion of left-sided heads
among his customers was almost 2 per cent. Two tailors, one of
whom had himself taken 40,000 measurements, stated that symmetry
or ambidexterity never exists, one side of the body being always stronger
than the other; in 98 per cent, cases the right shoulder is lower than
the left by one or two centimetres (more still in those who use the right
arm much), and the sleeve at the shoulder is larger on the right side.
The right leg, the tailors state (in agreement with most anthropologists),
is shorter than the left, but the right hip is more developed than the
left. In the majority of men (93 per cent.) the fork of the trousers is
in contact with the right thigh. Ladies’ tailors and corset-makers
confirmed their male colleagues; the great majority of women are
right-sided; the right arm is larger and longer, the right hip is more
developed, the breast is larger on the right side; the proportion of
left-sided persons was not found to be greater among women than
among men. The shoe-makers also stated that in from 90 to 95 per
cent cases the right foot is broader, though not longer, than the left, in
both sexes; the customer instinctively puts out his best-developed foot
for measurement. The glovers likewise declared that in 97 per cent,
cases the right hand is broader but not longer than the left, the
difference first becoming notable at the age of fourteen or fifteen, and
being less marked in women.

It is when we come to the asymmetry of the nervous system that we
reach the most original part of Biervliet’s study. He examined about
200 subjects (chiefly students) by carefully contrived methods. The
hands were tested in estimating two unequal weights; there was found
to be great individual variation in delicacy of sensation, but a constant
relation was found between the two hands ; the skill of the right hand
was superior to that of the left by one ninth. The force of the pre-

Digitized by VjOOQle

1900.]

RETROSPECTS.

355

dominant side is always that of the other side + J. A similar relation
was found with the special organs of sense. As regards hearing, for
instance, when abnormal subjects were eliminated, this relation held
good when the subjects were tested with an apparatus specially made
for this purpose. Great individual variations were found in the
estimation of differences of intensity, but not one was found who, being
right-handed, was left-sided in delicacy of hearing. As regards sight,
also, when the abnormal were eliminated and the subjects examined by
a special form of the Snellen test, the power of the right eye in the
right-sided (and of the left eye in the left-sided) was found to be about
one ninth greater than that of the other eye. It was the same with
tactile delicacy; if in the right-sided tactile sensibility is represented on
the right side by 10, on the left side it is equal to 9*06. These results
are the outcome of about 17,000 series of experiments on 200 subjects,
and not in any case was any crossed asymmetry observed; the right¬
sided were always right-sided, the left-sided always left-sided, through¬
out. Biervliet does not, therefore, believe in the existence of really
ambidextrous persons.

Another point brought out was that, when blindfolded and told to
walk in a straight line, right-sided persons deviate to the right and left¬
sided to the left. This point is discussed at some length, with reference
to the circular movements of animals and the observations of Guldberg.

With regard to the origin of normal asymmetry, Biervliet is unable to
accept the theory that would account for it as a result of exercise;
such a theory assumes that at the outset perfectly symmetrical human
types exist. He is inclined to regard the tendency as inborn. He
suggests that the structure of the pelvis may possibly influence the
position of the foetus, and in abnormal cases favours the development of
the left side. It is in the development of the vascular system that he
would find the primary cause of right-sidedness and left-sidedness.

Havelock Ellis.

Researches in Cross-education . (Studies from the Yale Psych, Lab.,

1898). Davis , W. W.

The fact that the effects of practice on one side of the body are
in part transferred to the other side, was first recorded by Weber in
1858, and confirmed by Fechner. It has lately been studied in
detail at the Yale Laboratory by Mr. Walter W. Davis. The investi¬
gation consisted largely of experiments in rapidity of tapping on
a telegraph key, the movements only involving a small amount of
strength. As the weight of the finger was sufficient to press down
the button of the key, the test was one of motor ability, with the
factor of muscular power almost eliminated. The toes as well as the
fingers were experimented on. The effects of practice were found not
to be uniform, not only different individuals, but different members of
the same individual, showing great variations. Still certain funda¬
mental results appeared, and with few exceptions a marked increase in
rapidity of tapping was reached, this increase manifesting itself not only
in the member exercised, but in the other members as well. Age was
found to be an important factor, the effects appearing more slowly at
higher ages. The independent use of the great toe possessed by a Japanese

Digitized by VjOOQle

356

RETROSPECTS.

[April,

student served incidentally to emphasise the fact, already known, that
civilised feet, as a result of tight and badly made shoes, are losing their
natural powers. Another series of experiments showed that exercise
producing a gain in growth of one arm caused a similar, though smaller,
gain in the other arm. “ Here it would seem,” remarks the author,

“ is a provision by nature to prevent a one-sided development. If the
right side of the body received all the benefit of its excess of exercise
over the left, it would tend to outgrow it in much greater proportion
than is actually the case.” A series of experiments with the dynamometer
showed similarly an increase of strength on the opposite side. The
general conclusions were that the effects of exercise may be transferred
in a greater or less degree from the parts practised to other parts of the
body. This transference is greatest to symmetrical and closely related
parts. There is thus a close connection between different parts of the
muscular system, through nervous channels, the connection being
closer between parts related in function or in position. Will-power
and attention are educated by physical training, and when developed
by any special act they are developed for all other acts. The most
important effects of muscular practice are thus more central than
peripheral, and the chief central effect is the education of the motor
centres, the development of attention and will-power being secondary.

Havelock Ellis.

A Study of the Relations between certain Organic Processes and Conscious¬
ness. (Psych. Rev., January, 1899). Angell y J. R., and Thompson ,
Helen B.

Since Mosso, Lehmann, and F£r^ first investigated the relationship
of organic processes to psychic processes, there has been a tendency to
believe that agreeable sensations of emotional tone are connected with
dilatation of the peripheral blood-vessels, and disagreeable sensations
with constriction. Some of the more recent investigations tend to
throw doubt on the conclusion, and reference may be specially made
to a series of researches recorded in this paper. The experiments
consist of two very complete series of tests carried out on two subjects
with Hallion and Comte’s air plethysmograph for the capillary pulse
tracings, and a modified form of Bert’s respirator for recording the
breathing curves. Eight plates showing the curves accompany the
paper. These curves show no evidence of any marked and constant
correspondence of agreeable states with one set of physiological pro¬
cesses and disagreeable states with an antithetical set. None of the
various factors involved—vaso-motor level, rate and amplitude of pulse
curve, position and emphasis of dicrotic notch, rate and amplitude of
breathing,—change uniformly in one direction for agreeable experiences,
and in the opposite direction for disagreeable experiences. Almost
all the emotional experiences, pleasant or unpleasant, produced vaso¬
constriction, a result which the writers hold to agree with what the wrork
of Mosso and Binet would lead us to expect. The search for uni¬
formity in regard to the action of sensory stimuli proved as fruitless as in
the case of emotional states. The great majority of the sensory stimuli
produced vaso constriction, and the few cases of pronounced vaso-

Digitized by VjOOQle

1900.]

RETROSPECTS.

357

dilatation do not correspond to distinctly pleasant stimuli. The most
pleasurable stimulus, harmony, caused constriction, and unpleasant
odours, like camphor and capsicum, sometimes caused dilatation.

Having regard to the very various circumstances in which the
organism is called upon to respond to changing stimulation, the authors
are inclined to think that it is the regularity rather than the presence
or absence of one feature in the organic process, which is the most
characteristic expression of the total condition. They are led to believe
that the changes in circulation and respiration which accompany altera¬
tions of consciousness can be formulated in terms of attention, as
follows : when the attention process runs smoothly and uninterruptedly
the bodily activities (/. e . of respiration and circulation) progress with
rhythmic regularity. Relatively tense, strained attention is generally
characterised by more vigorous bodily movements than in low level,
gentle, and relatively relaxed attention, but both agree, so long as their
progress is free and unimpeded, in relative regularity of bodily functions.
Breaks, shocks, and mal-coordinations of attention are accompanied by
sudden spasmodic changes and irregularities in bodily processes, the
amount and evidence of such changes being roughly proportional to
the intensity of the experience. No reference is made by these writers
to the bearing of these researches on the physiological theory of
emotion. Havelock Ellis.

A Contribution towards an Improvement in Psychological Method.

(Mind y 1898.) McDougally IV.

In a recent series of articles, Mr. W. McDougall presents an able
and noteworthy attempt to formulate the problem of consciousness in
accordance with modern scientific conceptions. In doing this he
makes considerable use of various recent views concerning the function
of neurons, and also Stout’s doctrine of apperception translated into
terms of neurosis. The nervous system, he argues, in agreement with
many previous writers, consists of superposed systems of reflex paths,
together with a great mass of new neurons at the top of the system,
not yet, or only partially organised into reflex paths. The organisa¬
tion of these neurons into complex groupings constitutes experience,
and is accompanied by consciousness. The young animal has great
capacity for experience, and a varied and intense consciousness; in
the older animal, more ruled by habit, there is little experience. The
essential condition of the occurrence of consciousness is the making
of new nerve-paths, the establishment of new functional connections
between neurons. It is a logical inference from this, he proceeds,
that the adaptation of nervous reaction to environment in the part has
been accompanied by consciousness, even to some extent when the
instincts of the lower animals were organised, and further, that if an
animal becomes perfectly adapted to its environment, all the parts of its
nervous system would become mapped into well-organised paths of
automatic reaction, with absence of consciousness. He thinks it pro¬
bable that this state has been reached in the Brachiopod zingula,
which has remained unchanged since pre-Cambrian times. Man’s
environment, however, is so complex that the author does not think he

Digitized by VjOOQle

358

RETROSPECTS.

[April,

will ever thus lose consciousness and enter Nirvana. On the con¬
trary, the multiplication of neurons still continues to be effected at a
relatively more rapid rate than their organisation into fixed paths, with
ever-increasing possibilities of the establishment of new relations
among nerve-paths, and a more intense and varied consciousness.

The author protests against those who are always insisting that an
impassable gulf lies between “ mind ” and “ matter,” but who do not
seem to be aware that an equally impassable gulf lies between any two
forms of energy. He holds that “unless we assume that the mind
either destroys or creates energy, we must believe that consciousness is
subject to the law of the transformation and the conservation of energy ;
we must, in fact, believe that it is a form of energy, and that it has its
heat equivalent, that may some day be determined with more or less
accuracy.” As he sums up, “consciousness is the force that makes
mind, that makes of neural processes experiences, that consolidates
new reactions and thoughts into habitual mental processes, and habits
into instincts and reflex actions. We act so and so, not because we are
conscious now, but because we have been conscious in the past.”

In this connection reference maybe made to a highly ^competent and
valuable “Critical Review of the Data and General Methods and
Deductions of Modem Neurology ” (Journal of Comparative Neurology ,
1898), by Dr. Adolf Meyer, of the Worcester Insane Hospital, Massa¬
chusetts. It is too full to be summarised, but may be commended to
all who are interested in the bearings of neurology on psychiatry. The
author points out how the search for centres is giving place to the
search for mechanisms, and at the same time protests against what he
considers to be the premature theoretical definiteness in physiological
and pathological processes asserted by Ramon y Cajal, Andriezen, etc.

Havelock Ellis.

The Psycho-motor Problem . ( Amer . Joum . Ins., 1897, vol. liv,p. 59.)

Nichols , H.

He studies the relation of mental processes to muscular activity. As
regards “ reflex action,” he traces its development from Descartes in
1646 to modern times, when it is conventionally used to cover all
conversion of afferent to efferent impulses. Similarly with “ instinctive
conduct,” which covers reflex conduct due to inherited tendency.
Finally, he discusses at some length those processes which are com¬
monly classified under volition and will. In reality all these processes
are the same, only of greater complexity. “ Almost the bulk of the
transactions of life fall under the same reflex categories with pulling
one’s hand out of the fire, etc.” The occurrence of the conscious
deliberate “ I will do that—Fiat,” is an infrequent occurrence, and is
due to the formation of abstract concepts of “ our bodily self doing
things,” which have definite neural bases, which in turn have strongly
developed associational strength, and which, if not checked, become
actual deeds,—all in strict accordance with the laws of reflex psycho¬
motor co-ordination. J. R. Dord.

Digitized by VjOOQle

1 900.] RETROSPECTS. 359

The Scientific Border-line between Sanity and Insanity. ( Amer . Journ.

Ins., 1898, zw/. Iv, p. 219.) Bunge, E. C.

The subject is treated in a very scientific fashion. He accepts as an
indisputable fact the existence of some cortical areas as centres of
psychic function. Insanity is the symptom of any pathological process
implicating these centres. From both clinical and pathological stand¬
points we have no facts to justify us in separating the acute delirium
of fevers or acute alcoholism from insanity. In both there is irre¬
sponsibility, and both require treatment along rational lines. The
question is only one of degree. The real objection is contained in the
word “ insanity ” itself, which word is objectionable and unscientific,
and its disappearance would be hailed with genuine satisfaction.

J. R. Lord.

Art and Literature in the Mentally Abnormal. (Amer. Joum. Ins.,
1899, vol. lv,p. 385.) Hrdlecka, A.

He finds that among the insane there is seldom any manifestation of
any high talent, and usually the faculties are acquired when sane. His
paper resolves itself into the study of the effects of abnormal mental
states on previously acquired artistic tastes. As regards education in
the insane, he has collected statistics showing its degree in the various
mental disorders, which point out that, on the whole, education is hostile
to the development of terminal dementia, and is favourable to paranoia
and chronic mania in men, and acute melancholia and paranoia in
women. He found artistic and literary tastes most prevalent in para¬
noics and chronic manias, and least ih paretic and terminal dements.
The melancholic may indulge in poetry, but any artistic production of
the acute maniac is confused and shapeless. As a rule the insane
indulge in drawing and music, and occasionally in decorative art or
construction. The drawings are commonly symbolic or allegorical in
nature. Supernatural figures, mysterious objects, secret signs and
symbols, often occur. Religious objects are also frequent, and occa¬
sionally indecent drawings are produced, the latter mostly by epileptics.
Execution is often most elaborate, but commonly lacks in detail and
fine points. Painting is seldom done, more usually crayon, coloured
pencil, and pen-and-ink sketches. Female patients sometimes produce
symbolic embroider. A curious feature is that some insane never
finish their work. He continues the subject in much more detail,
taking up music, dancing, literature, the theatrical art, etc., seriatim,
forming in all an interesting and instructive paper. J. R. Lord.

Brain Anatomy and Psychology. (Amer. Journ. Ins., 1899, vol. Iv,
p. 449.) Baton, S.

He reviews some of the influences which have aided psychology in
passing from its metaphysical to its scientific periods. He greets with
delight the advent of the “ new psychology.” He points out that the
attempt to study mental disease from the clinical side has failed, equally
with the effort of the introspective psychologist to establish his system
for the study of the mind. He shows that the most rational ideas
depend upon a knowledge of cerebral structure, and the correlation of
the latter with function. J. R. Lord.

XLVI. 2 5

Digitized by VjOOQle

36 o

RETROSPECTS.

[April,

Experimental Psychology, {Brit, Med, Joum., May 13 th —20 th, 1899.)

In this occasional the subject is treated from a general standpoint,
forming an excellent risume, the perusal of which would be helpful to
the beginner. J. R. Lord.

Motor Mentalisation, {Scot, Med, Surg, Joum,, April, 1899.)

Bruce, L. C,

A short study of the physiological association of motor and mental
activity with clinical deductions.

It traces their connections by examining cerebral activity in sleep and
during voluntary acts, attention, will power, and speech. Two cases of
melancholia are quoted which exemplify motor signs retarding return to
the physiological, and treatment is indicated. G. A. Welsh.

Suggestion and Ancesthesia in Dental Operations [Suggestion et anes-
the sic dans les extractions dentaires], {Rev, de r Hyp., Dec,, 1899.)
Bloch, A,

The writer points to the great part which apprehension plays in the
sum total of the sufferings in the dental chair. But if it be possible to
suffer by anticipation, it is likewise possible to suffer in the retrospect,
and it is precisely in these preceding and succeeding stages that the
field for suggestion opens out. The sense of reliance upon the
operator, the desire that he should assure us of the complete painless¬
ness of the operation he is about to perform, the willingness to accept
what we suspect to be a lie,—these states constitute a frame of mind
eminently suited for hypnotic suggestion. It is a great deal to believe
that we shall not suffer, and to learn that we have not suffered; and, as
the writer insists, the same solution strength of cocaine will give
different results according to the power of make-believe of the operator.

Harrington Sainsbury.

On the Mental States involved in the Post-hypnotic Appreciation of Time
[Les etats mentaux impliqu'es dans Cappreciationpost-hypnotique du
temps], {Rev, de PHyp,, Nov, atid Dec,, 1899.) Miltie-Bramwell,

This very intricate subject is discussed by Dr. J. Milne-Bramwell at
some length. The phenomenon concerned is the power of impressing
upon a hypnotised subject the performance of a given act after the
lapse of a given time. The performance suggests a post-hypnotic
memory, but inasmuch as the hypnotic memory ceases in the waking
state the wonder is how the impression carries on ,from the one state
into the other until its fulfilment, and the more so since this fulfilment
may take place either in the waking or the hypnotic state or during
ordinary sleep. Dr. Bramwell cites a number of experiments of his
own, in which the performance of the act was commanded after some
thousand odd minutes which he, as the suggestor, carefully avoided
calculating out in days and hours at the time of the suggestion. The
performance took place duly at the appointed time, and strangely
enough this occurred, though the subject at the time of the command
when questioned as to date of the imposed command gave erroneous
answers, miscalculating the time. The views on this subject of

Digitized by

Google

1900.] RETROSPECTS. 361

Bernheim, Beaunis, Delfcoeuf, Gurney, Janet, and of the author are
given, but they do not pierce the mystery.

Harrington Sainsbury.

The Psychology of Hierology [Les lots psychologiques de rhierogcnie].

(Rev. de I'Hyp ., Dec., 1899.) Binet-Sangle, C.

We are promised the study in succession of the devotional type and
its variants, also of religious suggestion, religious contagion, and the
developments of sects. Dr. Charles Binet-Sangle selects the Port
Royalists as examples of the devotional type, and finds in them
unhealthy, sickly beings with neurotic tendencies, “ leading an abnormal
life because themselves abnormal.” The description does not quite
seem to fit the stature of the whole man. Blaise Pascal and this
morbid anatomy of the saints strike us occasionally as rather inside
out. Harrington Sainsbury.

Raise Evidence by Suggestion [Les faux temoirgnages suggeres ]. (Rev.
de PHyp., Jan., 1900.) Joire, P.

He refers to this important subject under three headings: 1st, the
intentional suggestion of false evidence to the witness, who has been
hypnotised for the purpose; 2nd, false evidence through aw/<?-suggestion,
the witness belonging to the hysterical class; 3rd, the unintentional
suggestion of false evidence to, and the unwitting reception of the
suggestion by, the witness. The first category is of minor importance
because, though possible, it is unlikely by reason of its complication;
the second is of well-recognised importance; but the third, which may
be styled suggestion by the leading question, is less recognised, yet is of
great importance, more particularly in the legal examination of children
and of the impressionable. It behoves the doctor, as well as the lawyer,
to have it prominently in mind. Harrington Sainsbury.

Binocular Illusions [Les illusions binoculaires\ (Rev. Scient., Aug.,
Sept., 1899.) Dissard, M. A .

The author here analyses the phenomena of neutralisation in mono¬
cular vision and in diplopia, the neutralisation of phosphenes, the
phenomena of total neutralisation of the excitation of one eye (e.g. in
microscopy), etc.

As a result of his investigations he concludes that we may conceive
the unification of the perceptions of each eye in binocular vision
occurring in the following ways :

1. The perception of points of the common binocular field situated
upon the horopteric surface takes place by the fusion of the correspond¬
ing excitations of the two retinae.

2. The perception of points situated beyond the horopter takes place
by the neutralisation of the decussated excitations and the juxtaposition
of the direct excitations which are brought together in consciousness
along the antero-posterior diameter of the eye, or “ line of juxta¬
position.”

3. The perception of points situated in front of the horopter takes
place by the neutralisation of the direct excitations and the juxta¬
position of the decussated excitations.

Digitized by VjOOQle

362

RETROSPECTS.

[April,

4. Parts which are not common, seen mdhoculariy, harmonise with
binocular perception all the more easily that they are more distant on
account of the predominance in the vision of the eye of the corre¬
sponding side. H. J. Macevoy.

The Neuron and Cellular Memory [Le neurone el memoire eellulaire\
(Rev. Sclent., September gtk, 1899.) Renaut,J.

This is the subject of an eloquent introductory address given at the
University of Lyons. The morphology of the neuron, “ of which many
people speak learnedly, without taking the necessary step of carefully
studying it ” is described, taken with its pole of reception and its pole
of application (the extremity of the axon), and compared to a tree, such
as the palm, the central nervous system as a whole being a forest in
which the trees, shrubs, etc., intertwine their aerial and subterranean
offshoots, without there being true continuity.

Concerning the fascinating theory of nervous amceboidism to explain
the articulation of the neurons during the passage of the nervous wave,
Renaut recalls that it was in vainly searching for the pseudopodic
movements in living nerve-cells that he found something else—the
beaded appearance in the active branches of the neurons. With the
aid of the admirable method of the injection of methyl blue in the
blood of a living animal, the extremities of the processes of the neurons
are found to be free, but at their extremity they are kept in a fixed spot
by adhesive contacts (like the branches of ivy to a wall); and secondly,
at the level of their active arborisations, a certain number of branches
cease to be quite uniform and smooth like threads, and become
beaded (hence Stefanowska’s subsequent term “ pyriform appendices ”).
Renaut thereupon bases an hypothesis that one may consider the
variations in the beaded disposition, which are innumerable, as corre¬
sponding to the conditions, equally variable, of an accommodation of
the receptive nervous filaments to the passage of the wave projected
upon them by the inducing filaments (an analogy with the consonance
of two violins). Concerning the memory of cells, the author believes
that one of the most remarkable properties of the neuron is the aptitude
which it seems to possess of superposing in itself distinct memorial
impressions. He argues also in favour of the presence of recognition
as an attribute of the neuron. In conclusion he says, “ I am led to
believe that of all hereditary qualities, cellular memory, of which so
little has been heard hitherto in biology, has nevertheless played the
most important part in organic (and especially human) differentiations.”

H. J. Macevoy.

4. Etiology of Insanity.

Heredity and Insanity. (Amer. Joum . Ins., 1897, vol. liv, p. 227.)

Steams, H. P.

He takes exception to the teachings of Du Bois Raymond and
Weismann regarding the transmission of acquired characters. Ac¬
cording to Weismann unicellular organisms are propagated by a division

Digitized by VjOOQle

1QOO.]

RETROSPECTS.

363

into two, each part inheriting perfectly the characters of its parent.
With regard to multicellular organisms, during the process of evolu¬
tion there has occurred a division of the cell into germ cell and somatic
cell. The former cannot be influenced by the changes in the latter,
which are due to decay or hyper-development, because the ovaries are
so thoroughly isolated during both embryonic and mature life. If
influenced at all, the effect must be very slight. In other words, the
production of apparent acquired characters cannot, or only in a slight
degree, be transmitted to a future generation. Dr. Stearns makes a
grave assault on this doctrine; he points out the undoubted influence
of heredity in the production of insanity. He claims that the ovaries
depend absolutely upon their connection with the brain in discharging
their function. #

Many arguments are forthcoming; and from many considerations,
anatomical and otherwise, it would appear that the germ plasm, con¬
taining elements which constitute the representatives of future organisms,
must be influenced by the continuous stream of nerve stimuli radiating
from the brain, and thereby by the characters of the latter.

J. R. Lord.

Relations between Neuralgia and Transitory Psychoses. (Alien, and
Neurol., July, 1899.) ^ Kraft-Ebbing.

Professor v. Kraft-Ebbing observes that neuralgia may simply co¬
exist with mental disturbance, or it may be related to it aetiologically.
Pain as a cause may act psychically, producing a state of acute excite¬
ment or delirium; or it may act organically, /. e. by strong centripetal
stimulation of the cortex, which results in a state of morbid excitability
characterised by hallucinations, incoherence, and amnesia. Illustrative
cases are given. W. F. Penfold.

5. Clinical Neurology and Psychiatry.

The Clinical Position of Melancholia [Die klinische Stellung der
Melancholie\. (Monats. f. Psych, u. Neur., November , 1899.)
Kraepelin.

Professor Kraepelin first points out how the term melancholia has
become narrowed in its use by the exclusion of certain forms of
depression. He believes ordinary melancholia is distinguishable from
the depression of cyclical insanity. In his opinion, if a melancholia
show great intellectual and volitional circumscription and no great
affective disturbance, and occur before the thirtieth year, it is probably
a cyclical melancholia. He believes that melancholia which is going
to end in dementia praecox is more or less characteristic. Professor
Kraepelin closes his paper lamenting the imperfect methods of psychical
research at our disposal. W. F. Pen fold.

Recurrent Insanity: an Analysis of Relapsed Cases. (Glas. Med.
Joum., December, 1899.) Kerr, H.

A medical, psychological, and statistical inquiry into the causes,
nature, symptoms, and results of “ recurrent cases ” of insanity.

Digitized by VjOOQle

364

RETROSPECTS.

[April,

The statistics are compiled from 450 cases, and deal with—1st, the
percentage of recoveries in such cases as compared with other curable
cases of insanity; 2nd, the various factors in causation—heredity, epoch
of life, extrinsic causes ; 3rd, the termination.

The medical and psychological examination discusses—1st, the
nature of the heredity; 2nd, bearings of predisposing and exciting causes;
3rd, the mental features ; 4th, the mode of termination.

In conclusion, the opinions formed are tabulated, and the material
relations of medical and statistical facts formulated. G. A. Welsh.

Two Cases of Ephemeral Mania. (Ppt. Ann . Meet. Queb. Med.-Psych.

Soc., October, 1899.) By Dr. Burgess.

A record of two interesting cases of ftvere acute mania, lasting in
one case less than forty-eight hours, and in the other twenty-two hours.
In neither was there any factor like epilepsy, alcohol, or parturition.
In the first case the attack began with a sudden fear while in a railway
restaurant. The other case had insane heredity, and developed during
the attack, visual and auditory hallucinations, and apparently was the
result of fright. No evil results followed in either case, and both were
treated by a single dose of hyoscine hypobromate hypodermically.

J. R. Lord.

Two Cases of Auditory Peripheric Hallucinations . (Kept. Ann. Meet.

Queb . Med.-Psych. Soc., October , 1899.) By Dr. Chagnon .

The special point about these cases was that it was absolutely
necessary for them to undergo auditory or tactile impressions to expe¬
rience auditory hallucinations. Both apparently had abnormal mental
histories, the one having marked loss of will power (aboulia), the other
showing but slight intelligence. Any sound, such as that produced by
the patient or some other person walking, the pouring of water in a
glass, or the rumpling of paper, etc., awoke voices. J. R. Lord.

Acute Delirious Mania . (Joum. Nerv. Ment . Dis., Dec ., 1899.)

Mann, F. J .

The subject is approached from a purely clinical aspect. It contains
a full exposition of its claim to be recognised as a specific entity, of
its origin, course, symptoms, termination, and treatment.

Pathology deals chiefly with its origin, describing its bacteriological
connections, but there is a short paragraph on the actual changes pro¬
duced in the nervous system.

The onset, course, and symptoms are illustrated by cases, and allied
conditions from which it must be differentiated are described, as are also
useful points to aid a prognosis. The author gives statistics of his
experience regarding the termination.

General lines of treatment are indicated. G. A. Welsh.

States of Over-excitability , Hypersensitiveness, and Mental Explosive¬
ness in Children, and their Treatment by the Bromides. (Scot.
Med. Surg. J.,June, 1899.) Clouston, T. S.

A clinical description of “ Nervous States ” which are liable to occur
in children with a neurotic predisposition during the earlier stages of

Digitized by VjOOQle

RETROSPECTS.

1900.]

365

mental development, with special reference to the action of bromides
in reducing the explosive tendency.

Pathology .—Locus: Cortex cerebri. Condition: (1) an explo¬
sive tendency in various cells; (2) a diminution of the influence of
inhibitory cells. Consolidation of centres with development of con¬
necting strands (Flechsig) is discussed.

Clinical .—The common feature of the various states is exaggerated
action: the symptoms vary with the function of the cells affected. Treat¬
ment : dose and administration of bromides, auxiliary medical, dietetic,
and motor r'egime . G. A. Welsh.

A Cast of Epilepsy coming on after Ovariotomy [Epilepsie convulsive
survenue aprte une ovariotomie\ {Rev. de Psych., Sept., 1899.)
Marchand , L .

A woman, aet. 43 years, was admitted into Villejuif asylum suffering
from epilepsy with melancholia.

The history was that, having previously had good health and of good
family history (except that her mother had paraplegia), she had double
ovariotomy performed at the age of twenty-two years for cysts. During
the months following, she felt flushes and heats in the face. Two
months after the operation she had her first epileptic fit, and has
suffered from them ever since. At first, the fits seemed to be monthly and
periodical. At the present time, she has about four per month; they
are typical of epilepsy, and she once burned herself during an attack
(scars seen). Occasionally she has trembling of the head and a hot
feeling in the face before the fit. H. J. Macevoy.

Atheromatous or “ Arthritic” Pseudo-General Paralysis [La pseudo -
paralysie generate arthritique\ {Rev. de Psych., Dec., 1899.)
Klippel.

While relying especially on the accompanying symptoms referred to
other organs (/. e. outside the brain) in differentiating the atheromatous
form of pseudo-general paralysis from true general paralysis, the author
draws attention to the differences in the signs and evolution of the two
diseases, which often, though not always, exist (cf. more frequent
association of early slight hemiplegia; less marked delusions due to
more marked dementia; absence of infection; infrequency of febrile
attacks; closer relation to senile dementia ; less marked trophic affec¬
tions in the terminal period; death more frequently the result of arterial
lesion). The pathological lesions in the brain are quite different.

The notes of a typical case of atheromatous pseudo-general paralysis
recently observed are given. A shoemaker, aet. 43, admitted under
Klippel in April, 1899. At age of 35 : syphilis ; in 1895 : slight tem¬
porary R. hemiplegia; in June, 1898 : slight L. hemiplegia ; progressive
loss of memory and general enfeeblement; affection of speech charac¬
teristic of general paralysis; slightly unequal pupils; dementia. The
associated symptoms were : signs of aortic atheroma and aortic regurgi¬
tation. Atheroma of peripheral arteries. Signs of interstitial nephritis
(albumen, etc.).

Death was due to cerebral haemorrhage on Oct. 13th, 1899, and the
autopsy revealed cerebral haemorrhage from atheroma of cerebral

Digitized by VjOOQle

366

RETROSPECTS.

[April

arteries and of pia mater. No lesion or inflammatory encephalitis.
Degeneration of arterioles and nervous elements without signs of
diapedesis. Negative bacteriological examination.

H. J. Macevoy.

A Case of Post-operative Mental Confusion [.Relation (Tun cas de con
fusion mentale post-operatoire\. {Arch, de Neur., Oct., 1899.)

Fenayron.

In view of the great divergence in opinions concerning the aetiology
and characteristics of post-operative insanity, the author gives full notes
of an interesting case occurring in a pedlar, aged 60 years, born of
an unstable and alcoholic stock, and himself at one time addicted to
drink. Eight days after ligature of his left axillary artery for aneurysm
—the operation being complicated with septicaemia and high fever—
he became incoherent, excited, confused, and went through an attack
of mental confusion, with periods of excitement and depression, and a
morbid dream-like state (“ d&ire onirique ”). As the confusion of ideas
disappeared, some intellectual impairment and slow ideation persisted.
After nine months, recovery took place with mental enfeeblement.
Infection here seems to have been the determining cause of insanity
in a predisposed subject; but the author does not admit that there is
any special type of psychosis which can be termed post-operative.

H. J. Macevoy.

Fixed Idea [.Didee fixe ]. {Arch, de Neur., Aug., 1889.) Keraval, P.

Notes of fifteen cases are given, exhibiting the presence of fixed
or dominant ideas in various forms of insanity, with their characteristics
and the part they may play in the evolution of the disease. Two are
cases of melancholia. In eight cases the fixed idea occurs in degene¬
rates ; often for a time this apparently constitutes the sole delusion,
but sooner or later there are added delusions, and chronic delusional
insanity is the result. The others are cases of chronic delusional
insanity. Here, the fixed idea is a picture at the base of an edifice of
errors, although the execution in its architecture appears correct. Many
of the cases correspond to what has been called monomania or partial
insanity. Some hallucinations may be the starting-point; more
commonly the disorder is in the intellectual sphere, and the fixed idea
is the primary initial pathological phenomenon. The fixed idea-un¬
reasonable, insane, sudden,—is, as a rule, related to the patient's own
self, who is victimised or about to be. Hallucinations frequently
follow. Wernicke's cases of prevailing idea culminating in systematisa¬
tion belong to this class. H. J. Macevoy.

Psycho-motor Hallucinations {Verbal) in Alcoholism [Zes hallucina¬
tions psycho-motrices verbales dans Palcoolisme\ {Arch, de Neur.,
Nov., 1899.) Cololian, P.

The notes of four cases are recorded presenting this symptom
(rare in alcoholism) in association with hallucinations of hearing and
sight. In one case it is a voice, inarticulate, without quality, which
is nevertheless heard by the patient, and which answers the questions
put by the voices heard from outside—thus constituting a singular

Digitized by VjOOQle

RETROSPECTS.

367

1900.]

dialogue between the internal voice and the voices outside. At one
time this internal voice is thought by the patient 10 be her own auto¬
matic voice.

In the second case the voice is inarticulate but well understood, and
speaks in the patient’s stomach; it has no quality, but is clear in
expression; while these motor hallucinations are going on, the patient’s
tongue moves and becomes dry; there is also a certain oppression in
the chest.

In the third case the patient hears a blowing, a fluid in the chest,
throat, and head, but does not hear it through the ears; it is not an
articulate voice; it is a divine fluid, and she understands it. At the
same time, in this case also, the tongue moves in her mouth.

In the fourth case the patient says “ One speaks in my head ; I cannot
say whether it is the voice of a man or of a woman ; it has no quality.”
The voice also speaks at times in the chest, and at the same time there
is a kind of pang in the gastric region.

The author discusses the production of verbal motor hallucinations—
probably the reproduction of sensory, motor, and verbal images with
morbid intensity. The erethism of the cortical centre for language
extends to neighbouring centres—hence the association of certain
tactile and muscular sensations, etc. H. J. Macevoy.

A Case of Morphino-dipsomania [ Urt eas de dipsomanie morphinique\
{Rev. de Psych ., Nov., 1899.) Antheaume and Leroy .

The interest of this case lies in its being what the authors call true
morphinomania or morphinic dipsomania, characterised by anxious
irresistible impulses to morphia-taking in a degenerate patient subject
to other obsessions, alcoholic dipsomania, wandering, etc.

Estelle B—, aet. 32 years, admitted at Sainte-Anne Asylum under
Dr. Magnan, February nth, 1895. From the early age of eleven
subject to obsessions; at sixteen years takes a lover; has morphia
injected to soothe neuralgia at the age of nineteen years, which leads to
her becoming a chronic morphinomaniac. During eight years she gets
through a daily dose of over thirty grains, and her history is one of
gradual mental, moral, and physical degradation, fairly typical of such
cases. After the death of her lover (also a morphinomaniac) in 1892
she halves her daily allowance of morphia, but is soon compelled to
sell her belongings to satisfy her craving, and after an attempt at suicide
is taken to Sainte-Anne Asylum. During the treatment by rapid
gradual suppression she goes through the usual tortures (hallucinations,
insomnia, sensation of cold, diarrhoea, etc.), but rapidly improves. The
catamenia, absent for five years, reappear within a month of admission
(on March 3rd). Subject to frequent impulses and cravings for morphia,
on June 25th she breaks open a poison-cupboard and injects herself
with morphia. In July her obsessions return at the sight of another
patient who is injected twice daily, and a little later she satisfies her
craving by swallowing some morphia, which she obtains after stealing an
attendant’s keys. In November she is discharged, but within a month
she relapses again, and is readmitted at Sainte-Anne on January 16th ;
under treatment (sudden suppression of injection with a little opium per
os) she rapidly improves, but never loses her obsessions. After her

Digitized by VjOOQle

368

RETROSPECTS.

[April,

second discharge on June 26th, she had within the author's knowledge
two attacks of morphinomania of short duration (obsessive) without
relapsing into habitual morphinisation. H. J. Macevoy.

Dreams related to Attacks in Epileptics \Les sotiges dattaques des
epileptics\ (Journ . de Med. de Bord . 9 Nov . 26 th y Dec. 3 rd y 1899.)
Ducoste, M.

Certain epileptics, from the characters of their dreams, can tell when
they have had fits during the night. This is the point which the author
studies in this paper, fully convinced of its importance in the early
diagnosis of epilepsy, and convinced also that, if dreams were more
scientifically investigated, many cases of epilepsy would be detected
early, and perhaps cured.

Four cases presenting “attack dreams ” are given; these dreams are
painful and terrifying. Their characteristics are—a. They occur only
when the patients have attacks. / 9 . They do not occur outside the
attacks, y. They occur during the attack (not before or after), so that
the first conclusion is that there are special dreams—always the same in
the same patient—which overwhelm consciousness during an epileptic
attack. An examination of these dreams shows that in the crisis itself
there appear to be four marked phases. Another characteristic is the
predominance of red in the dreams (blood, fire, sun, etc.).

Such characteristics are not met with in the dreams of non-epileptic
individuals ; hence their importance as regards the diagnosis of epilepsy.
The author believes also that they may be of help m prognosis and
treatment In this connection he refers to the question of the part
said by certain alienists to be played by dreams in the production of
insanity (“post-oniric psychosis ”). Is it not possible that the incrimi¬
nated dream is an “ attack dream,” and the oniric psychosis in reality
post-paroxysmal ? H. J. Macevoy.

Recovery from Insanity after Operation on the Uterus \Heilung einer
Psychose bei Uterusmyom nach Totalextirpation\. (Wiener hi.

Wochensch., Nr. 29, 1898.) Elzholz , A.

An unmarried woman of forty, with neurotic heredity, had suffered
since June of 1894 with profuse menstrual discharges followed by
weakness, emaciation, palpitation, dyspnoea, loss of appetite, and
troubles of digestion. There was a great failing in mental vigour with
melancholy, which culminated in an attempt at suicide. This was
followed by recovery, which lasted for a year, after which the symptoms
again returned. A residence in the country restored her health, but in
the autumn of 1895 profuse and continued discharges of blood were
followed by severe pains in the lower abdomen, mental depression,
with occasional paroxysms of distress and hallucinations. In July,
1896, there was a second attempt at suicide, and later, outbursts of fury
following severe pains. On examination there was found endometritis
glandularis, metritis, and a myoma at the fundus. In March, 1897,
total extirpation of the genitals was performed. This was followed by
speedy bodily and mental recovery. W. W. Ireland.

Digitized by VjOOQle

1900.] RETROSPECTS. 369

Brain Bankruptcy of Business Men. (AHen. and Neur., July, 1899.)

Hughes, C. H.

A consideration of the early symptoms of brain exhaustion, with a
practical discussion on the follies of mismanagement as regards treat¬
ment, frequently seen in the termination of such cases.

G. A. Welsh.

Alcoholic Epilepsy [Alkohol und Epilepsie\ ( Allgem. Zeitsch. f
Psych., B. Ivi, H. 3.) Bratz.

In this long article of fifty-one pages, he arranges his cases, sixty-seven
in number, into three groups:—1. Patients who before the beginning
of the habit of drunkenness have had some epileptic attacks. 2.
Patients who before drunkenness had an unhealthy nervous system or
mental weakness. 3. Patients who before drunkenness were quite
healthy. A heredity neurosis of one kind or another was noted in
88 per cent, of Bratz's cases of alcoholic epilepsy. In most instances
of epilepsy directly caused by the misuse of alcohol, the tendency to
convulsions passes away with the drunkenness, or returns with it. The
first epileptic attack generally occurs about the end of a bout of
drinking, but it is commoner amongst steady soakers than amongst those
who only get drunk occasionally. In those affected with alcoholic
epilepsy there are other nervous disorders, such as a feeling of pressure
upon the nerve-trunks, dulness of touch or hyperaesthesia, a low or
over-great sense of pain, cramps, tremors, and startings of the muscles.
The vision was impaired in nine cases out of thirty-one. Headaches
and sleeplessness were frequent. There was much mental dulness in
those admitted to the hospital, but this wore off in part in a few days.
Most of them, however, continued to suffer from general listlessness,
weakness of memory, and obtuseness of the moral sense, similar to
that which is observed in habitual drunkards who are not epileptic.
Dr. Bratz observes that the weakening of the mental faculties in
alcoholic epilepsy is generally not so marked as in cases of ordinary
epilepsy coming on between the twentieth and fortieth years of life.
Some of those affected with alcoholic epilepsy have little toleration of
alcohol and suffer severely from the after effects of indulgence, though
incapable of abstaining from drink. He tells us that alcoholic epi¬
leptics are a very low class, outcasts from their families, beggars and
vagabonds, or have fallen into the hands of the police. In those cases
in which the epilepsy has become fixed and outlasts the indulgence in
liquor, the pathological lesion has been found to be arterial sclerosis,
especially affecting the walls of the finest vessels of the brain.

W. W. Ireland.

Mongolian Imbecility in Infants. (Pract. Dec., 1899.) Sutherland,

G . A.

This paper embodies the result of the writer’s observations upon
Mongolian imbecility in infants. In this variety, he tells us that the
ligaments of the large and small joints are loosely strung, so that on

fting a foot one can rattle the bones of the knee and hip-joints, hyper-
extend the knee, and find the ankle and toe-joints abnormally mobile.

Digitized by VjOOQle

370

RETROSPECTS.

[April,

In the cases examined after death, he has found the thymus, the thyroid,
and the supra-renal glands to be healthy. Treatment by the thymus
and thyroid extracts has been found useless. W. W. Ireland.

Trophad'cmc chrortiqut here ditaire. (. Nouv. Icon. de la Salpt ., Nov .—
Dec., 1899.) Meige , H.

He describes two young women who had tumefaction confined to the
right leg. Some instances of this perversion of nutrition have also been
described by Drs. Melroy, of New York, Vigouroux, and Falcome.
From cases published of this rare affection, it is clear that it runs in
families. In the cases described it seems to have descended from the
maternal side. Engravings are given of eight members of the same
family so affected in some parts of the lower extremities.

W. W. Ireland.

Chronic Thyroidal Fibrosis [D Hypothyroidie benigne chronique, ou
Myxcedeme fruste\ (Nouv. Icon, de la Salpt., July — Aug., 1899.)
Hertoghe, E.

This is a long article on an affection which has been already described
by Dr. George Murray, under the title of the Diagnosis of Early
Thyroidal Fibrosis. Dr. Hertoghe remarks that there is an infinity of
degrees between the perfect health of the thyroid gland and pronounced
myxoedema. In some cases where the gland is insufficient there is still
much intellectual activity and tolerable health. Generally, however,
there is habitual apathy with a tendency to corpulence. In children so
affected the growth is retarded, puberty is delayed, and even when they
grow up they retain an infantile appearance. Dr. Hertoghe’s descrip¬
tions are illustrated by numerous engravings, which are very clear and
striking. In this disease the use of the thyroid by the mouth is almost
always attended with benefit. W. W. Ireland.

Folie d Trois. (Neur. Cbl., No. 12, 1899.) Bouman, L.

He records the case of three brothers who were received at the same
time into the asylum at Bloemendal on March 7th, 1897. The
youngest of them was first affected. At the beginning of the year it
was noticed that his character was changed. He lost the desire to
work and complained of lasting weariness. On February 21st he began
to have maniacal attacks. Eight days later he disturbed the worship in
a church, and when turned out began to take off his clothes in the
streets. They put him into a strait jacket. The second brother, who
had to look after him, was much excited, and on February 28th became
restless and unmanageable. The day after the oldest brother also
became maniacal. On admission the three brothers were violent;
sometimes their fury ceased and they blessed one another, always using
the same words. The youngest brother was unquiet, incoherent,
destructive, resistive, and refused food. He improved slowly, so that
he could be discharged on July 21st; from later accounts it appeared
that the recovery continued. The second brother remained quiet for a
while after being separated from the others. He was dismissed on
September 14th, almost completely recovered. The oldest brother also
showed incoherent speech, with ideas of grandeur and religious notions.

Digitized by VjOOQle

1900.]

RETROSPECTS.

371

He said that he must do what his youngest brother wished. He
improved gradually, and was allowed to return home on May 17th.
The father of these three brothers was also restless and excited, spoke
much, and showed abnormal religious ideas. During the fits of excite¬
ment, he believed that he was driven about by spirits; but the attacks
passed away in a fortnight and he became well. W. W. Ireland.

On Injuries to Peripheral Nerves . . ( Pract., Aug., 1899.) Horsley, V.

He classifies injury to nerves in four classes, viz.: 1st, division; 2nd,
contusion; 3rd, compression; 4th, stretching. He discusses their
diagnosis, prognosis, and treatment, and gives illustrative cases. He
further discusses the influence of such lesions in the production of
neurasthenia, and the consequent difficulty of determining the value of
pain, peculiar sensations, loss of power, and similar symptoms.

W. F. Penfold.

Amnesic Aphasia [Aphasie amnesique\ (Nouv. Icon. de la Salpt.,
Nov. — Dec., 1899.) Trend.

He records the notes of two cases, in one of which there is an
account of the autopsy (with plates showing lesion). The predominant
symptom is amnesia of nouns, visual perception and psychical vision
being intact. A large subcortical haemorrhage, the lesion found in the
first case, supports Pitre’s view that these cases of subcortical aphasia—
aphasia of conductibility is perhaps a better term—arise from rupture
of the commissural fibres which connect the differentiated centres
for verbal images to those parts of the cortex which preside over
the higher functions. Clinically we observe in these cases amnesic
aphasia. The possibility of some lesion existing in the cortical cells
belonging to the system of the association fibres destroyed, and which
might explain the symptom, is not excluded in Trend’s case, as only
macroscopical evidence is given. H. J. Macevoy.

Post-epileptic Hemiplegia of Short Duration. (Glas. Med. Joum.,
December, 1899.) Gibb-Dunn, W.

Although such cases are not uncommon, yet the case recorded
presents peculiar features. The fit was of the slightest description,
and resulted in paralysis of left arm and leg, right side of face, and loss
of articulation. Condition lasted under half an hour. J. R. Lord.

Anomia and Paranomia. (Joum. Nerv. Ment. Dis ., December, 1899.)

Mill, C. K.

A peculiar form of aphasia in which the patient could recognise
objects by sight, hearing, touch, taste, smell, but was unable to give
names. There was no other symptom of focal lesion. There was
limited spontaneous speech (without concrete nouns), no agraphia,
word or letter blindness. He had also a marked form of paralexia
or paranomia. J. R. Lord.

Digitized by VjOOQle

372 RETROSPECTS. [April,

Hereditary Syphilis in an Infant resembling Cretinism, cured by
Mercury. (Dub. Journ. Med. Sc., December, 1899.) Wallace,

JR-

A record of a child presenting symptoms of inherited syphilis and
cretinism, who developed fits, evidently the result of hydrocephalus.
Child became quite well after a course of mercury and iodide of potash.
Two cases of undoubted cretinism, with suspicions of hereditary
syphilitic taint, who did well on mercury, are mentioned.

J. R. Lord.

On Cases of Myofathy. (Pract., June, 1899.) Beevor, C. E.

This is a clinical lecture on cases of idiopathic progressive muscular
atrophy, an affection of the muscles themselves, and not of the spinal
cord or peripheral nerves. He divides his cases into: 1st, pseudo-
hypertrophic paralysis. Of this variety he describes three cases. 2nd,
a juvenile form of muscular atrophy, first described by Erb. 3rd,
facio-scapulo-humeral type, first described by Landouzy and D£j£rine.
A pure case of the latter is given, and also a mixed case. The points
helping in diagnosis are: 1st, the distribution of the affected muscles ;
2nd, the absence of fibrillary contractions, and 3rd, the electrical
reactions. The prognosis is regarded as more hopeful than in spinal
cord lesions, excepting the pseudo-hypertrophic cases. The prognosis
is better in adults than in early life. Pathologically there occurs a
fatty and fibrous change in muscle, and then a granular degeneration.
Indications for treatment are scarce. J. R. Lord.

A stasia-Abasia. (Amer. Journ. Med. Sc., July, 1899.) Wilson, J. C.

The history of this curious syndrome is given with complete references,
and in addition a new case is contributed in detail, in which the patient
had to be taught systematically how to stand and walk. Motion,
co-ordination, and sensation were unaffected. J. R. Lord.

StriimpelPs Paralysis (Polio-encephalitis) combined with Infantile para¬
lysis. (Lane., July 1st, 1899.) Williams, E. C.

The clinical details of a case are given, and its aetiology discussed.
The lesion was a double one, both upper and lower motor segments
being affected; the suggested cause being the same toxic poison which
as a rule produces polio-myelitis alone. J. R. Lord.

Periodic Paralysis: a Study of a Case of Family. (Amer. Journ, Med.
Sc., Nov., 1899.) Mitchell, J. K.

A carefully detailed account, giving the electrical reaction of muscles
and chemical examination of the urine. Reference made to a paper
by E. W. Taylor (Tourn. Nerv. Ment. Dis., September and October,
1898) containing complete bibliography of previous work and analysis
of recorded cases.

Hemorrhage into the Ventricles of the Brain: Clinical Details and
Necropsy. (Scot. Med. Surg. Journ., Feb. 1 Sth, 1899.) Adamson,
R. O.

Convulsive attacks of unusual character brought on by haemorrhage
into the left cerebral hemisphere, and subsequent effusion into the
ventricles.

Digitized by VjOOQle

1 900.] RETROSPECTS. 373

Kernigs Sign in Meningitis . ( Amer. Journ . &., 1899.)

Herrick, J. B.

If the patient assumes the sitting posture with the thigh at right
angles to the trunk, or if, lying upon the side or, better, upon the back,
the thigh be flexed to a right angle with the body, then, if meningitis be
present, it will be found that extension of the leg at the knee is strongly
resisted; this is Kernig’s sign, and the investigations of Bull, Henoch,
Friss, Blumm, and more recently Netter, confirm its value. Dr.
Herrick adds nineteen cases of meningitis, in seventeen of which the
sign was present, i. e. a percentage of 89*4. Rise of intra-cranial
pressure does not appear to be the cause, as Bull has suggested.

Harrington Sainsbury.

Diagnosis 0/Locomotor Ataxia. (Medecine, Nov., 1899.)

Patrick, H. T.

The typical case of this disease with pronounced inco-ordination is
recognised at a glance, but inco-ordination may delay many years,
hence the importance of diagnosing the disease manifesting itself by
such symptoms as “pains, uneasiness, or numbness in the legs or
elsewhere, failure of vision, ocular paralysis, bladder trouble, refractory
constipation or rectal tenesmus, ‘ bilious attacks/ or attacks of gas-
tralgia, diminished sexual power, anaesthesia of the face, indolent ulcer
of the foot. ,, Di. Hugh Patrick discusses this problem in short compass
but very clearly. Harrington Sainsbury.

A Case of Mental Torticollis \ Un cas de torticolis tnentaf\. ( Nouv.

Icon . de la Salpt., Nov. — Dec., 1899.) Noques andSirol.

Drs. Noqufes and Sirol report a case of this particular form of spasmodic
wry-neck described by Brissaud. Under the influence of the will the
spasm would momentarily cease, and a pressure on the side of the
nose, cheek, or chin, wholly inadequate to overcome the spasm, would
abolish it. The patient showed evidence of a neurotic taint as a
stutterer by inheritance. Harrington Sainsbury.

Two Cases of Hemiplegia with Hemiancesthesia. (Arch. deNeur.,
Oct., 1899.) Mongour and Gentes.

(1) Female, set. 65 years, was seized suddenly with apoplexy and
complete left hemiplegia with left hemianaesthesia. About a month
later the anaesthesia was replaced by hyperaesthesia. At the autopsy
(death two months after seizure) a cerebral haemorrhage was found
which had destroyed the posterior third of the lenticular nucleus and
optic thalamus, and the posterior third of the lenticulo-optic segment
of the internal capsule.

(2) Male, aet. 68 years, was seized with sudden right hemiplegia

(complete) and progressive right hemianaesthesia. The post-mortem
(death occurring nine days after the seizure) revealed old cerebral
softening, with a cerebral haemorrhage having destroyed especially the
posterior part of the lenticular nucleus and the posterior third of the
lenticulo-optic segment of the internal capsule. The nature of the
hemianaesthesia in these cases is discussed. H. J Macevoy.

Digitized by VjOOQle

374

RETROSPECTS.

[April,

Suppurative Meningitis simulating the Syndroma of Weber supervening
in an Alcoholic in the Course of Facial Erysipelas. {Rev. de Psych.,
Sept., 1899.) Vigouroux and Vignicr.

Male, set. 23 years, was admitted into hospital suffering with erysipelas
of the face, fever, etc. On the fourth day he developed complete left
hemiplegia with some ptosis, and deviation of the right eyeball down¬
wards and outwards. Abdomen swollen; constipation.

Nausea and vomiting appeared with convulsions (generalised, but
predominating on the left side). From the fourth to eighth day less
fever, but convulsions and torpor persist. On the ninth day fresh spread
of erysipelas. After the fifteenth day the erysipelas improved, but the
cerebral symptoms persisted; the pulse was slow and feeble (fifty-four
per minute). The left hemiplegia, though persistent, varied; the
ptosis and ocular paralysis were present, and later both pupils were
noticed to be dilated and inactive. Atrophic retino-choroiditis was
present; occipital pain was complained of; knee-jerks absent. The
patient gradually sank.

At the autopsy the paralytic symptoms were found to be due to
suppurative pachymeningitis with purulent cysts compressing the cortex.
Crura cerebri quite normal (a diagnosis of some lesion of the inferior
part of the right crus had naturally been made). H. J. Macevoy.

Contribution to the Study of Isolated Paralysis of the Serratus Magnus

S Contribution ct 1 etude de la faralysie isolie du muscle grand dentele\.
Nouv. Icon, de la Salpt., Mav — -June, 1899.) Sougues and
Castaigne.

Isolated paralysis of the serratus magnus is clinically rare. The case
mentioned by the authors concerns C. T—, male aet. 29 years, a groom,
admitted at Cochin Hospital with pneumonia, which proved to be
typhoid in origin, and who, during convalescence, on the fortieth day of
his illness, noticed impairment in the moyements of the right arm
(paralysis of the serratus magnus due to neuritis of the posterior
thoracic nerve of Ball). Reviewing the literature of the subject,
attention is drawn to this accident occurring generally in men following
laborious occupations, and to its affecting the right side. The charac¬
teristic deformity is discussed at length (plates shown). With the arms
hanging by the side, there is a very slight displacement of the scapula;
the arm on the affected side cannot be raised beyond a horizontal
level; there is asymmetry of the thorax evidenced in the axillary
region and the thoracic wall (winged scapula) when the arm is raised.

H. J. Macevoy.

6 . Pathology of Insanity.

Pathological Observations in Delirium Tremens. {Arch. f. Psych.,

B. xxxi, H. 3.) Tromner.

Dr. Tromner has availed himself of the opportunity of examining
the bodies of seven patients who died of delirium tremens in the city
asylum of Dresden.

Di| y VjOOQle

1900.]

RETROSPECTS.

375

Pathological changes were found, even in uncomplicated cases of
delirium tremens, which affected all the anatomical elements of the
central nervous system. The cells of the cerebral cortex were found
more affected than the Purkinje’s cells in the cerebellum, and the
foreparts of the cerebrum, including the insula, were more affected
than the posterior parts. The region of the cuneus was least affected
of all. The cerebral vessels were also more degenerated than those in
the cerebellum and spinal cord. The arteries were more affected than
the veins. The intima was puckered, the connective tissue of the
media thickened, the lymph spaces widened and obstructed, and
scattered extravasations of blood could be seen under the microscope.
The veins were seen to have become varicose.

The fibres of the neuroglia were more conspicuous and augmented
in number and the spider-cells also increased in all the cases examined.
This was especially noted in the median and temporal convolutions.
The spider-cells were increased in the spinal cord, though not the glia
fibres. There was an increase of the free nuclei of the glia in the
cerebrum.

In the cortex there was, in all cases, a thinning of the tangential
fibres in the anterior and middle parts of the brain. This implicated
the fibres of both the projection and association systems.

In the brain-cortex there were found well-marked alterations in the
nerve-cells of the second and fourth layer, the nuclei contracted and of
a bluish hue, the outline indistinct, the processes withered, and the
plasma poorer in cell-chromatin, with other symptoms of degeneration,
which want of space forbids us to detail. Other cells were noticed
apparently healthy.

The degeneration of the brain-cells in its different stages was of the
same character as that observed in animals poisoned with alcohol. In
the diseased brains there was a mingling of the chronic alterations
following habitual drunkenness and the more recent lesions of delirium
tremens. W. W. Ireland.

Some Lesions of the Suprarenal in the Insane. (Trans. Path. Soc . 9
1899.) Beadles , C. F.

This is an instructive record of some fourteen cases of definite supra¬
renal disease. In five cases haemorrhage had occurred. As a rule
these cases were much collapsed before death. In three cases new
growth was the lesion. Only four cases developed true Addison's
disease, the lesion being limited to a chronic fibrotic condition or old
tubercular disease. Atrophy and cystic disease formed the two remain¬
ing cases. J. R. Lord.

XLVI.

Digitized by VjOOQle

376

RETROSPECTS.

[April,

7. Treatment of Insanity.

Subcutaneous Serous Transfusion in the Acute Psychoses with Auto¬
intoxication [De la transfusion sireuse sous-cutanie dans le psychoses
aigues avec auto-intoxication ]. (Prog. Med., Sept. 30/A, 1899.)
Cullerre, A.

Dr. Cullerre’s experience is limited to six cases, but they are carefully
observed and are most suggestive. The psychoses have belonged to
the class of melancholia, acute delirious mania, and confusional insanity.
The stage has been that of extreme vital depression marked by emacia¬
tion, profound anaemia, proneness to bedsores, diminished secretions
(in particular obstinate constipation), sordes on the lips, thready pulse,
and, in fact, all the symptoms of the typhoid state. The injections
have consisted of a 7 per 1000 sodium chloride solution, sterilised at
the time of the injection, and at the body temperature. The quantities
have varied between 60 and 1000 grms. (2 oz. to 35 oz. about), the
larger quantities being essential when it is desired to rouse the circula¬
tion, the smaller sufficing, often, when a stimulant nervine action is
sought. The results obtained call strongly for further investigation,
and, indeed, they raise the question of the applicability of this treat¬
ment to the typhoid condition however brought about.

Harrington Sainsbury.

Methylene blue as an Hypnotic [Le bleu de methylene comme hypnotique],
{Prog. Med, Oct. 21 st, 1899.) Vallon and Wahl.

They confirm the hypnotic powers of the drug, but they do not
recognise any striking advantages. The blue staining of the urine is a
great drawback where the habits are dirty, and, moreover, it may cause
delusions. The dosage was 25 cgrms. (about 4 grs.) in capsules,
repeated twice, vespere. Harrington Sainsbury.

Eosinate of Sodium in Epilepsy and its Toxic Effects [De Piosinate de
sodium dans le traitement de Pipilepsie et des accidents qu'ilproduii],
(Prog. Mid., Dec. 30/A, 1899.) Bourneville atid Chapotin.

They report upon twenty-three cases. The administration was in
4-grain capsules, the dose being advanced to twelve and sixteen capsules
in the course of nine weeks. The drug is rich in bromine, hence its
selection. Red staining of the stools, fluorescence of the urine, slight
reddening of the skin, especially of the face, with swelling and various
trophic changes are all recorded, but for the most part these manifesta¬
tions were not very persisting. The beneficial influence upon the
epilepsy (whether idiopathic or sympathetic) is by no means apparent.

Harrington Sainsbury.

Sulphonal Poisoning. (Scot. Med. Surg. Journ., March, 1899.)

Lovell Gulland, G.

Dr. Lovell Gulland records a fatal case in a man, an alcoholic, who
for about six weeks took nightly thirty grains of sulphonal. Slight
staggering, thickness of speech, haematoporphyrinuria, lassitude, and
heaviness were observed during the last week; death occurred from

Digitized by VjOOQle

RETROSPECTS.

377

1900.]

sudden heart failure. Dr. Gulland contrasts acute poisoning from the
massive dose, a narcosis, with chronic poisoning from the repeated
dose. Cumulative action appears to be the cause of the latter, and
even moderate doses, fifteen grains, may bring it about.# The chief
symptoms of chronic poisoning are : vomiting and constipation, citaxia,
depression, a heaviness tending to coma, albuminuria and haemato-
porphyrinuria. The last-named rarely appears in acute poisoning.
Fatty changes are usually found in the heart in chronic poisoning, but
the most constant change is a spoiling of the secreting cells of the
kidney. Dr. Gulland advises that the maximum daily dose of sulphonal
should be thirty grains for a man, fifteen to twenty grains for a woman,
“ and it should never be given continuously, but pauses of at least three
to four days should be allowed from time to time to permit of elimina¬
tion.” Harrington Sainsbury.

Treatment of Herpes Zoster [Zur Therapie des Herpes zoster ]. (Neur.

Cbl ., No. 22, Nov., 1899.) Bleuler.

The writer records the remarkable curative effect of cocaine ointment
on herpes zoster, in addition to a distinct sedative action. He employs
a 1 per cent, strength, the constituents being equal parts of lanolin and
vaseline. Harrington Sainsbury.

Treatment of Locomotor Ataxia by Exercises. (Tract., March, 1899.)

Campbell Thomson, H.

Dr. Campbell Thomson, following the teaching of Dr. Frenkel and
others, cites a case of ataxy treated by planned exercises. He claims
some improvement in the finer co-ordinations—*.^. of the hand, as in
writing. Only time and extensive trials can, as he says, prove the
value of the method. Harrington Sainsbury.

8 . Sociology.

(1) Offence against Morals . Plea of Insanity and Epilepsy set aside by
Medical Examination. (2) Absence of Moral Sense. Third Arrest.
Committed to an Asylum. (Rpt. Ann. Meet. Queb. Med.-Psych. Soc.,
October, 1899.) Villeneuse.

Two cases showing the importance of a thorough examination where
there is the least doubt as to the mental condition of those accused of
crime. In the first case, a Belgian was charged with offering for sale
three pictures of an obscene nature. The plea of irresponsibility on
account of undoubted insane heredity, and actual insanity and epilepsy,
was raised by the brother and wife of the accused. M. Villeneuse
states the steps of his examination, and came to the conclusion that
the prisoner was not insane, and that the supposed epilepsy would not
account for the crime. The prisoner was condemned. In the second
case the prisoner had been convicted twice before, and had spent part
of his career in a reform school and penitentiary. He was accused of
theft, but was committed to an asylum on M. Villeneuse showing the
presence of congenital non-development of moral sense.

J. R. Lord.

Digitized by VjOOQle

37^ NOTES AND NEWS. [April,

The Rdle of Science in the Material and Moral Education of the People),
(Rev. Scient ., November 18 th, 1899.) Berthelot .

This is a presidential address at the opening of the session of the
Philotechnfc Association. Two periods—two phases seemingly
opposed—have occurred in the practical applications of science; in
the first, mechanical inventions have led to the enslaving of the work¬
man by making him practically subordinate to some complicated
machinery, of which he ignored the workings or laws; in the second
period the object is to enfranchise him, to develop him by scientific
education, so that he may in his turn dominate over the machine.
Berthelot shows also that the goal of science is not only utilitarian, but
that it fulfils an ideal educating rdle. The double knowledge of the
facts and laws of the moral world as well as of the physical world is
indispensable for the amelioration of humanity. H. J. Macevoy.

9. Asylum Reports.

Report of the Secretary and Registrar of the Province of Quebec .

June , 1898.

This report contains some very interesting figures with regard to the
three great asylums of this province, two of which (Quebec and St.
Jean de Dieu) are for the exclusive use of Catholics, and one (Verdun)
for Protestants. There was a percentage of cures of 31*23 on the
admissions, which was most satisfactory considering that 46 per cent.
of the admissions were considered incurable. The percentage of deaths
was 9*49 per cent. Phthisis was the most frequent cause, senile
debility coming next, and then general paralysis. A severe epidemic
of influenzal pneumonia raged in one asylum, resulting in death in
36*67 per cent, of those affected. There has been established in the
Protestant Hospital for the Insane a perfectly equipped laboratory, the
gift of one of its Governors, M. G. B. Burland, Esq. This is the only
laboratory of its kind in the province. At St. Jean de Dieu the work
of reconstruction of the asylum is in progress, which will take several
years to complete. E. P. Chagnon.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

GENERAL MEETING.

A General Meeting was held at the West Sussex County Asylum, Chichester, on
Thursday, February 15th, 1900, at 3.30 p.m.; Dr. J. Beveridge Spence, President,

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

379

in the chair. The other members present were H. Hayes Newington, Charles
Mercier, R. Percy Smith, D. M. Cassidy, P. W. MacDonald, Fletcher Beach,
H. T. S. Aveline, James Chambers, Harry A. Benham, H. Gardiner Hill, A. Helen
Boyle, D. G. Thomson, C. K. Hitchcock, T. S. Adair, Harold A. Kidd, A. N.
Boycott, Elliot Daunt, Robert H. Steen, Alfred Miller, Lancelot W. Rolleston,
R. C. Stewart, J. Turner, F. Perceval, J. E. Finch, William Bubb, and Robert
Jones (Secretary).

Visitors: Drs. H. C. L. Morris, Tidcombe, G. Bely, and Rev. E. Lopresti.

Letters of apology for non-attendance were received from Drs. W. R. Watson,
T. G. Soutar, Crochley Clapham, E. B. Whitcombe, J. Carlyle Johnstone, G.
Stanley Elliot, A. R. Urquhart, G. Braine-Hartnell, David Bower, and T. W.
McDowall.

The minutes of the previous meeting were read and confirmed.

The following candidates for election as ordinary members were duly elected:—
Gregor, E. W., M.R.C.S., L.R.C.P., Assistant Medical Officer, Derby County
Asylum (proposed by Drs. Legge, Macphail, and Elkins); Shera, J. E. P., L.R.C.P.I.,
Assistant Medical Officer, Norfolk County Asylum (proposed by Drs. Thomson,
Gardiner Hill, and Rolleston); Shoyer, Arthur F., M.B., B.C., B.A.Cantab.,
Assistant Medical Officer and Pathologist, County Asylum, Lancaster (proposed
by Drs. Cassidy, David Blair, and Robert Jones); Watson, Wm. Muir Crawford,
M.D., C.M.Edin., Hon. Medical Officer, Northern Police Orphanage and Conva¬
lescent Home, Beechville, Ripon Road, Harrogate (proposed by Drs. Crochley
Clapham, W. B. Ray, and T. Stewart Adair); Worth, Reginald, M.R.C.S.,
L.R.C.P., Assistant Medical Officer, Middlesex County Asylum, Tooting (proposed
by Drs. Gardiner Hill, Rolleston, and Robert Jones).

A letter was read from Mrs. Casberd-Boteler, presenting the Society with an
engraving of her late father, Dr. J. H. Paul.

The President said that while they did not require a picture to keep Dr. Paul’s
memory green, they were exceedingly pleased to have it. Those who came after,
and heard how hard he had worked for the Association, would find it most interest¬
ing to connect Dr. Paul’s name with the portrait on their walls. He was in favour
of often publishing portraits of their leading members in the Journal, and hoped
that the Treasurer and the Editors would do what was possible in that direction.
The President concluded by moving that the thanks of the Association be sent to
Mrs. Casberd-Boteler for her gift, and that they assure her how much her kindness
is appreciated.

Lantern Demonstration.

Dr. Turner showed lantern slide pictures illustrating—

1. The appearance of the infiltration seen in the pia and around the cortical
vessels in chronic and acute cases of general paralysis. He holds that the
" round-cell infiltration ” in this disease is largely composed of the segmented and
extruded nuclei of leucocytes which have escaped by diapedesis. Then followed
several pictures showing sections of nerve-cells with invading bodies, in all respects
similar to those which make up the infiltration in general paralysis, lying com¬
pletely within the substance of the nerve-cell, and surrounded by a clear space. It
was suggested that the size of this space varied probably with the length of time
the invading nucleus had been in the cell. An entire cell was shown with an
invading body within it, surrounded by a paler zone, and he inferred that this paler
zone was of a more fluid nature, and hence in tissues subjected to dehydrating
agents and then cut it appears as a clear space or vacuole. The action of other
bodies (endothelial and adventitial nuclei) on nerve-cells was also referred to and
illustrated.

2 . Some morbid nerve-cells (both sections and entire cells) were shown, met
with in the brain of the insane in certain cases of dementia. These present the
characters which are seen in nerve-cells after section of their axon.

Dr. Turner mentioned that a short account of the clinical and pathological
appearances of these cases was published by him in the winter number of Brain ,
1899, and that since then Dr. Wiglesworth had drawn his attention to two similar
cases with, in all probability, similar changes in the nerve-cells (allowing for
differences of technique), which had been described by Dr. Wiglesworth in this
Journal in 1883.

Digitized by

Google

38 o

NOTES AND NEWS.

[April,

3. A series of surface sections showing the tangential system of medullated
nerve-fibres of the first layer of the cortex from different regions of the cerebrum
were shown on the screen.

He mentioned that he had examined sections from the second frontal, the top of
the ascending frontal, and from the occipital cortex in over sixty cases of insanity
of all sorts and ages.

In 64 per cent, of the cases fibres were absent in the frontal sections examined;
but this only applies to the part examined, and must not be taken to mean that
they were absent from other parts of the frontal region. Very often where none
are seen in one convolution many are found in an adjacent one. Whether this is
so in ordinary hospital cases further investigation is needed to show.

The densest plexus of fibres he had yet met with in the frontal region was from
a case of chronic alcoholic insanity in a woman aged fifty-four.

In 58 per cent, of the cases fibres were absent in the occipital region examined.

As a rule the calibre of the fibres in the frontal and occipital regions is finer than
in the motor. He suggested that the diameter of the fibre was in relation to the
size of the underlying large pyramidal nerve-cells. At any rate, the crowds of
stout fibres from the region where the giant-cells are numerous seem to bear this
out.

In the motor region the tangential fibres were only absent in 20 per cent., and
nearly all these cases were general paralytics.

The cases classified as recent, chronic, and general paralytics gave the following
results:—Tangential fibres absent in only 3 of 40 of the two former classes, but in
8 out of 14 of the general paralytics.

He was doubtful whether it is one of the earliest changes in general paralysis.
In a case recently examined, where from the partial distribution of the lesion it was
evident that the disease was of fairly recent origin, the fibres were very abundant
in the motor and occipital regions of both sides, but absent from the frontal; but
in this case they did not stain so darkly as usual, but appeared pale, and as though
most of their myelin had been extracted or dissolved out, leaving only a faintly
double-contourea fibre.

He mentioned that the densest plexus he had yet come across was from the
motor region of a congenitally weak-minded woman suffering from melancholia,
aged fifty.

The President congratulated Dr. Turner upon his demonstration and speci¬
mens, the Secretary referred to the “ phagocytosis ” exhibited in the specimens,
aod Dr. Turner replied.

Asylum Construction.

Dr. R. H. Steen (of Chichester) read an interesting paper on “ Modern Asylum
Construction,” a subject which in his opinion demands the earnest attention of
many of the local authorities in this country. Within the last five years six
new asylums had been completed and opened; seven existing institutions had
recently completed and eight others were at present making extensive additions;
seven new asylums were now in process of construction, and preparations were
being made for the construction of no less than ten new asylums. As to the
question of what medical men had to do with asylum construction, Dr. Steen
pointed out that suitable dwellings had an important influence upon their patients,
either towards the amelioration of their symptoms or recovery from their disease.
Moreover the administration of such buildings was entirely in medical hands.
Lay committees naturally looked to their medical officers for advice when about to
enlarge existing asylums or to build new ones. Dr. Steen having recounted the
main requirements of an asylum, and given an historical survey of asylum architec¬
ture—speaking particularly as to the asylum-hospital system and the detached or
villa or cottage system,—went on to discuss the comparative merits of the systems
now in vogue, viz. the connected and the detached. He concluded by remarking
that in preparing his paper he had been actuated by a desire to point to the great
activity now prevailing in asylum construction, and to draw the attention of the
members to the importance of the subject. There was little modern literature
dealing with the question, but there were many of the members with expert know¬
ledge, with a full acquaintance with the defects, and able to suggest an appropriate

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

381

alteration in the mode of asylum construction; but their rich stores of experience
were in a great measure lost to those public bodies which most stood in need of
them. He would therefore suggest that it was the duty of the Association to take
the matter into official consideration, and if possible to formulate a statement, not
only in regard to the main features in plan of asylums, but also in regard to the
many important details in their internal construction.

The President complimented Dr. Steen upon the great value of his paper
coming at a time when new asylums were being built, and extensive enlargements
were being made in so many parts of the country. The President stated that
it would be interesting to hear Dr. Kidd’s views upon points about which there
might have been a diversity of opinion among members who had gone round the
asylum that morning, and who had similar experience in the opening of new
institutions.

Dr. Hayes Newington remarked that Dr. Steen had coupled the East
Sussex Asylum with that at Alt Scherbitz, but he himself would not consider it to
be in anything like the same category, although he congratulated Dr. Steen on
his able and interesting paper. The East Sussex Asylum could not be called
detached, composite, or of any particular style. The ideas they had in mind were
not to follow a particular style, but to work out the details as they thought
applicable to the various classes of patients. In no sense could it be called a
detached asylum, for the main building held 840 patients—a good-sized county
asylum in itself. They had only a few detached buildings for particular cases,
such as a hospital for acute mental disease, and villas for thirty patients each for
the farm, and so on. That was as far as they were prepared to go.

Dr. H. A. Kidd considered that Dr. Steen’s paper contained an excellent
suggestion in regard to the Association seriously taking up the question of the
construction of asylums. When a new institution like that they were in was
opened members of various committees came round with the desire of finding
out the latest ideas upon asylum construction. It seemed to him that a great
deal of useful knowledge of asylum construction was bottled up in the minds of
members who had had special experience, and it would be a very good thing if it
were possible for the Association to collect all that knowledge and publish it.
The Commissioners in Lunacy published regulations as to superficial areas to
be allotted to each patient in dormitories, day-rooms, etc., together with other
requirements relating to the construction of asylums, and suggestions which were
useful to public authorities building new asylums. He considered that it would
be a good thing if the Association were to publish something in the same way
dealing with debatable subjects, such as detached villas, hospital blocks, detached
chapel and superintendent’s house, etc., and also upon points of internal arrange¬
ment, such as heating and ventilating systems, lighting, etc. On going round
that day with members he heard a variety of opinions on such points. He thought
these could be very well collected by the Association. No decision need be made
as to the relative merits of those points, but it would be of advantage to collect
the pros and cons., so that anyone, reading up all the arguments upon any particular
subject, would be able to frame his own opinion. He felt sure that such a paper
would prove a valuable guide to public bodies.

The President said it would be very interesting if Dr. Kidd would state one or
two of the points upon which there was a diversity of opinion. He (the Presi¬
dent) went round the asylum that morning, and could see no reason to find fault
or criticise.

Dr. Kidd. —I was not thinking of any particular criticism of this institution, but
of general comments upon much-debated subjects, such as the detached chapel,
the “ open door ” system, the general dining hall, etc. With reference to this
last subject, it is said that we should make asylums as “ homelike ” as possible.
I do not see how a large dining hall, where patients are all crowded together for
dinner, contributes to this end. They are not used to it. People of the class from
which we derive our cases are not in the habit of dining together in large numbers,
and it is not in the least homelike. (The following notes regarding the West Sussex
County Asylum may be inserted here.— Eds.): —It was designed by Sir Arthur
Blomfield and Sons on the pavilion system, with the entrance on the north. There
is a detached chapel and a farmhouse for fifteen patients. The estate extends to 245

Digitized by

Google

382

NOTES AND NEWS.

[April,

acres, and occupies an elevated site on gravel soil near Chichester. The heating and
ventilation are carried out on the Korting system, and electric lighting has been
adopted. There is a private water-supply, but the drainage is connected with the
town system. It is noteworthy that the building was begun in May, 1895, and
opened for the reception of patients in July, 1897—perhaps the most expeditious
erection on record. The asylum is now being enlarged, and will, when complete,
accommodate 765 patients at an inclusive cost of £330 a bed. Calculated on the
buildings alone, the cost is £220 a bed. There are no airing courts ; the patients*
gardens are laid out with gravel walks and surrounded by a light low fence. The
unofficial name of the institution is Graylingwell Hospital, after the name of the
estate, and it has been found that patients and their friends appreciate the less
formidable title in writing and visiting. The dietary is made out for a month,
and varies every month as regards dinners. The Commissioners visited on 24th
February, and reported very favourably on the condition and management of the
asylum. They remark that the day-rooms present a bright appearance, are well
warmed, and in every way comfortable. The air in the rooms is quite fresh and
sweet. The staff by day is in the proportion of one to every nine patients.

Dr. Steen, in reply, thanked the members for the reception of his paper.

Dr. Mercier afterwards read a paper upon w Memory,” which we hope to
publish in the next number of the Journal.

The President congratulated Dr. Mercier upon his thoughtful and original
contribution, and proposed a hearty vote of thanks to Dr. Kidd, which was unani¬
mously carried.

After remarks by the Hon. Sec. (Dr. Robert Jones), to which Dr. Mercier
replied ; members met and dined at the Dolphin Hotel at 6.30 p.m.

SCOTTISH DIVISION.

A meeting of the Scottish Division was held in the Hall of the Faculty of
Physicians and Surgeons, St. Vincent Street, Glasgow, on Thursday, March 8th,
1900. In the absence of the President, Dr. Rutherford (Dumfries) was called to
the chair. There were also present: Sir William T. Gairdner, and Drs. Bruce,
Campbell Clark, Clouston, Graham, Havelock, Hotchkis, Carlyle Johnstone,
Midalemass, Alexander Rotrertson, G. M. Robertson, Rorie, Turnbull (Secretary),
Urquhart, Watson, and Yellowlees.

The minutes of the previous meeting were read, approved, and signed by the
Chairman.

The Divisional Secretary intimated apologies for absence from the President of
the Association, Dr. Beveridge Spence, and from the General Secretary, Dr. Jones.

It was agreed unanimously to suggest to the Council the names of Dr. Havelock
for election to the Council, Dr. G. M. Robertson for the Examinership, and
Dr. Turnbull for the Divisional Secretaryship.

Position op Nurses in Scotland.

On behalf of the Committee appointed at the previous meeting to consider the
position of the Nursing Staffs in Scottish Asylums in regard to administrative
questions, Dr. Campbell Clark made a preliminary report, mentioning that they
had issued a schedule of inquiries, and proposed to collate the information given
in the answers as soon as possible. He asked the meeting to say in what way it
would be best to deal with the report when ready; and after discussion it was
agreed to hold a special meeting of the Division in Edinburgh on Saturday,
June 2nd, to consider the report, and thereafter to have it printed in the Journal
if found desirable.

Dr. Havelock drew attention to the days fixed for the meetings of the Division,
and moved that the Divisional Secretary be asked to make inquiry from the
members whether Thursday continues to be the day most suitable for the majority,
or if a change is desirable. This was unanimously agreed to, and the Secretary

Digitized by VjOOQle

NOTES AND NEWS.

1 9OO.]

383

was also instructed to mention the greater facilities for travelling at the end of the
week, in the way of railway tickets being cheaper and available for longer periods,
as a point to be kept in view in settling the matter.

Training of Attendants.

Syllabus of Practical Work at Roxburgh District Asylum.

The Wards and Sick Rooms.

Ventilation. Warming and Cooling. Regulation of Temperature. Ward
Thermometer. Lighting. Cleansing.

Beds and Bedding.

Bed Making. Changing Sheets. Lifting and Moving Helpless Patients.
Draw Sheets. Waterproof Sheets. Water Beds. Prevention and Manage-
ment of Bedsores. Bed Pans. Urine Bottles. Chamber Utensils. Foot
Warmers. Bed Rests. Bed Cradles.

Food and Feeding.

Serving Food. Feeding Helpless and Paralysed Patients. Feeding Cups.
Sick Room Cookery. Preparation of Gruel; Beef-tea; Boiled Bread and
Milk; Milk Puddings; Custard; Broth; Lemonade, etc. Artificial Digestion
of Food: Peptonised Milk, Gruel, Beef-tea. Arrangements for Forcible
Feeding.

Washing and Bathing.

Bathing Regulations and Precautions. Bath Thermometer. Attention to Hair,
Mouth, Eyes, Ears, Nails, etc. Washing the Sick and Bed-ridden Patients.

Clothing.

Dressing and undressing.

Observation and Recording of Symptoms .

Pulse. Respiration. Temperature. Excreta. Clinical Thermometer. Charts.
Day and Night Records.

Administration of Medicines and Remedies.

Measure Glass. Mixtures; .Oils; Pills; Powders. Gargles. Liniments;
Ointments; Lotions.

Enemata: Laxative; Nutritive; Medicated. Suppositories. Douches.
Eye Lotions and Drops. Ear Syringing. Inhalations. Bronchitis Kettle.
Massage or Rubbing.

Use of Moist and Dry Heat; Cold ; Counter-irritation .

Poultices : Linseed; Bread ; Mustard; Starch ; Antiseptic.

Fomentations: Simple; Antiseptic; Turpentine Stupe.

Warm Water Dressings*. Simple; Medicated. Wet Compresses. Wet
Packing, hot and cold.

Cold Water Dressings and Cooling Applications. Sponging. Irrigation.
Application of Ice.

Dry Heat: Hot Water Bottles, Sand Bags, Bran, Brick. Cotton-wool
Jacket.

Counter-irritation: Mustard Plaster and Leaves; Turpentine; Iodine;
Blisters.

Bandaging.

The Triangular Bandage. —Preparation. Folding. Application. Fastening.
(1) Unfolded. (2) Folded Broad. (3) Folded Narrow. Application to
Wounds of Top of the Head; Forehead, Sides, or Back of Head; Lower Jaw
or Side of Face ; Eyes or Front of Face; Chest; Shoulder; Hip; Upper Arm
and Forearm; Elbow; Hand; Thigh; Knee; Leg; Foot; Stump; to secure
Splints ; to improvise a Tourniquet. Large Arm Sling. Small Arm Sling.
The Roller Bandage. —Preparation. Rolling. Application. Fastening. Rules
to be followed—(1) Fix the Bandage ; (2) Bandage from Below Upwards, and
from Within Outwards, over the Front of the Limb; (3) Use Equable Pressure
throughout: (4) Let each succeeding turn overlap two-thirds of its prede¬
cessor ; (5) Keep all the Margins parallel, and let the Crossings and Reverses
be in one line and rather towards the outer aspect of the Limb; (6) End by

Digitized by VjOOQle

384

NOTES AND NEWS.

[April,

fixing the Bandage securely. The Spiral ; the Reverse; the Figure of 8.
Application to Hand and Arm; Foot and Leg; Elbow, Knee, Heel; Shoulder,
Hip, Groin, Breast; Head. " T” Bandage.

Disinfection. Antiseptic Methods and Materials.

Prevention of Infection. Disinfection of Rooms, Furniture, Bedding, Clothing,
Persons, Discharges, Utensils, Instruments, Catheters, etc. Use of Carbolic
Acid; Sulphur Fumes; Chlorine; Condy’s Fluid (Permanganate of Potash);
Heat.

Antiseptic Treatment of Wounds and Sores. Surgical Dressings, Solu¬
tions, etc. Nurses’ Requisites. Carbolic Acid; Boracic Acid; Corrosive
Sublimate; Iodoform.

Accidents and Emergencies ; First Aid and Immediate Treatment.

Insensibility. —Shock or Collapse. Fainting. Concussion and Compression
of Brain. Epilepsy. Apoplexy. Sunstroke or Heat Apoplexy. Poisoning.
Asphyxia.

Poisoning. —Simple and Safe Emetics. Poisoning by Acids and Alkalies;
Opium ; Alcohol; Carbolic Acid.

Asphyxia .—Drowning. Choking. Smothering. Strangulation and Hanging.
Suffocation by Gases. Artificial Respiration.

Haemorrhage. External Bleeding. —Arterial; Venous; Capillary, (i) Direct
Pressure on Bleeding Spot, (a) Elevation of Wounded Part. (3) Compres¬
sion of Main Artery by Fingers, Tourniquet, or Forcible Flexion. Removal
of Constrictions. Use of Cold and Heat. Points where Arterial Circulation
may be arrested by Pressure : Common Carotid Artery ; Facial; Temporal;
Subclavian ; Brachial; Radial; Ulnar; Femoral; Popliteal.

Internal Bleeding .—From Nose; Lungs; Stomach; other Organs.

Extemporary Treatment of Wounds. —(1) Cleansing Wound. (2) Arrest of
Bleeding. (3) Replacing Edges of Wound in Natural Position. (4) Dressing
and Bandaging Wound.

Sprains. Strains. Contusions and Bruises .

Bums and Scalds. —What to do when the Dress catches fire. Burns from
Corrosive Acids and Caustic Alkalies. Scalding of Mouth and Throat.

Fire. —Precautions. What to do when it breaks out.

Bites from animals. Insect Stings . Frost-bite .—Chilblains.

Foreign Bodies in Eye; Ear; Nose; Air-passages; Swallowed.

Fractures. —Simple and Compound. Prevention of further damage to the
parts. Temporary Treatment of Fractures of Skull, Spine, Pelvis; Ribs;
Lower Jaw; Upper Arm; Fore-Arm ; Thigh; Leg; Knee-Cap. Improvised
Splints, Bandages, and Pads.

Dislocations .—Prevention of Further Mischief.

Hernia or Rupture.

Laying out the Dead.

Helpings Lifting ; and Carrying the Sick and Injured .

I. One Helper. —(a) To assist a Patient who can walk, (b) When Patient
cannot walk: (1) in arms; (2) on back; (3) on shoulders.

II. Two Helpers. —(1) Two-handed Seat. (2) Three-handed Seat. (3) Four-
handed Seat. (4) 11 Fore and Aft Carry.”

III. Lifting and Carrying the Sick and Injured on Stretchers or Litters. —(1)
Stretcher at Patient’s Head. (2) Stretcher at Patient's Side. (3) In narrow
Passages and Cuttings.

Improvised Stretchers and Seats. Use of Blanket, Rug, or Sheet.

Dr. Carlyle Johnstone, in submitting this syllabus of practical training for
asylum nurses and attendants, said that it represented the scheme of practical

Digitized by

Google

NOTES AND NEWS.

385

1900.]

training for nurses and attendants which had been in use at the Melrose Asylum
for some years. It must be clearly understood that it referred only to practical
work, and was not intended to embrace those subjects which were more properly
dealt with in lectures and exhortations or set forth by precept or example. It
was, in brief, nothing more than a printed list of those matters which pertained to
an asylum nurse's handicraft. As he had found it useful in more ways than one,
he commended it to their favourable consideration. It would be admitted, he
thought, that, if their people were to be regarded and designated as nurses , as
distinguished from the attendants and keepers of old times, they were bound to
do all they could to give them such a training in the practice of their profession
as would make them good general nurses in deed as well as in name. He used
the term general nurse for want of a better word. They could not, of course,
attempt to give them the training of a first-class hospital nurse; they could
not expect them to possess the special skill of a surgical, an obstetrical,
or other special nurse; but they ought to be able, he thought, to give them
a practical training in those methods and operations which were common
to all nurses worthily so-called, and in addition to that they must, of course,
give them that special training which was necessary in that special line of
the nursing profession which they followed. The question was what subjects
should be included within the scheme of such a practical training and what should
be excluded. Probably no two asylum physicians would, if it were left to them to
prepare a scheme, be in perfect agreement as to all its details ; but he thought it
would be found that those who had personally devoted much of their time and
energies to this question would differ only on a few points, and these not serious
ones. At any rate, he ventured to think that in the scheme which he now pre¬
sented to them nearly everything that was necessary had been included, and that
very few things had been put in which ought to have been left out. It was not
claimed that the scheme was perfect or final. It was only claimed for it that it
had been very carefully drawn up in the light of a considerable experience, and
that in practice it had been found to work well. Any suggestions for its amend¬
ment would be gratefully received, and would be given effect to when the form
was reprinted. He thought he might add that, if an asylum nurse was taught to
do, and showed herself able to do, all the things enumerated in this syllabus, they
need not be ashamed to designate her, within these limits, a trained nurse. It
would be noticed that, as he had said, the syllabus was merely a list of subjects,
a detailed list arranged in a convenient order, but free from any descriptions or
explanations. It would be of no use to the nurse for “ cramming” purposes. It
would be of no use to the teacher who did not mean honestly to teach ; but it
might prove very useful as a reminder to the nurse of those things which she
ought to know how to do, and it might prove of some use to the teacher as a
reminder of those things which he ought to teach the nurse how to do. The
general adoption of that or some similar scheme might be expected to result in
further and perhaps equally important advantages. Most of them thought that
our nurses should not only be trained, but that they should also be examined, and
many of them desired that they should obtain the Certificate of the Medico-
Psychological Association. Now, although the regulations of the Association
were in many respects excellent, he feared it must be confessed that as regards
the practical training and practical examination of candidates they were by no
means thorough or satisfactory. It was not too much to say, he thought, that it
was quite possible for a candidate to obtain the certificate on the strength of her
possessing a sufficiently complete remembrance of the contents of the Associa¬
tion’s Handbook and without her being required to demonstrate that she had
received anything like a thorough practical training in nursing handicraft. The
syllabus of the Association was so slight and so vague as regards practical require¬
ments that, even though candidates might have been thoroughly well trained,
examiners must either fix an arbitrary standard for themselves (and so run the
risk of giving offence and of acting unfairly), or they must regard the practical
training and examination as of secondary importance, with the result, he feared,
that many of their certificated nurses must sooner or later bring discredit upon
the Association by the exposure of their deplorable incapacity as nurses % as the
term is understood bv the public and by the medical and nursing professions.
He suggested that a detailed scheme of practical instruction such as he had pre-

Digitized by tjOOQle

NOTES AND NEWS.

386

[April,

pared, should be laid down by their Association, and that the Association’s
examiners should be instructed to make use of it as their standard and guide in
conducting the practical part of the examinations. If that was too much to expect
of the Association, then he ventured to suggest that members should individually
give his syllabus a trial.

The Chairman thought this was a most useful and important production by Dr.
Carlyle Johnstone and a very useful guide in the training of nurses.

Dr. Rorie said that the Division was very much indebted to Dr. Carlyle John¬
stone for having brought this before them, because in all cases where he had had
an examination in connection with nurses and attendants he had found that prac¬
tical experience was the weak point in their training. Dr. Carlyle Johnstone had
kindly sent him a copy some time ago, and as imitation was the best compliment,
he had borrowed very freely from it in the classes trained at the Dundee Royal
Asylum. Some years ago, in the cookery class, he had issued a small syllabus of
a similar nature, and it had been a great stimulant to the teaching. He thought
this a very important matter, and would be very glad if the Division could see its
way to adopt Dr. Carlyle Johnstone’s syllabus, and if some such scheme were
drawn out and fixed by the authority of the Association.

Dr. Campbell Clark said that he had often been in the minority in discussing
the real nature of the training of attendants and nurses. He had tried time and
again to get the Association in committee to realise that a practical examination was
the all-important thing for the certificate of the Association. He thought it was
deplorable that many had obtained their certificates who could not make a poultice.
He had had one such nurse who came as a charge nurse, and had never given an
enema in her life. He had got a copy of Dr. Carlyle Johnstone’s syllabus some
considerable time ago, and he had gone over it and had made a few excisions
before putting it into use, but was not able to speak of the results yet, because it
had only been in operation for a few months. Dr. Carlyle Johnstone was un¬
doubtedly on the right lines. The only question was as to whether he was not going
too far, for instance, in training a nurse to deal with insect stings and frost-bite.
A nurse might never have occasion to treat a patient for insect stings and frost¬
bite. There were many things in the present training which he would call more
ornamental than useful, and which might be left out. He would, however, be pre¬
pared to agree to make it a sine qud non that everyone who went in for training in
asylums should go through this syllabus and be examined on the subjects con¬
tained in it.

Dr. Havelock thought that this was a most admirable syllabus drawn up by
Dr. Carlyle Johnstone. It comprised what they taught the attendants at Sunnyside
before they were put forward for examination. It was so admirable that he would
suggest that they should extend it and altogether abolish the Red Book, which
was the greatest stumbling-block in the way of training. Those who had had the
advantage of a fairly good education had to read it over a few times before they
grasped the meaning of it. Like a certain book published by a certain learned
professor, it was so crammed full of knowledge that they had to read every para¬
graph five or six times before they fully understood it. He thought that they had
gone wrong in teaching attendants what they could not understand, and it was very
discouraging to them when they sat down to answer the questions set. For instance,
“ What is sleep ? " How could they expect anybody to answer that ? It would
puzzle most professional men. The invariable reply was, “ Closing for repairs.”
He thought that the person who gave that answer should get full marks, for he had
learned that from the Handbook. If they could leave out these difficulties, which
they did not understand, and which he confessed he did not understand himself,
they would do well.

Dr. Clouston said he desired to add his emphatic testimony to the value of
this practical syllabus. He remembered very well the first occasion on which
Dr. Johnstone did him the favour of coming up as an examiner, and had been
impressed by his thoroughness and by the practical way in which he took the
candidates over their work. He did not think he had ever seen any one, in the
great number of gentlemen who had assisted him, who was so practical and so very
thorough. He was not going the length of Dr. Havelock in consigning the Red
Book to perdition ; he thought the Red Book was in itself valuable. It was like
the Ten Commandments, an ideal of something to be aimed at, and it was well to

Digitized by LjOOQle

1900.]

NOTES AND NEWS.

387

give nurses and attendants an opportunity of learning something about theory
as well as about practice. It gave them an intellectual fillip and made them
have more conceit of themselves, which was a good thing if not pushed too far.
Anyone who had been teaching them, especially by clinical examples, and who
haa endeavoured to explain the higher department of medico-psychology, must
have been very much pleased with the interest shown. Of course that was still on
practical lines. He would never think of delivering a lecture on the more advanced
topics in the Red Book without giving a clinical exposition in regard to the
practical matters. He was prepared to join in a recommendation that this
syllabus should be homologated in a general way by this meeting of the Division,
and he would strongly urge that it should be added to the next edition of the
Handbook, although it might be adopted before waiting for that event. They were
infinitely indebted to Dr. Johnstone for the trouble he had taken, and he made
certain that there was not a doctor in any asylum who would not heartily welcome
such an addition to the Handbook, and who would not heartily thank Dr. Johnstone
for having drawn up this syllabus.

Dr. Watson said that the syllabus would be a help to medical officers. It was
a matter of great difficulty to get many nurses to understand their teaching, their
early education having been so defective. They were exceedingly indebted to Dr.
Carlyle Johnstone for leading them in the way of practical teaching.

Dr. Graham said that Dr. Johnstone’s syllabus seemed to show practically what
would be proper instruction to attendants to entitle them to be raised to the grade
of nurses. He did not suppose that in an asylum the superintendent would always
have clinical material at hand. He must take the cases as they came. There was
far too much lecturing in medical education, and he thought that Dr. Johnstone’s
scheme could be applied by superintendents in the ordinary work of asylums.

Dr. Carlyle Johnstone, in replv, desired to emphasise the point that all the
items in the syllabus were meant to be dealt with in a practical way. The theory
was to be explained in each instance, but the teacher must see that the thing was
actually performed. The subjects were divided into convenient groups, but the
syllabus could be taken up at any point. At Melrose they generally began with
bandaging, as being the simplest and most practical introduction to nursing handi¬
craft, and they found that they could go over the whole syllabus in one year, or two
years at most. While he had tried to make the syllabus comprehensive, it would
not be found in practice, he thought, to present any serious difficulties, or to take
up too much time. He devoted one or two hours in the evening once a week for
about nine months in the year to teaching his staff, practical demonstrations
alternating with systematic lectures. Much of the practical work was, of course,
taken up in the wards as opportunity occurred. The training was compulsory, but
the staff were not obliged to go in for the Certificate of the Association, though
they were encouraged to do so. Each superintendent must arrange his course of
instruction in the way most convenient to him. With a small staff of medical
officers there would always be difficulties in regard to the division of nurses into
seniors and juniors, overlapping of lectures, etc.; but by the systematic use of a
suitable practical syllabus it could be secured in every institution that within a
given time every nurse should receive a practical training and understanding of all
those matters which were proper and necessary for her calling. He had always
maintained that this practical training was of the first importance, and that mere
lecturing was of quite secondary value. While he was of opinion that a syllabus
such as he had prepared would be found most useful both to teacher and to pupil,
he had no desire to impose it upon the Association as compulsory under the
regulations. He would be quite satisfied if it were printed in the Journal, and if
the members individually would give it a trial. They might add to its contents or
take from them what they chose; but he did not expect that they would find that
it required much alteration.

Dr. Urquhart undertook that it would appear in the April number of the
Journal, and that copies could be got through Dr. Turnbull.

Digitized by LjOOQle

388

NOTES AND NEWS.

[April,

The New System of Night Nursing.

Dr. G. M. Robertson read a paper on “The New System of Night Nursing,’*
which was followed by a discussion.

Laboratory of the Scottish Asylums.

Dr. Clouston, on behalf of the Committee, made a statement regarding the
work of the Pathological Laboratory. He mentioned that under the supervision
of Dr. Ford Robertson the work is proceeding very satisfactorily, and that it is
proposed to remove the laboratory from the buildings of the Royal College of
Physicians to those of the Royal College of Surgeons in the course of the summer.
He hoped that all the asylums of Scotland would be induced to join, on special
efforts being made by those of their colleagues who had not as yet been successful
in persuading their committees to support an institution of which they could not
but approve.

A vote of thanks was given to Dr. Rutherford for presiding, and the meeting
then closed.

PARLIAMENTARY NEWS.

Lunacy Bill.

The Bill to amend the Lunacy Acts, introduced by the Lord Chancellor and
read a second time in the House of Lords on February 12th, is a measure con¬
sisting of 31 clauses and two schedules. It deals with such subjects as urgency
orders, judicial authorities, and reception orders, the removal of lunatics to work-
houses, disqualifications for signing medical certificates, visits to licensed houses,
powers of dealing with the property of lunatics, the reception of boarders, the
management of hospitals and their branch establishments, compensation to
asylum officers for injury sustained in the discharge of their duties, the temporary
care of incipient lunatics, and the jurisdiction of Masters in Lunacy. With regard
to urgency orders the provisions are that the currency of the order shall be
reduced from seven days to four, and that every order shall be accompanied by a
statement, to be made and signed by the person who signs the order and by the
medical practitioner who signs the medical certificate on which the order is
founded, that it is necessary for the safety and proper treatment of the alleged
lunatic or for the safety of others that he should be forthwith placed under care
and treatment, and showing fully and specifically the reason why an order of this
description is required. The disqualifications for signing medical certificates in
support of a petition for a reception order are extended considerably. They are
made to apply among others to persons in the employment of the licensee. Cer¬
tain amendments have been introduced, as has been explained on p. 312, and the
Bill has now been introduced into the House of Commons. Among the additions
made in the House of Lords are a provision that the judicial authority shall in his
report to the Commissioners state definitely whether in his opinion the detention
is or is not proper, and another to the effect that the power of two or more local
authorities to agree to unite in providing and maintaining a district asylum shall
be construed as including a power to unite in providing and maintaining a labora¬
tory for pathological research in connection with lunacy.

The Inebriates Act in Scotland.

There is in course of passage through the House of Lords a bill designed to
strengthen the administration of the Inebriates Act in Scotland. It confers on the
local authorities increased powers of assistance for the establishment and main¬
tenance of inebriate reformatories, and it makes eligible for committal to these
institutions persons convicted of drunkenness and disorderly conduct in a public
place.

Homes for Inebriates.

In answer to a question by Sir Charles Cameron, who called attention to the
complaints of magistrates as to the want of homes except for Roman Catholics,
the Home Secretary informed the House that the complaints were made under

Digitized by VjOOQle

NOTES AND NEWS.

1900.]

389

some misapprehension as to the facts. In realityyioo females and two males have
been committed to, and received in, certified reformatories, and of these fifty-nine
are Protestants. More accommodation is needed, and action is being taken by
many local authorities with a view to providing it.

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mbrcier.

[The editors request that members will oblige by sending full newspaper reports of

all cases of interest as published by the local press at the time of the assizes.]

Reg. v. Flower,

James Flower, 37, greengrocer, was indicted for the murder of his wife. Prisoner
appears to have been a sober man until a month before the murder. He then lost
a horse, which he said drove him to drink. About midnight on November and the
prisoner was found in his shirt and drawers in the street by a policeman, to whom
he said, 11 I’ve murdered the missus. She has poisoned my life. I have killed her.”
The woman was found dead from a wound in her throat. It was proved that since
he became addicted to drink he had had suspicions of his wife's fidelity, had persisted
that there was a man in the cellar, and had become very strange. Three doctors
deposed that a few days before the murder he had visited them, and was then
bordering on delirium tremens, and to one of them he had stated that his wife was
poisoning him. Dr. Hunt, medical officer at the county gaol, said that on the day
after the murder the prisoner said that someone was trying to murder him; that
his head had been examined, and that the man who examined it was offering large
sums of money for it. Subsequently he had said that his wife was concerned in a
plot against him, and had been offered a large sum to poison him. Dr. Spence, of
Burntwood, said that at the time Flower killed his wife he might have known that
he was doing a wrong act, but he might have believed that there was some con¬
spiracy against him, and that he had to defend himself against his wife. He would
not know that he was doing a wrong act in the same way that a sane man would
know. The judge (to prosecuting counsel): ” On this evidence is it possible to
submit to the jury that this is a case of wilful murder?” Guilty but insane.—
Stafford Autumn Assizes, Dec. 4th—Mr. Justice Mathew.— Times , Dec. 7th, and
Manchester Guardian , Dec. 5th.

The brief period for which this prisoner had been drinking complicated the case.
If the murder had been committed after a single day’s debauch he must have been
found guilty of murder. If he had been drinking for months the jury would have
had no difficulty in finding him innocent. But the fact that his drunken habits
had lasted for only about a month made it difficult to decide whether the act was
the outcome of ordinary drunkenness or of alcoholic insanity. No doubt the well-
marked delusions saved him from the gallows.

Reg, v. Beddoe.

John Beddoe, 24, gunner in the militia, was indicted for the murder of a comrade
named Hammett. Prisoner was a recruit, and was somewhat lacking in intelli¬
gence. He was made a butt of by the other men in the regiment, and orders had
been given that if anyone molested him he was to be put in the guard-room, and
he had been put in a tent next the company sergeant-major, so that the latter could
keep an eye upon him and see that he was not bullied. He was in a tent with five
other men, one of whom (the deceased) began to sweep the floor at a time when
the prisoner was standing near the tent pole, upon which hung the belts and bayo¬
nets of the men. As deceased was sweeping he came near the prisoner, and told
him roughly to get out of the way, at the same time giving him a blow on the shin
with the broom. The prisoner immediately snatched one of the bayonets from its
scabbard and, with a back-handed blow, plunged it into the right side of the
deceased, who died shortly afterwards. The prisoner appeared stupefied when he
saw what he had done, and upon being asked what had happened said “ I have
stabbed him.” Subsequently he said, “ I was cleaning my bayonet and he fell upon

Digitized by VjOOQle

390

NOTES AND NEWS.

[April,

it; it was his own fault.” In summing up the judge drew attention to the
evidence as to the prisoner's lack of intelligence, and pointed out the provo¬
cation received might have affected him more strongly than it would a person
of ordinary mental calibre. Guilty of manslaughter. Three years’ penal servi¬
tude.—Carmarthen Assizes, Mr. Justice Bucknill.— Times , Nov. nth.

This case is notable for the recognition, still too rare, although it is gradually
increasing of the principle of partial or limited responsibility. It is natural, and it
is pleasing to find this principle recommended by a judge so enlightened and so
well grounded in psychology as Mr. Justice Bucknill.

Reg. v. Jennings .

Robt. Jennings, 60, labourer, was indicted for the murder of his wife. The jury
was first impanelled to try whether he was fit to plead, and decided in the affirma¬
tive. Prisoner was seen holding his wife under water. The man who witnessed
the occurrence got the woman out of the water and ran for assistance. Another
man came up and prevented the prisoner from further injuring his wife, and
there was a struggle between them. Other men came up and prisoner fetched a
gun, which he pointed at them, and they ran away. Prisoner then took his daughter
and carried her towards the water, but stumbled over the body of his wife, and the
daughter escaped. He then jumped into the water and pulled his wife after him,
and held her head under water. Guilty, but insane.—Cambridge Assizes, Mr.
Justice Ridley.— Times , Jan. ist, 1900.

Reg. v. O'Byrne.

Thomas O’Byrne, 29, labourer, was indicted for the murder of his brother-in-
law, James Pullan. Prisoner and deceased had a trifling quarrel, in the course of
which prisoner leaned over a table that stood between them and stabbed the
deceased in the chest with a small knife, of which he died. Pullan said, ” Oh ! Jim,
I did not think you would do that.” Prisoner replied, ” I am sorry; I should not
have done what I did.” Both were in drink at the time. His lordship’s charge
to the jury is well worthy of being recorded: A state of drunkenness deliberately
produced was no defence for any crime whatever. When, however, the
existence of a certain intent—that is of positive mental activity—was of the
essence of an offence, and drunkenness disabled a prisoner from forming any
intent at all, it clearly disabled him from commission of that particular offence,
simply because a material element in it was lacking. It was for the jury to decide
whether the prisoner was in such a condition as to intend to commit serious bodily
harm on the deceased. It was worthy of notice that the police officer who arrested
the prisoner did not charge him with the offence because of his drunken condition.
Guilty of manslaughter. Liverpool Assizes.—Mr. Justice Kennedy.— Times ,
Dec. 4th.

The jury did not share the very humane and enlightened view of the judge, but
found prisoner guilty. The problem of when, and under what circumstances, and
how far drunkenness, or rather the effects of drink, are an excuse for crime, is an
extremely difficult one. It is admitted that ordinary drunkenness is no excuse, and
it is admitted that delirium tremens and the permanent insanity due to alcohol do
form valid excuses. The difficulty arises in cases of brief debauchery, which occupy
an intermediate position. In dealing with these cases the charge of the judge in
this case will be of great assistance.

A curious case has occurred at Manchester, in which a man was indicted for
the murder of his wife and acquitted. Subsequently he confessed the crime, but of
course he could not be again tried. He was, however, brought before the magistrates
by his own physician, and while under arrest he appeared to be insane. Having been
already acquitted of the crime the magistrates had no jurisdiction over him, and
he was discharged and re-arrested at once as a lunatic wandering at large.—
Manchester Guardian , Feb. 13th.

Charleston v. Steward.

Jessie Charleston sued David Steward for breach of promise of marriage.
Among other grounds of defence was that several relatives, both on the father’s
and mother's side, had suffered from insanity. There was no suggestion of insanity

Digitized by VjOOQle

NOTES AND NEWS.

1*900.]

391

in the lady herself, but only in members of her family. The Sheriff Substitute
had held that these averments were irrelevant, and that the defender had no case.
The defender appealed. The procedure of the Scottish courts is a little difficult
to follow. The appeal was allowed and the case sent for trial, but at the same time
the Court of Appeal abstained from saying whether the plea was relevant or no.
—Court of Session, June 8th.— Scotsman , Jan. 10th.

Redfern v. Gough .

Joseph Lamb, the testator, was admitted into Cheadle Asylum in 1891, and was
discharged therefrom in March, 1892. Shortly afterwards, finding that his mind
was again becoming affected, he voluntarily returned to the Asylum, where he
remained. In March, 1894, he was desirous of making a will, and Drs. Rayner
and Scowcroft were of opinion that he was competent to do so. The will was
correctly made and executed in the Asylum. It was now admitted to probate by
Mr. Justice Barnes .—Manchester Guardian , Nov. 18th.

Reported by Dr. Percy Smith.

Bedford v. Jackson.

The following case, in which a will made by a patient while insane was upset
and probate of an earlier will was granted, seems worthy of record, if only for the
fact that at the formal trial in the Probate Division of the High Court no attempt
was made to dispute the evidence of insanity or to uphold the will made while the
patient was insane.

H. B—, aet. 86, was said to have been "eccentric ” for years; to have been in
the habit of going out always with an umbrella up, so that people should not see
him, and on one occasion to have wired to his brother, asking him if he were of
sound mind, when there was no reason to doubt this.

He had some property, which he managed jointly with his brother and nephew
(a solicitor), but which the latter managed for him from 1892 to 1896. During
this period the “ eccentricity ” continued. He used to keep the blinds down in the
front of his house and the front door permanently shut. He used to keep one part
of the house entirely to himself, only allowing the servant in for cleaning purposes,
and then locking himself in. People used to call him “ the old lunatic,” and at
one time he spoke of complaining to the justices about this.

By a will made June 22nd, 1892, he benefited his relatives, and there was no¬
thing unreasonable in its contents.

In 1896 he changed in his manner to his nephew, who, on visiting him, found
that he locked himself in his rooms, and that it was very difficult to obtain access
to him. He asked his nephew if he was " better,” and said, “ You have been
mentally afflicted,” though there was no reason for this. He ceased to pay the
share of rents received to his nephew, on the ground that the latter could not give
a valid receipt, and this continued for three years.

In March, 1899, his nephew visited him at the express request of the rector of
the parish, as his condition was becoming notorious. When his nephew appeared
he called him an “ impostor,” and on his nephew’s visiting-card, which was after¬
wards found among his effects, he had written ” from an impostor, March, 1899.”
He also called his nephew and the latter’s brother “ thieves and lunatics,” and then
shut himself up in his room.

On July 2nd he is said to have stood in the road shouting out that the passers-
by were “ lunatics.” He had a hammer in his hand, with which he was striking the
doors and fences. He is said also to have called ladies " whores and prostitutes.”
About this time he also violently assaulted an old man, and had to be forcibly
removed from him.

On July 3rd he went to a new solicitor, having quarrelled with the one who had
acted for him before, and made a new will, ignoring his relatives and leaving his
property to charities.

On July 12th, having become more excited and violent, he was certified, and was
sent to the Holloway Sanatorium. While there the excitement passed off, but he
continued to be insane; did not realise the nature of the institution, nor that he
was under medical care; continued to believe that his brother and his nephew
XLVI. 27

Digitized by tjOOQle

392

NOTES AND NEWS.

[April,

were insane, and when the latter visited him said he was an impostor. He also
said that the person who visited him there (the nephew) was not the same indi¬
vidual who had visited him at his home; that he could with difficulty recognise
that his doctor who visited him there was the man he really knew; and that the
house of a neighbour was an asylum. He acknowledged that he had made a fresh
will, and said that it had now received the sanction of the Lord Chancellor, “ or
whoever was the proper authority.” He died in the institution on October 18th,
having become demented.

A “caveat” was entered against the will made in July, 1899, and another was
also entered by the executors of the will of 1899. The money having been left to
charities and not to individuals, it became the function of the Attorney-General, as
representing the public, to consider the facts on behalf of the charitable bodies to
whom the property was left. On consideration of the proofs which could be pro¬
duced of the patient’s insanity during the previous three years, the evidence of
insanity shown in the medical certificates and in my report of his condition on my
visit to him at the Holloway Sanatorium, on July 26th, 1899, the Attorney-General
concluded that the evidence of insanity at the time when the will of July 3rd, 1899,
was made was so strong that there would be no likelihood of its being successfully
upheld, and therefore he decided not to oppose probate of the will made in 1892.

The case was brought before the Probate Division on February 12th, 1900.
Evidence was given by the clerk to the firm of solicitors who prepared the will of
1892 as to due execution of such will; by the nephew as to the deceased’s insanity
in March, 1899, and in July before his admission to the Holloway Sanatorium;
and by me as to his insanity at my visit. No evidence was brought forward in
favour of his being of sound disposing mind in July, 1899, and the judge found
that he was insane at the time of execution of the second will, that of 1892 being
allowed to stand.

In this case the evidence of such insanity as to vitiate the will of 1899 was so
strong that there was no case on the other side. The patient’s mind was so
possessed by the delusion that his relatives were insane that he was unable to take
their claims into consideration. It will be noted that there was evidence of
H eccentricity,” not improbably amounting to insanity, existing at the time of
execution of the first will; but apparently the testamentary capacity had not been
affected by it.

Aphasia and Will-makino.

An interesting case, lately heard in the Probate Court before the President, Sir
Francis Jeune, is noticed as an occasional article on p. 320.— Ed.

ASYLUM NEWS.

The Cost of Asylums.

The London County Council lately considered a report by the General Pur¬
poses Committee upon the increased cost over the estimates of the Bexley and
Horton Asylums. It appears from the discussion that the H estimates ” were
rather of the nature of a sum which, at the time, it was hoped might prove suffi¬
cient, and was rather intended as a check upon extravagance than as a figure
arrived at by measuring up of quantities and the careful analysis of specifications.
The Committee of Inquiry assert that there has been good value for money, and
that the urgent demand for accommodation, and the excessive cost of boarding
cases out of London, justified the pressing forward of the erections with as little
delay as possible. Comparing the cost per head at the Bexley Asylum with that
at other recently constructed asylums, it is clear that the actual cost has not been
excessive. At Claybury the cost per bed was £ 236, at the new West Somerset
Asylum ^377, while the projected North Stafford Asylum is estimated to cost for
the building alone ^280 per bed. It is stated that the Asylums Committee is
considering the propriety of varying the stereotyped plan of erecting huge palatial
buildings for the insane in favour of detached residences.

Digitized by LjOOQle

1900.]

NOTES AND NEWS.

393

The Private Class of Insane.

The London County Council has recently announced to medical practitioners
that it has provided accommodation for about sixty female patients having a legal
settlement in the county of London at the Manor House, Horton, Epsom, at a
weekly charge, as at present fixed, of 155., exclusive of clothing and special
luxuries. Full particulars can be obtained from Mr. R. W. Partridge, clerk of the
Asylums Committee. At the Claybury Asylum provision is also made for private
patients who can claim a settlement in the county of London at a charge of 30s. a
week, and for others at a charge of £2. This action of the London County
Council has our hearty approval. Similar arrangements have been made in other
counties, and the results have proved satisfactory in affording most needful
accommodation to the poorer class of the private insane.

Hours of Duty of Asylum Attendants.

Another report brought before the London County Council by the Asylums
Committee, dealt with the hours of duty of the nursing staff. It recommended
that no reduction should at present be made. Day attendants are on duty four¬
teen hours (6 a.m. to 8 p.m.) for six days a week. One day a week is allowed off
duty, and twelve days annual leave is granted. Night attendants are on duty for
ten hours per diem. Any attempt to introduce a system of three shifts of eight
hours each is regarded as impracticable, and the superintendents are unanimous
against the reduction of the daily hours of duty. To allow two days off a week
would cost ^17,600 per annum, and would mean the enhanced weekly cost for
each patient of 105. 5 d. t instead of 9s. nd., as at present. The Chairman of the
Committee, after defending the report, concluded by offering to take it back for
further consideration. The general opinion appeared to be against fourteen hours
duty a day—at any rate in some of the most exacting wards,—and the Council
seemed to doubt whether all possible methods of effecting reduction had received
due consideration at the hands of the Asylums Committee.

We do not learn, however, that any suggestion of a way out of the difficulty
was made. A committee of the Scottish Division is at present considering this
and similar matters of importance in regard to administrative details, and a
special meeting will be called to receive their report on Saturday, the 2nd June.
We trust that there will be a full attendance when these questions come up for
debate.

Deficient Asylum Accommodation in Lancashire.

At the meeting of the Bolton Board of Guardians on November 23rd the
Chairman called attention to the provision for lunatics in the Bolton Union. At
the present time, he said, the asylums in Lancashire were full, and it was necessary
to send imbeciles into other counties. There were 611 lunatics in the Bolton
Union, and of these 557 were in Lancashire at the asylums of Prestwich, Whitting-
ham, Lancaster, Rainhill, and Winwick, and 54 were outside, including 20 in Hull,
6 in Birmingham, and others in Ipswich, Carmarthen, Derby, Northampton, and
elsewhere. Not only was the inconvenience entailed by the distance very great to
the officials of the Board and the relatives of the lunatics, but the question of cost
was very important. The expense at Prestwich, for example, was 8s. 9 d. per week
for each lunatic, whereas at the asylums in other counties something like 25s. was
the charge imposed. He moved—“That the Bolton Board of Guardians
respectfully suggests that the Lancashire Joint Asylums Board should make
provision, either temporary or otherwise, for lunatics belonging to this Union at
present placed in asylums outside the county.” The new asylum at Winwick
would on its completion be entirely filled. They ought to build another large
asylum, but so far as he knew they had not commenced. It took about five years
to build an asylum, and therefore for several years to come they in Bolton would
be under the necessity of sending lunatics all over the country. That some
temporary accommodation, at least, should be provided, was a very reasonable
request. The resolution was adopted.

At the quarterly meeting of the Lancashire Asylums Board held on August 24th,
letters were read from the guardians of the Prestwich, Rochdale, Stockport, and

Digitized by LjOOQle

394

NOTES AND NEWS.

[April,

Chorlton Unions complaining of the lack of accommodation in the asylums of the
Board. The Chairman said that the letters pointed to the fact that before long
they would have to look out for a site for a sixth asylum. The Winwick asylum
would not be finished for eighteen months or so. The provision made for epileptics
and harmless cases differs much in different unions. Blackburn deserves com¬
mendation, for with 908 inmates in the workhouse provision has been made for 187
of these cases. The Bolton guardians “ were, perhaps, the worst offenders in this
respect, for with 1156 inmates in their workhouse they provided for 18.”

At the meeting of the Chorlton Union Board on September 1st, the Chairman,
Dr. J. M. Rhodes, stated that the proportion of paupers in that union was 1 in 52
persons, the average for Lancashire being 1 in 53, while that for England and
Wales was 1 in 39. He thought the figures showed that there was a large amount of
thrift, and that the people in the district were improving in social position, but those
statistics relating to lunacy were a matter for regret. In the Lancashire workhouses
they had only an increase of 220, but the number in the asylums had risen from
7930 to 8561. The Chorlton Board provide for their own harmless imbeciles and
epileptics, and there are 306 in their own workhouse. He was sorry that some
unions did not make similar provision, for it was unjust to such unions as Chorlton,
Blackburn, Prestwich, Manchester, and Salford, and though they had been asking
for justice on this question for many years “ the Local Government Board turned a
deaf ear to all they had to say.” One of the guardians said that the question of
providing temporary accommodation for lunatics should be constantly impressed
on the Lancashire Asylums Board. Dr. Rhodes stated that the increase of insanity
was such that according to some of the best authorities they ought to be building a
new asylum every year.

A similar difficulty exists in Cheshire. Although £ 90,000 were lately spent in
enlarging the Upton asylum at Chester, proposals have been recently made to
grant ^70,000 for the enlargement at Annet. The plan consists of a detached
infirmary for 206 patients, an epileptic ward for 50 patients, and a nurses’ home.

Lancashire Asylums Board Rate.

In the Court of Appeal, 22nd January last, judgment was given in the case of
the Lancashire Asylums Board v. the Manchester Corporation as to whether the
Lancashire Asylums Board in estimating the amount required by them annually
from the county of Lancashire and the county boroughs therein, should divide it
between them in proportion (1) to their assessable value, or (2) according to
their rateable value under the Agricultural Rates Act, 1896. The Asylums Board
contended that it was now their duty to take as the basis of the division to be
made by them the assessable value of the county and county boroughs as specified
by the Rating Act of 1896, in place of the rateable values as calculated under the
Local Government Act, 1888. The Corporation of Manchester, however, con¬
tended that these assessable values have no operation except for the levying of
rates, and that as the Asylums Board was not an authority for levying rates they
ought to base their calculations on the rateable values found as they were before
the passing of the Rating Act, 1896, which, as they contended, operated on the
amount so apportioned to each council after it was so apportioned and not before.
The Court answered question one in the negative and question two in the affirma¬
tive. The appeal of the Corporation was therefore allowed.

Imbecile Children in London.

It would seem from a complaint by the Shoreditch and St. Saviour’s Board of
Guardians of the **grave inconvenience and annoyance” caused by the lack of
accommodation for imbecile children, communicated to the Metropolitan Asylums
Board, that further provision for this class is required. It is to be hoped that the
educable imbeciles at Darenth (about 400 in number) will be separated by removal
to a distinct establishment. The operation of the new Act relating to defective
children will have an effect upon this question, and more time should not be lost
in setting to work.

Operations on the Insane in Asylums.

The Paris correspondent of the Lancet reports that this question has been under
discussion at the Society of Legal Medicine, the subject having been introduced

Digitized by LjOOQle

i goo.]

NOTES AND NEWS.

395

some six months ago in an important paper by M. Picqu£ and M. Briand. They
came to the conclusion that the surgeon should only interfere in cases of absolute
urgency. M. Leredu, a barrister, sent in a report to the Society on the question
formulated as follows :—“ Is a surgeon within his rights in performing a surgical
operation upon a lunatic without the consent of the patient’s relatives ? ” He
answered in the negative, except in a case of absolute urgency. A lunatic is
unable to give consent; it is his relatives who must give consent to the operation.
But the relatives may refuse consent, possibly from fear of an unsuccessful
result, or, on the other hand, with the deliberate wish to deprive a person who
is a disgrace and expense to them of a chance of life. Again, the relatives
may not choose to answer, or the lunatic may have no relatives. It is, then,
the legislature that must be asked to supply an answer to the question. It would
be easy to settle it by an enactment drawn in some such terms as these: “ When
a surgeon is of opinion that surgical interference is called for in the case of a
person who is an inmate of a lunatic asylum, he shall obtain leave to operate from
the relatives of the patient. In case the relatives refuse, the director of the
asylum shall at once inform the Procureur of the Republic. This official shall
put the tribunal in possession of the facts, whereupon it may rule the case to be
one of urgency and the proposed operation to be a last resource, making the
order in the Chambre de Conseil, after having referred the matter, should it
think fit, to medico-legal experts for an opinion as to the propriety of surgical
intervention.*’ M. Picqu£, in supporting the opinion of M. Leredu, showed how
difficult it was to obtain a really valid consent from relatives. In twenty cases
where he applied for leave he received but one answer. The disagreeable conse¬
quences (which may arise to a surgeon through operating without consent) being
taken for granted, M. Picqu£ would only dispense with such consent in the three
following instances: suffocation, strangulated hernia, and arterial haemorrhage.
There might be others, such as metrorrhagia and conditions associated with the
urinary organs, but so long as the matter was not settled, either by statute or
by a resolution of the Society, he would not interfere, unless he had some
authorisation in writing, for fear of incurring both moral and material respon¬
sibilities, which in France were very grave. If the patient were to die his
relatives, who had shown themselves absolutely indifferent when permission was
asked of them, would not hesitate to claim damages and to attack the surgeon
in the public prints. Even if the operation were successful the surgeon would
not be free from the risk of disagreeable consequences. In the discussion which
followed, without any conclusion being then arrived at, it was curious to see
the legal members, among whom was M. Jacobi, the Advocate-General, giving
their opinion that it was right for the surgeon to operate if he thought it neces¬
sary, even against the wishes of the relatives, while the medical members were
less bold and demanded some legal protection to cover their responsibility.
As a matter of fact, despite the philanthropic and philosophic views of indi¬
vidual members of the magistracy, the medical profession know only too well
how of late these very magistrates have, when sitting in court, shown them¬
selves both severe and unfair towards medical men, and how ready they are to
entertain complaints from the relatives of patients against their medical advisers.

Wounded Soldiers in Scotland.

We note that the Board of Directors of the Crichton Royal Institution, Dumfries,
have offered to accommodate ten wounded soldiers from South Africa, preferably
men suffering from nervous disorders.

AFTER-CARE ASSOCIATION.

The annual meeting was held on February 19th, at the house of Dr. Blandford,
who presided. The Chairman, in his introductory remarks, pointed out that the
main object of the Association was to help those who had left asylums recovered
from an attack of insanity to make a fresh start in life; and this was the more
necessary as mental illnesses were often matters of months, not days or weeks, and
consequently situations could not be kept open for the sufferers, as they were some-

Digitized by VjOOQle

396

NOTES AND NEWS.

[April,

times for hospital patients. The Secretary (Mr. Thornhill Rexby) then read the
annual report, from which it appeared that, during 1899, 222 cases had been before
the council, the largest annual number ever dealt with. Cases had been assisted,
as in the past, by being boarded out in cottages in the country, by grants of money,
and by finding occupation. The investigations involved had been of an onerous
character. The failures had been comparatively few. Boards of guardians had
availed themselves largely of the help of the Association, and in some few cases
thev had subscribed to its funds. The total amount of subscriptions, donations,
and contributions for maintenance was ^549 8s. id., a falling-off from the previous
year, when they amounted to £652. In moving the adoption of the report, Dr.
G. H. Savage remarked on the difference between hospital and asylum patients, and
the usefulness of such a society to bridge the gulf (too often exaggerated by popular
prejudice) between “ alienism ” and the ordinary conditions of social life. The
Association had done valuable work in two directions—in confirming health, and
in preventing relapse. The resolution was seconded by the Rev. Dr. Springett
(Vicar of Brixton), who bore personal testimony to the admirable character of the
agencies employed by the Association, and having been supported by the Rev. W.
St. Hill Bourne and by Dr. Shuttleworth, was carried unanimously. Dr. Percy
Smith moved, and Mr. Deputy White seconded, the reappointment of the council
and officers of the Association, and the meeting concluded with a vote of thanks to
the Chairman, moved by the Rev. Henry Hawkins, and seconded by Dr. Rayner.
The offices of the Association are at Church House, Dean’s Yard, Westminster, S.W.

HABITUAL DRUNKENNESS.

The Inebriates Act of 1899 was passed just before the close of the session to
remedy a defect of the Act of the previous year. But, although it has been
remedied in regard to the expenses of prosecution, complaints are made by
magistrates that it is practically a dead letter, and the Home Secretary has
admitted that the accommodation provided is insufficient.

NEW SOUTH WALES BILL.

The New South Wales Bill, introduced by the Hon. Dr. J. M. Creed, passed
the Legislature Council, and has been presented to the Legislature Assembly.
The main provisions show an advance upon what has been done in this country.
Under this Bill it is lawful for a judge or magistrate or the master in lunacy, and
after the evidence of a medical practitioner and on inspection, to make an order as
to the control of an inebriate.

On the application of—

(a) An inebriate or any person authorised in writing on that behalf by an
inebriate while sober;

( b ) The husband, or wife, or a parent, or a brother, sister, son, or daughter of
full age, or a partner in business of an inebriate; or

(c) a member of the police force of or above the rank of sub-inspector acting
on the request of a duly qualified medical practitioner in professional attendance
on the inebriate, or on the request of a relative of the inebriate, or at the instance
of a justice of the peace—

to order that the inebriate be placed under private or public treatment for a
period not exceeding twenty-eight days ; or be placed in a licensed institution for
such period not exceeding twelve months, as may be mentioned in the order; or
that the inebriate be placed for any period not exceeding twelve months, to be
mentioned in the order, under the care and charge of an attendant or attendants to
be named in the order, and who shall be under the control of the judge, master in
lunacy, or magistrate making the order. . . .

Where an inebriate has thrice within the preceding twelve months been con¬
victed for an offence of which drunkenness is a necessary ingredient, it shall be
lawful for any Court of Petty Sessions to order that the inebriate be placed for
such period of not less than six or more than twelve months, as may be mentioned
in the order, in any institution which may be established by the Government for

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

397

the reception, control, and treatment of inebriates so convicted ; and on the order
of a Judge of the Supreme Court, or of a District Court Judge, or of the Master
in Lunacy, such period may from time to time be extended for further periods not
exceeding twelve months each.

Power is given to place these inebriates under immediate medical treatment in
any convenient hospital, gaol, or private house, and to direct that the expense of
the care, charge, and maintenance of the inebriate be paid out of any property
of the inebriate, and to fix the amounts to be so paid, and the amounts so
fixed may be recovered in any court of competent jurisdiction.

These directions may be given on orders varied, renewed, or rescinded, as those
making the order may think fit.

A notable feature in the Bill is that the attendant shall be authorised to prevent
the supply of intoxicants to any inebriate under his charge. Further, any such
attendant who neglects to comply with any such direction shall be liable to a
penalty not exceeding ^5.

LANCASHIRE INEBRIATES ACTS BOARD BILL.

Sir J. T. Hibbert presided over an important conference of representatives of
county and non-county boroughs held in Preston, on 29th January, for the purpose
of considering a Bill for the establishment of aboard for carrying out the provisions
of the Inebriates Act in Lancashire.

In opening the proceedings, the Chairman said he experienced great regret that
some time had elapsed in dealing with this subject. They were all acquainted
with the difficulties of carrying out the plans which had been put forward for having
a combination of the authorities of the county and non-county boroughs, and
possibly the delay which had unavoidably arisen might in the end place them in a
position to do more good—and that very likely with equal speed—than if they had
been left to themselves under the present law, fighting the various central
authorities in London in the effort to overcome the difficulties of their position.
It would be remembered that at the last meeting resolutions had been adopted in
regard to the course of procedure. He trusted that they would find it a successful
endeavour to carry out the objects they had in view. He regretted to say that one
county borough (Oldham) had declined to join in the movement. He trusted that
if the Bill to constitute an Inebriates Acts Board for the County Palatine of
Lancaster went through the House successfully—and he did not anticipate opposi¬
tion from any person or authority; indeed, he hoped the measure would receive
the support of the Home Secretary—it would be placed on the Statute Book
before many months had passed. Granted that they were successful, it had been
suggested that the first meeting of the board to be constituted under the Act should
be held in November, but he looked forward to a gathering being held not later
than August.

After discussion upon several clauses of the Bill, the following resolution was
adopted :—“ That this conference approves of the Bill as directed to be amended,
and that the County Council proceed to the promotion of the Bill in Parliament.”
On the suggestion of the Town Clerk of Manchester it was decided to summon
the conference after the Bill had left the House of Commons, in order that there
might be a further discussion of its clauses if necessary.

The representation of the various authorities interested will, as provided by the
Bill, be as follows:—Barrow, Bootle, Burnley, Bury, Rochdale, St. Helens, Stock-
port, and Wigan, one each ; Blackburn, Bolton, Preston, and Salford, two ; Liver¬
pool, five ; and Manchester, four.

The Bill says the Board will or may require to borrow ;£50,000 f° r purposes
of the Bill. It is provided that the term “ entire county ” shall mean the
geographical county of Lancaster, and “ county ” the administrative county.
There shall be in and for the entire county an Inebriates Acts Board, consisting of
eighteen representatives of the county and twenty-five representatives of the
contributory boroughs, and the Board shall be a body corporate. The eighteen
representatives of the county are to be elected at the County Council’s quarterly
meeting in November, and representatives of contributory boroughs (who may or

Digitized by VjOOQle

398

NOTES AND NEWS.

[April,

may not be members of the Council) shall be elected at the corresponding meeting
of the councils of the contributory boroughs. Members of the Board will hold
office for twelve months. There is the usual provision as to members being
interested in contracts, and a member of the Board elected by the County Council
who ceases to be a member of the County Council also ceases to be a member of
the Board. Resignation is effected by notification in writing to the clerk of the
Board, and casual vacancies are to be filled by the Council by whom the vacating
member was originally chosen. A member so chosen shall retain his office only
so long as the vacating member would have done. Chairman and vice-chairman
are to be elected annually, and the Board has full power in the appointment and
payment of clerk and officers. Subject to the provisions of this Act, the Board
shall have and may exercise all the powers of a local authority under the Inebriates
Acts, 1879 an< * 1808, for granting, renewing, transfering, and revoking licenses to
keep retreats under those Acts, and the Board shall be the sole local authority for
the purposes of those Acts in and for the entire county exclusive of any county
borough not at the time a contributory borough, and of any non-county borough
which has established a separate inebriate reformatory. The Board may apply to
a Secretary of State to certify a reformatory under the Inebriates Act of 1898, and
may themselves undertake and contribute to the establishment and maintenance of
such institution or institutions, and may acquire lands, erect or provide and main¬
tain and furnish buildings, and generally may do all acts and things necessary or
proper for the purpose. The Board may defray the whole or any part of the
expenses of detention of any person in any certified inebriate reformatory, and may
contribute to retreats to the same extent as the council of a county or borough
may under the 1898 Act. The proceeds of the sale of any land acquired by the
Board shall go to capital account. All expenses incurred by the Board in the
execution of their duties shall be paid out of a fund to be called the Inebriates
Board Fund, and all sums acquired by the Board shall be carried to that fund.
Should such receipts be insufficient, the deficiency shall be raised by the county,
and by each of the contributory boroughs. Before March 1st in each year the
Board is to estimate the total amount required to be raised by contributions for the
ensuing year, and that amount is to be divided between the county and contributory
boroughs in proportion to rateable values. Contributions may be made retrospec¬
tive, and any difference arising concerning the precept shall be referred to a single
arbitrator. The financial year will end on March 31st each year, and a return of
receipts and expenditure is to be forwarded annually to the Local Government
Board. The Board will have borrowing powers for sums not exceeding in the
whole ,£50,000, repayable as follows (1) Money borrowed for the purchase of
lands, fifty years; (2) money borrowed for the erection of buildings, thirty years ;
(3) money borrowed for furniture and fittings, fifteen years; and (4) money
borrowed with the sanction of the Local Government Board in such periods as that
Board may prescribe.

In 1905 and every subsequent fifth year it shall be lawful for the County
Council or for the council of any contributory borough to apply to the Board to
increase or diminish its number of representatives, and if the Board fail to settle
the number to the satisfaction of the council applying, the matter shall be applied
to the Home Secretary. The council of any contributory borough may with¬
draw itself and its borough from the operation of the Act on six months’ notice,
and an adjustment of property and debts shall be made within twelve months of
the notice of withdrawal by agreement or arbitration. Section 30 provides that
nothing in the Act shall affect the right of any non-county borough to establish
an independent inebriate reformatory, and in the event of that being done such
borough shall not be liable to contribute towards any expenditure incurred by the
County Council under the Act of 1898, or by the Board under this Act, so long as
the reformatory established by the borough is certified and open for the reception
of inebriates, and the rateable value of such non-county borough shall, during
such exemption, be deducted from the rateable value of the county, and there
shall be reserved to the council of the borough all the powers of a local authority
under the Acts of 1879 and 1888. The council of any county borough for the
time being not represented on the Board may apply to the Board to be admitted
to representation, and the Board may thereupon make an order assigning a repre¬
sentative or representatives to the applicant council on such terms and conditions

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

399

as they deem fit. If the applicant borough accept the order the Act shall apply
to them and to their borough as if the borough were a contributory borough
subject to the order, and the number of representatives on the Board shall be
altered accordingly. If the applicant council does not accept the order, then
application shall be deemed to have failed, but without prejudice to a future
application.

INEBRIATE REFORMATION IN IRELAND.

We learn from the Dublin Express that Ennis Gaol has been set apart for the
purpose of a State Reformatory in Ireland, and that the Irish Women’s Temper¬
ance Union is taking steps to establish an Inebriate Home for Women. It is
further stated that the Irish Association for the Prevention of Intemperance is
moving the County Councils in this matter.

INEBRIATES IN FRANCE.

Dr. Legrain, of the Ville Evrard Asylum, with Dr. Antheaume, has lately
published a report dealing with the treatment of habitual drunkards. “Their
opinion of the drunkard is that he is a moral invalid whose cure depends upon
hospital rather than prison treatment. Three essential principles should enter
into and govern this treatment. They are (1) that the patient should abstain from
all intoxicants; (2) that he should be provided with suitable labour; and (3) that
he should be subjected to influences conducive to moral reform. In order to secure
as far as possible the realisation of the third principle, the report strongly urges
that an inebriates’ home should never under any circumstances be built to
accommodate more than 200 patients, and in a letter addressed to a corre¬
spondent, Dr. Legrain expresses his condemnation of large establishments in very
definite terms. It is also suggested in the report that the reformatory should
be situated in the open country, far away from centres of population, so as to
preserve the patients from the temptation to drink. The home itself should
realise the conception of an agricultural and industrial colony. Special emphasis
is laid upon the physical ana nyaral value of work performed in the open air.
The summer months are to be spent in agricultural and gardening operations;
in winter the patients are to be trained in various occupations, such as brush-
making, locksmiths’ work, carpentry, bookbinding, basket-making, smithy work,
leather work, etc. This labour should be obligatory upon the inmates. Dr.
Legrain and Dr. Antheaume are of opinion that, next to the practice of total
abstinence, muscular exercise is the most important factor in the process of
mental and physical reform. Each hour of the day should be occupied ; and
in the evenings lectures, games, etc., should be enjoyed. A central hall should
be provided for the realisation of the latter object. The entire separation of the
sexes is held to be necessary, but the buildings in which they are to be severally
housed ought not to be so placed as to be entirely independent the one of the
other. It is suggested that the distance between them might be anything from
four to six thousand yards, and that they should be connected by tram lines.
By this means the work of the men would supplement that of the women, and
vice versd. The men would grow garden and field produce, and the women do
the washing, cooking, mending, etc., of the home for men. As for the buildings
themselves, they should be of small size. An inebriates’ colony should be a
series of pavilions, and no one of them ought to accommodate more than sixty
patients. They should also be designed and placed so as to produce a pleasing
effect upon the inmates. Gardens should separate them from each other. Large
dormitories are condemned. The general oversight of an inebriates’ home should
be entrusted to an experienced medical specialist who is not only capable of
classifying the patients properly, but who also has the entire work at heart. It is
also considered to be essential that total abstinence should be rigorously practised
by the officials as well as by the patients. The treatment of an inebriate should
be continued for from six to twelve months, and, on his release, it is recommended
that he should ally himself with a temperance organisation, so as to assure the
continuance of the good influences of the reformatory.”

Digitized by tjOOQle

400

NOTES AND NEWS.

[April,

RESPONSIBILITY IN THE CARE OF INEBRIATES.

We have received copies of a New Zealand newspaper (The Press of November
last), giving an account of the case of McFarland v. Stewart, tried before Mr.
Justice Denmiston. The defendant had received the plaintiff’s husband into his
home for inebriates at Opawa, while he was in a state of delirium tremens.
Apparently he had made a rapid recovery from his mental troubles, but within a
few days of his reception found a pea-rifle in the hall, got a cartridge in the
lavatory, and shot himself in the absence of the defendant’s son, who had been
instructed to look after him. He had previously, while still mentally affected, tried
to cut his throat with a knife. The action was brought under the Deaths by
Accident Compensation Act, 1880, to recover damages on behalf of the widow, and
it was admitted that seven guineas a week was to be paid, as the patient required
two attendants. The judge gave his decision in favour of Dr. Stewart, on the
ground that no such negligence had been shown as would have entitled the
deceased man to recover damages if he had merely wounded himself. As he had
so much improved, the defendant was justified in relaxing supervision in the
patient’s interests. Some of the medical witnesses gave their opinion that the
patient was sane when he took his life, and this also influenced the judge. The
Press, however, expresses the feeling that the state of matters disclosed by the
evidence is unsatisfactory. It is not satisfied that inebriates should be placed in
private homes not subject to Government inspection, and animadverts on the
dangerous nature of the weapons within easy reach, and on the facility with
which the patient got whisky when he asked for it. It would appear that the
Government has done nothing to provide institutions for the reception of habitual
drunkards under their Inebriate Institutions Act of 1898. This is much in accord¬
ance with our experience at home, and The Press, in urgingfor the due application
of the existing law with reference to the insane in private houses, makes the same
demand as we have repeatedly found necessary here. Apparently insane persons
are being kept in private houses which are not licensed under the Lunatics Act,
and of which the Government has no official cognizance. In a new country special
difficulties exist in meeting the wants of the insane of all classes, and for that and
other reasons it is desirable that facilities for proper treatment should exist; but
while interposing no incapacitating difficulties in the way of developing public
and private asylums and suitable houses for single care, the Government should
insist on knowing where every person of unsound mind is kept for gain. We
firmly believe that the best results for the patients and for the public are to be
gained by a system of healthy competition under the inspection of capable
physicians. The haphazard methods which permit of acute alcoholic cases having
access to sharp knives and loaded firearms constitute a grave scandal. The
suicidal tendencies of such patients are well known, and their treatment by whisky
as reported, although not unknown in less remote localities, will hardly bear
repetition in far Opawa. We sometimes hear of the blessed facility in law¬
making in new countries, in disparagement of a slower legislative coach elsewhere ;
but the duties and responsibilities of Parliament do not end with the eruption of
brand-new Acts. The more onerous and the more important matter comes later in
due enforcement by properly equipped executors.

ANTI-ALCOHOLIC SERUM.

The Paris Academy of Medicine is responsible for a newspaper sensation. At
its meeting on the 26th December last, MM. Broca, Sapelier, and Thi^baut
presented a paper on the discovery of an anti-alcoholic serum, and a committee
has been appointed to investigate and report. The preliminary principle adopted
by the authors is that in alcoholic intoxication, as in morphia intoxication, there is
a period of gradual toleration, and of desire for the poison. Certain organic
poisons form in the organism antitoxins representing elements of resistance to
infection. These antitoxins injected into another organism place it in a position
of similar resistance. The observers produced tolerance to alcohol in the horse by
giving it by the mouth, and found that the serum of this horse injected into other
animals rendered tolerant and fond of alcohol, produced in these animals a pro¬
nounced distaste to alcohol. M. Broca declares that the injections caused no

Digitized by

Google

1900.]

NOTES AND NEWS.

401

disorder in the patients experimented upon, and that each turned away in disgust
from spirits which the stomach could no longer assimilate. The remedy, in
addition, possesses powerful qualities of regeneration, due to an unknown sub¬
stance called “ stimulithe.” M. Broca proposes that the serum should be named
44 Antiethylene," and is convinced that the committee will, by continuing the
experiments, soon be able to define the new serum clearly. At present it seems to
have no effect upon the organic changes consequent on chronic alcoholism; and
the Academy has been informed that, while it abrogates the taste for brandy, the
taste for wine is preserved unimpaired! Some of us are even yet unfashionable
enough to prefer wine.

ASYLUM CONSTRUCTION.

Many new asylums have been built within the last few years, and by an interest¬
ing return obtained by the county of Worcester it would appear that great
consideration has been given to the problems of construction by local authorities.
Comparatively few invited competitive plans. Most of the architects were selected,
either on account of their eminence and experience, or on account of their local
connections. The general rate of remuneration would appear to have been 5 per
cent. Not a few appointed committees of inspection, and it is to be regretted
that this course is not more commonly adopted. We are strongly of opinion that
the medical superintendent should be appointed in the first] instance, and that he
should so advise his committee that they would proceed to the formidable task
before them in the light of his knowledge of special requirements, and with him
to advise as to which of the existing institutions should be visited. Progress in
this direction has been mainly on the initiative of the medical superintendents,
and each should, in so far as possible, develop ideas in building and construction.
We are glad to note that the acreage held by the committees of recently erected
asylums is on the whole satisfactory, although there are still too many content
with fifty or sixty acres. The cost per head calculated on the number of patients
is stated at sums varying from ^150 to £420, These calculations and returns,
however, must be received with caution, for there are so many considerations
entering into the question that economical management in one locality might be
the very reverse in another.

COMPLIMENTARY.

Presentation to Sir John Sibbald.

At a meeting of Sir John Sibbald’s friends in February of last year it was
resolved to present him with his portrait, painted by the President of the Royal
Scottish Academy. On the 22nd of December last the presentation was made in
the Royal College of Physicians in Edinburgh. The Master of Polwarth occupied
the chair, and before calling on Dr. Yellowlees made complimentary reference to
Sir John Sibbald’s work in connection with the Lunacy Board.

Dr. Yellowlees, who spoke in the unavoidable absence of Sir William Gairdner,
in the course of his remarks said—I recall a great many memories in going back
over Dr. Sibbald’s career. I remember him long ago when he went to be resident
physician at Perth Infirmary. Afterwards he went to be resident in Brompton
Consumption Hospital. He was nearly settling down as a London practitioner.
Happily he did not do so* but took to the line in which he distinguished himself.
Of all the memories by far the most vivid are those associated with Morningside.
I look back on that as the best period of my life. But if I once began with remi¬
niscences I should not know where to stop, although we have scarcely ever met
without recalling reminiscences of these days, and of our honoured chief, Dr. Skae.
After that memorable time Dr. Sibbald went to Lochgilphead Asylum. That
asylum was opened and organised by him. Sir John Sibbald, I am sure, will be
the first to acknowledge and recognise that his experience there was invaluable in
future administrative work. I remember him leaving that post to become deputy
Commissioner, and the long years of earnest and unobtrusive work he did in that

Digitized by tjOOQle

402

NOTES AND NEWS.

[April,

capacity; and then I well remember twenty years ago, on the death of Sir James
Coxe, he succeeded to be Commissioner along with Sir Arthur Mitchell. Of that
work I have very intimate knowledge, and can speak with absolute certainty as to
the admirable way in which it was discharged. I need not say more about Dr.
Sibbald’s work; it has been attested sufficiently by the Chairman of the Board
to-day in your presence, and it was sealed by the knighthood which was so well
earned and so worthily bestowed, and in which we all rejoice; but 1 think 1 know
Sir John Sibbald well enough to say that the gathering to-day touches even a
tenderer cord than that, and comes nearer than any public appreciation, and that
he cares more for the appreciation of his personal friends, who know him best, than
for official recognition. I would like to say something not only about the very
admirable work of Dr. Sibbald, but also something about the spirit and the tone in
which that work had been done, because I think that of the very utmost importance,
and 1 think that spirit and tone which pervades the whole lunacy administration of
Scotland has been of far greater significance than people know. To inspect the
work of your professional brother honestly and truthfully, and fearlessly to say
what is wrong and what is right, and to do that without giving offence, is no easy
matter, and that very delicate duty was discharged by Dr. Sibbald most admirably.
It is the distinction of Scotland compared with other countries that the Commis¬
sioners were always regarded as the friends of superintendents, that their visits
have been an encouragement and a help, and the personal relations that have
existed between the board and the superintendents have been a very important
factor indeed in making the Scotch lunacy system what it is to-day. In that respect
Sir John Sibbald fully sustained the traditions of his board. I speak not for the
profession alone, but I speak in the name of this meeting and of subscribers to this
picture. So I will do what you have given me the great honour of doing, and will
address myself to Dr. Sibbald. In the name of this meeting and of all those repre¬
sented by this meeting, I now ask your acceptance of this portrait, as a testimony of
our high appreciation of your public work. May it long adorn your home, and may
it tell to your children’s children in future years what manner of man he was whom
his friends thus delighted to honour.

Sir John Sibbald in reply said—Master of Polwarth, ladies and gentlemen, I
thank you, Sir, very sincerely for the great honour you have conferred upon me
of presiding upon this occasion, and for the very kind words you have used in
regard to me. I have also to thank my distinguished friend, Dr. Yellowlees. He
was my friend during the early period to which he has alluded, when we climbed
together the hill which all youths must climb, my friend while we journeyed over
the table-land of middle life, and now in my declining years my friend—true and
kindly as ever. I have to thank all the ladies and gentlemen here present very
expressly for the kindness which they show to me on this occasion. I have to
thank all who have been associated with them in this presentation; especially I
have to thank the committee and Dr. Philip, the Secretary, who must have had an
immense amount of trouble in bringing to a conclusion the work which is finished
to-day. With regard to the portrait, the kindness of which it is the token will
always make it the most valued of my possessions. But apart from that, I value
it as a work of art, which, in spite of the imperfections of the subject, is, I believe,
worthy of the reputation of that prince of painters, Sir George Reid. Two feelings
to which it is impossible I can give adequate expression arise in my mind in regard
to this presentation. One of these feelings is the oppressive sense of my own un-
worthiness of so distinguished an honour; and the other is an overwhelming sense
of the large-hearted kindliness and magnanimous generosity of my friends who are
associated in the presentation. I shall not dwell upon these things, for an attempt
to enlarge upon them would tend rather to weaken than strengthen the expression
of what I wish you to receive as the outpouring of a heart that is deeply moved.

On an occasion such as this it is scarcely possible to avoid glancing backward
over the period of one’s working life and thinking of those with whom one has
been associated as a fellow-labourer. I have, as most of you know, been chiefly
associated with those whose work has been to promote the curative treatment of
insanity, and to ameliorate the condition of the insane. If, therefore, in a few
words I have still to say, I take occasion to congratulate my fellow-labourers on the
improvement that has been effected during the past half-century in the way that
the insane have been treated and provided for, I trust that those of my friends who

Digitized by tjOOQle

NOTES AND NEWS.

1900.]

403

have not been specially engaged in that work, but whom I have no less reason to
thank on this occasion, will not deem me forgetful of their kindness.

There has been more or less improvement during the past fifty years in the
condition of the insane in every quarter of the globe, but nowhere has it been more
remarkable than in Scotland. Some of those who were leaders in the work have
passed from their labours, but others who have been specially eminent are, I am
glad to say, still with us, and are now in this room. It has not, however, been an
affair of leaders alone. Some of the most effective work has consisted of the re¬
cognising and fostering of improvements inaugurated by less prominent, though
equally devoted workers. The notable character of the change that has taken
place may be measured if we bear in mind the deplorable condition of the insane,
in Scotland and over the civilised world, up to the middle of the century that is
now drawing to a close. Those who can remember, as I do, the publication in 1857
of the Report of the Royal Commission on the Condition of the Insane in Scotland,
do not need to be reminded of the thrill of shame and horror produced by its reve¬
lations. A large number of the insane, both in and out of asylums, were found to
be in a condition which Mr. Ellice, speaking in the House of Commons, truly
characterised as “ disgraceful to this or to any civilised country." With the
legislation which followed that report, however, a new and happier day began to
dawn. An efficient system of lunacy administration was established ; and, since
then, as time has rolled on, the lot of the insane has been more and more
alleviated; and we may now claim that, though there is still room for im¬
provement, they are now cared for in Scotland in a way that accords with
the feeling of sympathetic kindliness due to those who suffer from the most
disastrous of all afflictions. We may claim, indeed, that, as regards the way
in which the insane are provided for, Scotland stands as it ought to do,
“second to none." Asylums have been transformed from gloomy prisons or
cheerless barracks to well-appointed hospitals and comfortable homes, and the
insane in private dwellings are under an organised system of supervision which
secures, as far as possible, the detection and the correction of abuses whenever
they arise. Grave abuses either in or out of asylums now, however, rarely occur.
The persons entrusted with the care of the insane are as a whole well worthy of
the confidence of the public. In saying this I have not only in view those
occupying the higher professional positions, of whose eminent ability we are justly
proud. I have also in mind those less widely known who are in more immediate
and constant association with the insane, and I am glad of this opportunity of
referring to those whom I have known (and I could make a long list of them)
whose unselfish devotion to duty, whose capacity for exercising gentle yet effective
control, and whose thoughtful tenderness in circumstances of difficulty and trial
have again and again, and with increasing frequency in recent years, excited my
admiration and commanded my respect. I need not say that I have felt it no
small honour to have been a fellow-worker with men and women so distinguished
for high and noble qualities.

Perhaps I ought to say before I sit down, that I do not forget how much the
improvement that has been made in the condition of the insane has been promoted
by influences independent of the efforts of those who have specially devoted them¬
selves to the work. We must recognise that these efforts could not have been
attended with great success had there not been much in the circumstances of the
time to favour them. The improvement would, I fear, have advanced but slowly,
if it had not been borne onward by the flowing tide of intellectual and moral pro¬
gress which has been a distinguishing feature of the last half-century. That period
indeed has been one of great enlightenment. Our knowledge of the world in
which we live, and of man himself, has advanced by leaps and bounds, and we
have been enabled to obtain truer views of much that was formerly shrouded in
mystery. As a result of this, the superstitious ideas connected with insanity, which
deprived the insane of the sympathy that was their due, have ceased to influence
the public mind. And the flood of light which the researches of physiologists,
pathologists, and psychologists have shed upon the functions of the brain, has
made us realise, in a way that our fathers could not realise, that mental disorder
is, as truly as bodily disorder, a state of disease, that is governed by the same laws
and must be treated on the same principles. The mere increase of scientific know¬
ledge has thus done much to benefit the insane. But they have benefited also by

Digitized by VjOOQle

404

NOTES AND NEWS.

[April,

movements which are more moral than intellectual. There has been during the
past fifty years a great awakening of the public conscience to the responsibility of
society for the welfare of its constituent members. There has been a general
quickening of philanthropic movement. Benevolent action in every direction has
been developed and made more efficient; and in such a movement tne insane could
not fail to be benefited. The era of that great reform in hospital administration,
and in the nursing of the sufferers from bodily disease, with which the name of
Florence Nightingale will ever be associated, must needs have been a favourable
time for improving the treatment of sufferers from mental disease.

I have ventured on this occasion to refer to the improvement that has been made
in the condition of the insane, because it has fallen to my lot to be one of those
who have endeavoured to promote that improvement; and I am glad to have lived
at the time when it and kindred triumphs of beneficence have been achieved.
These triumphs have, no doubt, been mingled with much failure and imperfection.
The benevolent work of the time has been often ineffective, often misdirected:
and it leaves much misery and evil still untouched. Yet we may claim for the last
half-century that in spite of tragic episodes, such as that which at present weighs
upon our hearts, it has been the greatest period in the history of philanthropy.
And 1 think that we may, not unfitly, while thinking of the past and hoping for the
future, adopt the words of the apostle who, having reached the last stage of his
journey to Rome, “thanked God and took courage ,—gratias agens Deo % accepit
jiduciam."

Dr. Clouston. —Master of Polwarth, ladies and gentlemen, this function is not
quite over. We have yet something to do before we part. You, Sir, said you
looked on it as a privilege and pleasure to preside here and speak of Sir John
Sibbald. Now it is a still greater pleasure, if that is possible, for me to stand and
speak in name of this meeting in regard to Lady Sibbald. Dr. Yellowlees has
spoken entirely of Sir John. I give to Lady Sibbald a good deal of the credit
which has been accorded to him. That being so, his friends have done me the
great honour of making me their spokesman in asking Lady Sibbald if she would
be good enough to accept at our hands those bowls, so that in her future life and
at her own table when she sees them she will feel that she and her husband have
had many friends, and by means of that little present she will remember us with
kindness and affection, I hope. 1 now ask Lady Sibbald in your name to accept
those bowls that stand on the table. (Applause.)

Sir John Sibbald having returned thanks for Lady Sibbald, and a vote of
thanks having been accorded to the chairman, the meeting separated.

OBITUARY.

William Whitney Godding, M.D.

We regret to have to record the death of Dr. Godding, who was elected an
honorary member of the Medico-Psychological Association in 1886. The following
notes are taken from the memorial written by Dr. Witmer, his distinguished
colleague and senior assistant physician.

With but a few days’ illness, death came suddenly to Dr. William Whitney
Godding, late Superintendent of the Government Hospital for the Insane at
Washington, D.C.

He passed away quietly in the early morning of May 6th, in the midst of his
labours, and within the walls of the institution over which he so zealously presided
for twenty-two years. The best record of his splendid career as an alienist, and of
the spotless integrity of his life, are embalmed in the annals of the great hospital
which was but in embryo when he undertook its superintendency, and its develop¬
ment was still advancing when death removed him from that office.

An only child, he was born in Winchendon, May 5th, 1831. From early man¬
hood with singleness of purpose he devoted himself to the study of mental diseases,
both in theory and practice. His preparatory education was begun in Andover.
His named is enrolled among the alumni of Dartmouth College. Crowned with
the academic bays of his alma mater , Dr. Godding attended the medical school
of Castleton and, after graduation, the College of Physicians and Surgeons in New

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

405

York, and in due time entered professional life. In June, 1859, he became
assistant physician in the Concord (New Hampshire) Asylum for the Insane.
Here were laid the foundations of his future study and work ; and in September.
1863, he was called to Washington as a member of the medical staff of St.
Elizabeth—the Government Hospital for the Insane—then under the superinten¬
dency of Dr. Charles H. Nichols, its builder and founder.

Called in April, 1870, to the superintendency of the asylum at Taunton, Mass.,
he for seven years managed its affairs with the same conscientious zeal and
enlightened wisdom which afterwards characterised his matchless administration
at Washington. When the late Dr. Nichols resigned, to become medical director
of Bloomingdale Asylum, Dr. Godding was appointed his successor at St.
Elizabeth. His recall found him in the full maturity of his intellectual and moral
powers, and in a wider field of usefulness with which he was not unfamiliar.

In making this anouncement of his death, it seems hardly proper that I should
attempt any detailed account of Dr. Godding’s splendid career at St. Elizabeth as
superintendent. This has already been done in a careful memorandum prepared
by the Board of Visitors, at a special meeting called in consequence of his death,
the concluding words of which are as follows:

“ Dr. Goddard was learned, wise and strong; a man of large cultivation and
grasp of mind ; earnest and patient; singularly free from bias and hasty judgment;
a man of thorough integrity, conscientious and devoted to duty; he ceased from his
labours only to obey the call which has taken him from us. No single incident
of difference or disagreement occurred between the Superintendent and ourselves
during all the years of our association. Courteous and attractive in personal
intercourse, he exerted a strong influence in the communities in which he resided.”

After twenty-two years daily intercourse, Dr. Godding comes before me now in
all the freshness of his matured manhood, so admirably equipped for the work he
had set before him. His was a completely rounded character, in which were
united intellectual and moral forces not often found in the same man. He had
the simplicity of heart of a child, the gentle tenderness of a woman, and the un¬
yielding firmness of a strong man. Acts the result of mere impulse or caprice
were certainly foreign to his nature. Practical in all the affairs of the important
work committed to his charge, a realist in the conception and discharge of his high
duties and responsibilities, Dr. Godding was, for all that, an idealist—he lived in
a world of his own mental creation, which produced, when his work was done from
day to day, the sweet flowerage of duty fulfilled, the solace of their nightly
decline. This beautiful sentiment of our highest humanity pervaded his whole
being, and, as some would say, had its origin in the altruistic spirit now dominating
all great souls labouring for the betterment of their afflicted fellow-men. 1 prefer
to think of it under another symbol of speech, and as taking its rise in the practical
elucidation, or expansion if you please, into the daily routine of life of those great
principles of conduct which the Divine Exemplar has embodied in the beatitudes
recorded as part of His revelation to men.

Then, again, when I turn to the hard, dry details of common life, and the drudgery
which his vocation entailed, I seem to see in clearer light the wonderful power
enabling him to transform the veriest commonplaces into the sublimest duties. No
routine ever became soulless to him, and the wear and tear of the flesh and spirit,
which so lamentably exasperate the lives of men of all vocations, never tormented
him. A pure soul like his, to use the language of Sainte-Beuve, “ lives an invisible
life ; it is healed by its own balm, it is restored, it begins anew, it has not died out;
it goes even to the tomb, and is there immortal.’*

From an intellectual point of view Dr. Godding was a strong man. The natural
powers of his mind were refined with a literary culture which made him a peer even
among men of letters who followed literary studies professionally. His pleasantries,
his geniality, his sprightly fancy, made him when at leisure a charming man
among men of his own and other professions; while his broad charity saw always
the best in every character with whom he was brought in contact. In this respect
he admirably illustrated the verses of Longfellow:

“We see but what we have the gift of seeing;

What we bring we find.”

As I close this brief announcement of the departure of our beloved fellow-
member, so worthy of this great name among his distinguished colleagues, there

Digitized by VjOOQle

NOTES ANI) NEWS.

406

[April,

crowd upon me the purest and tenderest recollections of happy association with
him, and they shall only pass away when life itself shall be no more.

Professor Ludwig Meyer.

Ludwig Meyer was the founder of the modern treatment of the insane in Germany.
He was the first in Germany to initiate the non-restraint treatment, and that at a
time, indeed, when a large number of the German alienists were directing their
minds to devise very effectual means of restraint. His proposal was described then
as foolhardy and impracticable; but to-day, after thirty years, the procedure has
stood its trial with the most brilliant results. There are in Germany only a few
asylums, and these certainly not the best, where the non-restraint method is not
carried out.

In addition to his having done away with restraint, Meyer's constant effort
was to treat the mentally ailing in the same way as other patients. This, according
to his conviction, has also to be given expression to in the construction and
management of asylums. A modern lunatic asylum, he asserted, requires to be
constructed in no different way from any other hospital. Dominated by this idea,
he has from the time specified endeavoured to allow the patients the utmost
liberty, and has, with the courage necessary to carry out that object, never dis¬
claimed the responsibility. Accordingly in Gottingen for more than thirty
years the modern free method of treatment of the insane has been uniformly
practised.

It was only with the commencement of this method of treatment that the scien¬
tific observation of the insane became possible, because struggling against means
of coercion, which used to cause great exasperation in the patients, and restriction
to a monotonous life, without work, behind closed and grated windows and doors,
cause symptoms to appear and seem of importance although they have nothing to do
with the psychoses in question. Meyer early recognised this. What the patients
do of their own free will and what they say is of importance, but not the manner
in which they react to an external coercive force.

With similar independence Meyer approached the scientific study of insanity,
witness a long list of important publications, among which we specially mention
his Observations ( researches) upon the Pathological Anatomy of Dementia Para~
lytica, upon Caput Progeneum and the Scoliotic Skull, upon the Signification of
Fatty Granules in the Brain and Spinal Cord, upon the Pathological Anatomy of
the 11 Insane Ear,” and upon the Psychoses of Intention.

Ludwig Meyer was born on the 29th of December, 1826, at Bielefeld. As a little
child he came with his parents to Paderborn, and spent his youth in that city. He
attended the school of the Jesuits, and passed the final examination at the age of
seventeen years. His intention to become an architect caused him first to attend
the technical school in Hagen, and then to turn his attention to land surveying.
After these provisional attempts he approached the study of medicine, for which
he was destined by his nature. In the spring of 1848 he entered the University of
Bonn ; but there he had little success. Like many of our most distinguished men
he plunged with zeal into the political commotions of that restless year. He was
arrested and kept five months in durance at Cologne. Virchow’s star on the
ascendant drew him next to Wurzburg. There he became friendly with Troltsch
and Biermer, and assimilated with eagerness the epoch-making lectures of Virchow
and v. Kdlliker.

In the year 1851 he proceeded to Berlin, became amanuensis to Reinhart and
Meckel, and worked diligently with Johannes Muller. In the winter of 1852-3 he
passed the Government and Medical Examinations. Really against his will, as he
himself asserted, he became assistant in the Psychiatric Department of the Charitd
Hospital, to be in a short time called as second physician to Schwetz. In the
year 1857 he returned as head physician to the Psychiatric Department of the Charitd
—then under the care of Ideler—and delivered in the summer of 1858 his first lectures
on Clinical Psychiatry. In the autumn of 1858 he was elected Reorganiser of the
Hamburg Lunatic Asylum, and entered on the office of chief physician of the
Psychiatric Division of the General Hospital. This department was situated in
the basement story of the building. It was here that he caused to be sold by public
auction the whole collection of strait-jackets, after having convinced himself by one

Digitized by VjOOQle

NOTES AND NEWS.

407

1900.]

case to what consequences coercive means lead. For a very trustworthy attendant
in the case of a female patient, who with great deftness was in the habit of
divesting herself of her strait-jacket, had caused an iron collar like a dog’s to be
made for her. Another important point was brought to light, as Meyer himself
related, by the experiences of the old lunacy department of the general hospital;
namely, that the public need not be held aloof so anxiously from mental cases
as used formerly to be thought necessary. On Sundays all the rooms of the lunacy
department were filled with visitors, who did not stare at the patients with curious
looks, but brought them a number of presents. There never occurred any dis¬
turbance from this; on the contrary, there was the advantage that the public did not
harbour any suspicion against the institution. Meyer remained true to these
convictions. At the present time in Gottingen such visits to the patients are
allowed. By this means the public are educated, and the institution is divested
of mystery, so that there subsists no difference in this particular between it and
any other hospital.

That a man like Meyer, under the hygienic conditions that were prominent in
the Hamburg Lunatic Department, entered into the design of a new building for
the insane patients, goes without saying. Already in 1864 was he able to migrate
with the patients committed to his care into an asylum built quite to his own mind,
and arranged for the non-restraint treatment, at Friedrichsberg. In 1861 he had
previously, in the course of a prolonged sojourn, carefully studied the immense
progress of English treatment. But at Friedrichsberg he was not destined long to
labour. In the year 1866 he accepted a call as Professor in the University and
Director of the Lunatic Asylum of Gottingen, to open the first German clinic
for Psychiatry in a building specially constructed for the purpose. In this position,
despite of various inducements, he remained, equally beloved and valued as Clinical
Teacher as well as Director and Officer in the Provincial Asylum.

In the year 1867 Meyer, in conjunction with Griesinger, established the Archives
of Psychiatry, The works of Meyer range over the whole region of Psychiatry.
In addition to works relating more to the social side of Psychiatry, the care of the
insandf the management of asylums, and such like, we find exact pathologico-
anatomical investigations and excellent clinical studies. These are to be found in
great number—in Virchow's Archives , the Chariti Annals , the Archives of Psy¬
chiatry, etc.

That the advice of a man so experienced and so rich in projects of reform was
frequently claimed in the building of insane asylums, scarcely needs to be
mentioned. Meyer drew up the programme of numerous institutions, or co¬
operated in their projection. Among these were Hamburg, St. Urban, and
Marburg. He was elected an honorary member of the Medico-Psychological
Association in 1867.

Professor Meyer died in October, 1899, in his seventy-third year, lamented by
his colleagues throughout Germany. We are indebted to Dr. Cramer for the
sketch of his life above presented.

Dr. Bouchbrbau.

Dr. Louis Gustave Bouchereau, who died the 22nd of February, was born the
20th of June, 1835, at Montrichard, in the mild and pleasant country of Touraine,
the garden of France and cradle of such illustrious men as Georget, Bretonneau,
Trousseau, Moreau de Tours,and Baillarger. He studied medicine in Paris. Externe
of the hospitals in 1859, interne in 1863, he was the pupil of Jean Pierre Falret,
Baillarger, Charcot, and Vulpian. He obtained the doctor’s degree in 1866; the
subject of his thesis being “ HemipUgies anciennes." In the same year he was
elected, conjointly with Dr. Magnan, as medecin du service de repartition at the
Ste. Anne asylum, and held this post till 1879, when he became superintendent of
the female wards. During the war of 1870—71 he served in a field hospital, was
wounded at the battle of Chatillon, and received, as a reward for his gallant con¬
duct and devotedness, the badge of the Legion of Honour.

Bouchereau was elected as a member of the Societe Medico-Psychologique of
Paris, on the 27th of November, 1871, and became President in 1891. In 1866 he
was elected secretary by the Association mutuelle des medecins alienistes de
France . The object of that association, which was recognised d ’ utiliti publique

XLVI. 28

Digitized by tjOOQle

408

NOTES AND NEWS.

[April,

by an Imperial decree in 1866, is to help those members who might be in distress,
and to aid the widows and orphans of alienists. Since its foundation the presidents
have been Baillarger, Blanche, Armand, Semelaigne and Meuriot; the treasurers
have been Lunier and Mitevil (a great-nephew of Esquirol), Legrand du Saulle;
the first secretary was succeeded by Brierre de Boismont, Mitivi^ and Bouchereau.

Bouchereau was frank, sincere and modest. Every one who came into contact
with this kind and loyal gentleman rapidly formed a deep affection for him. His
patients were sb devotedly attached to the good doctor, that a palsied woman
earnestly prayed to be carried into the death chamber to view his features once
more.

Bouchereau entertained great friendship with the late Dr. Hack Tuke, who,
during his holidays in 1893, was his guest at Montrichard.

It may be said of Bouchereau, as of Tuke, that he left a wide circle of
sorrowing friends and no enemies.

Ren& Semelaigne.

NOTICES BY THE REGISTRAR.

Certificate of Proficiency in Mental Nursing. .

The next examination will be held on Monday, the 7th day of May, 1900, and
candidates are earnestly requested to send in their schedules, duly filled up, to the
Registrar of the Association, not later than Monday, the 9th day of April, 1900,
as this is the last day upon which, under the rules, applications for examination
can be received.

Certificate in Psychological Medicine.

The next examination will be held on July 19th, 1900.

The examination for the Gaskell prize will take place at Bethlem Hospital on
the 20th of the same month.

THE PRIZE DISSERTATION.

Although the subjects for the essay in competition for the Bronze Medal of the
Association are not limited to the following, in accordance with custom the Presi¬
dent suggests—

1. Developmental general paralysis.

2. The surgical treatment of epilepsy and epileptiform seizures.

3. The effect of influenza on the production of states of mental unsoundness.

The dissertation for the Association and prize of Ten Guineas must be deli¬
vered to the Registrar, Dr. Benham, City of Bristol Asylum, before May 30th,
1900, from whom all particulars may be obtained.

By the rules of the Association the Medal and Prize are awarded to the author
(if the Dissertation be of sufficient merit) being an Assistant Medical Officer of
any Lunatic Asylum (public or private), or of any Lunatic Hospital in the United
Kingdom. The author need not necessarily be a member of the Medico-Psycho¬
logical Association. Due notice of the exact dates will appear in the medical
papers. Further particulars respecting the various examinations of the Associa¬
tion may be obtained from the Registrar, Dr. Benham, City Asylum, Fishponds,
Bristol.

NOTICES OF MEETINGS.

Medico-Psychological Association.

General Meeting .—The next General Meeting will be held on Thursday, 10th
May, 1900, in the Rooms of the Association, 11, Chandos Street, W., at 4 p.m.

At this meeting the following papers will be read:

1. “The New Psychology,” by H. Maudsley, M.D., F.R.C.P.Lond.

Digitized by CjOOQle

1900.] NOTES AND NEWS. 409

2. “ Pupillary Anomalies in Paralysed and Non-paralysed Idiotic Children ” (to
be read in English), by Dr. Koenig, of Dalldorf Asylum, Berlin.

3. “ The Arrangement of Nerve-fibres and Nerve-cells in the Cerebral Cortex
of a Series of Idiots’ Brains ” (a demonstration by lantern photographs, micro¬
scopic specimens, and drawings to scale), by A. W. Campbell, M.D., Rainhill
Asylum.

The sub-committee for the investigation and collection of evidence, and for
practical suggestions as to the isolation of phthisical patients in asylums, will be
appointed at the Council meeting.

South-Eastern Division. —The Spring Meeting of this division will be held at the
City of London Asylum, near Dartford, on Wednesday, April 25th. Dr. White
will read a paper upon “ The Remodelling of an Old Asylum,” and Dr. A. E.
Patterson one upon “An Analysis of 1000 Admissions into the City of London
Asylum since 1892.” Luncheon will be provided at 1 p.m., and in the evening
members will dine together at the Cafe Monico, Piccadilly Circus, W.

South- Western Division. —The Spring Meeting is to held at Bailbrook House,
Bath, on Tuesday, 24th April. Business Meeting at 3 p.m.

Northern Division. —The Spring Meeting will be held at Whittingham Asylum
on the 18th April.

Scottish Division. —A Special Meeting will be held in Edinburgh, on Saturday,
2nd June, to consider the report by the Committee on the position of the nursing
staffs in Scottish asylums in reference to administrative questions.

Irish Division. —The next meeting will be held on April 10th, at noon, in the
College of Physicians, Dublin.

International Medical Congress ok 1900.

The section of Psychiatry will meet from the 2nd till the 9th August. The
names of the Committee of Organisation are—

MM. Magnan, President; Joffroy, Gilbert-Ballet, Pierret (Lyon) and Cullerre
(La-Roche-sur-Yon), Vice-Presidents; Ritti (Charenton),Secretary; Bouchereau,
Bourneville, Albert Carrier (Lyon), Christian (Charenton), Doutrebente (Blois),
Jules Falret, Ch. Fere, Febvrd (Ville-Evrard), P. Gamier, Giraud (Saint-Yon),
Mairet (Montpellier), Meuriot, Motet, Parant (Toulouse), Regis (Bordeaux),
Seglas, Taguet (Maison-Blanche), Vallon (Villejuif), Jules Voisin.

The section will meet at the Sorbonne, and will not deal with neurology.
Arrangements will be made for the display of lantern slides.

The following subjects have been chosen for discussion, but separate papers will
also be received :

1. Mental Pathology.—" Psychoses of Puberty.” Introduced by Drs. Ziehen,
Marro, and J. Voisin.

2. Pathological Anatomy. — “Idiocy.” Introduced by Drs. Shuttleworth,
Fletcher Beach, Mierzejewski, and Bourneville.

3. Therapeutics. —“Rest in Bed in the Treatment of Acute Insanity and the
Modification of Arrangements which are Necessary in Asylums for the Insane.”
Introduced by Drs. Neisser, Korsakoff, and Jules Morel.

4. Legal Medicine. —“ Sexual Perversions.” Introduced by Drs. Krafft-Ebing,
Morselli, and Paul Gamier.

A resume of these papers will be sent to each member of the section on an early
date. Other papers must be sent to Dr. Ant. Ritti, Maison nationale de Charenton,
Saint Maurice, Seine, before 1st June. They must not have been presented to
any Society or published before the opening of the Congress, and must not exceed
fifteen minutes in delivery.

Regarding the special reductions on railway fares, etc., inquiries should be
addressed Bureaux, 21, Rue de l'Ecole de M^decine, Paris. The subscription
of 25 francs should be sent, together with full name and address, to Dr. Duflocq,
64, Rue Miromesnil, Paris.

Dr. Ritti, in sending the circular from which this information has been obtained
for publication in the Journal, in order to bring it prominently before our mem¬
bers, expresses the hope that they will attend the Congress in full strength.
After a reference to that distinction which is to be drawn between the irresponsible

Digitized by VjOOQle

410

NOTES AND NEWS.

[April, 1900.

journalists of the Boulevards and the French Government, which has dealt with
difficult questions with tact and decision, Dr. Ritti expresses the hope that the
compatriots of Harvey, Hunter, and Lister will be well represented. He savs,
“ We should consider our section of psychiatry incomplete without the disciples
of Tuke, of Conolly, and of Bucknill, without those men of distinction who have
cast a lustre on psychological medicine in Great Britain. We hope that Dr.
Shuttleworth and Dr. Fletcher Beach will not come alone, but that they will be
accompanied by a great number of their colleagues, communications from whom
we shall gladly receive. I assure them that France will not fail in the duty of free
and cordial hospitality. We shall be glad to have the opportunity of exchanging
opinions on those scientific and professional questions which are the objects of our
specialty.”

We lay Dr. Ritti’s kindly and cordial invitation before our colleagues with
every confidence that it will meet with due appreciation and wide-spread acceptance.
It is expected that the annual meeting of the Medico-Psychological Association
will be arranged on dates which will permit of members proceeding to Paris in
time for the Congress, as our President-Elect is to take a prominent part in the
proceedings there.

APPOINTMENT.

George A. Rorie, M.B., Ch.B., appointed Senior Assistant Medical Officer at
Cumberland and Westmoreland Asylum, in place of J. W. Leitch, M.B., M.A ,
resigned.

Digitized by tjOOQLe

THE

JOURNAL OF MENTAL SCIENCE

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

No. 194 [To."T] JULY, 1900. Vol. XLVI.

Part I.—Original Articles.

The New Psychology . An Address delivered by Henry
Maudsley, M.D., at the General Meeting of the Medico-
Psychological Association, London, 10th May, 1900.

My choice of subject for this address has not been altogether
fortunate, and what I have to say will need your indulgence.
Having fixed the subject hastily when I had the honour to
receive your secretary’s invitation, I soon found, on taking
stock of my knowledge, that I had no clear idea what the new
psychology was, what it had done, and on what the claim
sometimes made for it to supersede an old and effete system
was grounded. A new method of study making large promises
was evident enough, but of the new conquests which are to
revolutionize psychology I must confess ignorance. My remarks,
then, will be critically interrogative, on purpose made to elicit
definite information. If that light be forthcoming it will prove
how little mere theoretical criticism is worth.

One effect of growing old is to be less sure of anything, and
certainly the older I grow the less sure I am what the old
psychology is. A list of examiners to be appointed by the
London University specifies an examiner in mental science and
an examiner in the separate subject of mental physiology. From
which ft appears that mental physiology, although it means
literally the science of the nature of mind, is not mental science,
and that mental science on its part stands aloft and aloof from
a knowledge of the nature of mind—at all events from a know-
XLVI. 29

Digitized by VjOOQle

412 THE NEW PSYCHOLOGY, [July,

ledge of the exquisitely fine network of nervous organisation
which is the indispensable condition of mind’s being, which
grows in complexity with its growth, and on the integrity of
which its every function depends. Then, again, it does not
seem to be quite certain always that psychology is synonymous
with mental science ; for although it means literally the science
of mind, we constantly hear talk of a science of psychology,
that is a science of a science of mind. Lastly, above all towers
mental philosophy , a kind of holy of holies into which high
priests only may enter. Thus we have four formidable systems
dealing with one and the same subject, yet having different
names, pursuing separate paths, speaking different and mutually
unintelligible languages, often hostile in attitude towards one
another, almost as averse to meet as parallel lines. Is not that
an odd and rather sad state of things ? And is it not wonder¬
ful where the hapless student gets the information enabling him
to answer the questions put to him—that is, if his examiner
does not chance to be a professor whose lectures he can attend,
or to have written a book which he can buy and learn by rote ?
It is no great breach of charity, I hope, to doubt whether the
examinee always understands really what the examiner means,
or the examiner really understands what the examinee means,
or either really understands what he himself means.

Another consequence of growing old is to see plainly how
the evil that one does lives after one ; and I sometimes feel a
pang of penitence when I recollect that it was at my instigation
many years ago that the Senate of the London University
established an examination in mental physiology and pathology
instead of its former examination in such set books as Bacon’s
Advancement of Learning and Mill’s System of Logic , books
which at any rate were calculated to inform definitely, not
sadly to bewilder, the student’s mind. To complete which
bewilderment now, lest haply it might fail otherwise, a psycho¬
logist who probably knows nothing of physiology is yoked as
co-examiner with a mental physiologist or pathologist who
perhaps knows little or nothing of psychology.

Leaving this subject, on which a good deal more might be
said, I go on to comment on two late methods of research
which, vaunting in their youthful zeal, promise so largely.
They are (a) the systematic study of the child’s mind ; ( b ) the
so-called psycho-physical research.

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

413

i. Psychology of Children .

Much diligent pains has lately been given to the observation
and interpretation of the mental operations of infants and young
children, in the praiseworthy hope of helping to lay the founda¬
tions of a positive psychology. How far then are the results
of scientific worth? Interpretation presupposes an interpreter
who must not only understand the language which he interprets
but also the language into which he translates. Now can the
student of the child’s mind possibly understand and rightly
construe by the light of his ripe thought and feeling, his formed
and conscious thought, that which is only forming and scarce
conscious in its immature mind ? Can he translate the one
correctly into the other ? It is obvious that he may easily,
almost certain that he will, read into its mind that which is in
his mind and so misread that which is there actually. All the
greater, too, is the risk of fallacy when it is the proud parent
himself who, oscillating and perhaps osculating between inquiry
and admiration, studies the mind of his own wonderful child.
After all is said the only way to know really what goes on in
the child’s mind would be to get inside the child’s brain
without being the child : an impracticable feat even for a meta¬
physical philosopher.

It is natural to think that the child’s utterance of a thought
or feeling means the same as the like utterance of a like thought
or feeling by an adult who is trying to imagine himself in its
situation. But that is not so ; no feeling nor thought, however
much the same in look, can possibly have the same meaning in
the forming and in the formed mind. In the immature mind
the word, like the underlying idea or feeling, is simple, single,
without associations, almost detached, naked, so to speak,
whereas in the mature mind it is involute, containing layers on
layers of experience ; intimately and intricately connected, too,
having manifold associations which are aroused into more or
less conscious thrills, emotional or intellectual, by every use of
it. The man cannot speak the word himself nor hear it spoken
by the child without a stirring, obscure or clear, of these asso¬
ciations in him ; he must think what he says in terms of himself,
which is thought that the child cannot possibly have—in terms,
that is, of his own character and all which that implies in regard
of bodily organisation and mental formation, conscious and un-

Digitized by VjOOQle

414

THE NEW PSYCHOLOGY,

[July.

conscious. Can he, however, as is sometimes alltged, allow for
the necessary correction ? Can he, in fact, strip off so much of
the structure of his own mind as to reduce it to the simplicity
of the child-mind (without a standard, too, to tell what the
requisite subtraction must be), and then use his so mutilated
mind to observe and interpret as if it were its sound and whole
self ? He would find it easier, I think, to walk the walk and
talk the talk of his infant.

Let me give an illustration of what I mean. When the
child asks its astonished father, “ Daddy, why does not God
kill the devil ? ” it puts as simple, direct, and natural a question
as it would do were it to ask “ Why does not daddy kill the
rat ? ” The extraordinary question is not a whit more wonder¬
ful than the ordinary question. The child has been taught
ever since it learnt to kneel to pray on its mother’s knee with
uplifted hands and eyes looking heavenwards that God is a big
strong Being living out of sight high up above, who can do
whatever He will, loving to do good and those who are good,
angry with those who are naughty and do wrong—to picture
Him mentally, in fact, as a kind of bigger and stronger father,
who will help it in trouble if it is good, just as its father helps
it out of a difficulty and seems to it all-powerful to do so ;
reasoning, then, from the particular to the particular, as incipient
intelligence cannot choose but do, it naturally wonders why
God does not kill the devil, who is always going wickedly
about to do wrong to everybody by making everybody do
wrong. How can the little creature so instructed treat its
simple, direct, and positive idea or image of a sort of magnified
man doing real work everywhere as vaguely as if this were an
abstract and general notion shrouded in solemn obscurity and
consecrated by immemorial reverence? The ideas no more
mean the same than the vice of five means the vice of fifty
years old.

The truth is that the simplicity, directness, and innocence
of a young child’s mind signify the absence of mind. A direct,
single, and confident reaction to the impression is not tram¬
melled by modifying associations, nor vitiated by conventional
errors and prejudices; therefore its utterance is sometimes
singularly fresh, startling, and suggestive. As to the latent
intuitions and trailing clouds of glory from afar which senti¬
mental adorers detect and dote on in its innocent simplicities,

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

415

it is they, the enraptured gazers, who project them into it out
of their own feelings ; they bestow the glory which they see in
the show ; not otherwise than as the fond mother, watching the
flicker of a smile across her sleeping baby's face, projects a
heavenly meaning into the purely reflex movement excited by
a pleasant visceral stimulus. Such actual mind as the infant
has is surely more vicious and ugly than innocent and
beautiful. What is there to admire in its squalling passions of
temper when it is uneasy and wants, something, and in the
furious bodily contortions which, did it possess power equal to
its passion, would make it the most dangerous wild beast alive.
Passionately selfish, prompted solely by the instinct of self¬
conservation, quintessential embodiment of the colossal egoism
and self-idolatry of man from the beginning of his despotic
reign on earth, it exacts tyrannically all the services which,
happily for it, maternal devotion likes instinctively to give, and
feels rewarded for giving by the kitten-like playfulness and
affection which it shows when it is pleased. Howbeit neither
child nor kitten feels much, if any, of the attributed affection,
the show of which is but its purposive and glad placement of
itself in the fit situation and attitude to receive and to respond
to caresses. Is there in sober truth any other living creature's
offspring which is so passionate, so selfish, so noisy, so trouble¬
some, so exacting, so offensive in some respects as the human
baby?

These are the positive qualities of the real baby, the concrete
creature, not the supposititious qualities of the ideal baby; and
it owes them to the fact that it is the product of the most
powerful, tyrannical, and selfish animal in the world. For as
man, ever since he brought things to a bad end in the Garden
of Eden, has rigorously and ruthlessly used the dominion there
given him over all living creatures, thrust like him out of the
garden, though they had not like him sinned by eating for¬
bidden food, and has counted their lives and happiness of no
account in comparison with his rights to do with them as he
pleases for his sport and profit, his infant in the cradle naturally
exhibits a monstrously masterful and clamorous egoism. Heir
to all the ages of human selfishness and self-worship, it shows
the distinctive marks of its descent ; and it is by positive
observation of what it does and is, not by imaginary intuition
of what it feels and thinks, that we shall best know its real

Digitized by VjOOQle

THE NEW PSYCHOLOGY]

416

Duly,

mind-stuff and mode of mental growth—not by prying into its
mind, but by watching its performances.

Now as natural sentiment is not likely to suffer the
philosopher thus to study his own baby, or perhaps any
human baby, impartially in the dry light of reason, there is an
incalculable weight of bias to be added to the inherent and
inevitable imperfection of the method of psychological inquiry ;
not only an incapable method, but also an observer incapacitated
to use it properly. Nq wonder, then, if he, trying to make a
baby-mind of his mind in order to feel and think like his baby,
runs the risk of making a baby of himself in another sense.
And what shall be said of the latest development of this line of
inquiry in the person of the lady psychologist who in mature
years sets forth elaborately all the wonderful thoughts, feelings,
and imaginations which she had as a child from the time she
left the cradle and presents them as a contribution to psy¬
chology ?

I might, did time allow, extend the range of these criticisms
by applying them to some of the observations and experiments
made to discover the mental operations of chickens, ducks, hens,
cats, puppies, and the like. The descriptive terms necessarily
used in such cases are imbued with meanings which as neces¬
sarily involve misinterpretations of the simplicities of mind they
are used to describe. Moreover, no precise definition is made
of that which the terms used shall mean, though that is an
indispensable preliminary in order to avoid vagueness and
ambiguity if any good is to come of discussion. What profit
is there in disputing whether animals can reason or talk without
previously defining exactly what reason and talk shall mean,
and thereafter using the words in that precise sense. It is
obviously easy to communicate intelligence by other move¬
ments than those of articulate speech ; every busy little ant
will teach us that. Nor is the mute eloquence of two lovers
who understand not a word of one another's articulate language
inadequate to teach them what they mean when they go
through all the performance of love from its first gleam to its
final ecstatic rapture. Is there a single intelligent action, again
performed by an animal, whether acquired by itself or taught
to it, which does not then signify implicit reason? Or a sensible
shepherd who knows not well that he speaks intelligently to
his dog and is understood by it, owing his rational use of it to

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

417

its responsive reason, and values it because of and in proportion
to its intelligence ? Ask him why he is loth to sell it at any
price, and his answer may, if its full import be well considered,
render superfluous much discussion and experimentation to
prove or disprove that which an experimental psychology, in
daily and immemorial practice, has proved long since—that is
to say, assuming a clear and distinct definition of what words
are to mean and that the facts shall govern the words instead
of the words governing the facts.

But this is too large a subject to go into now, and I will
conclude the first part of what I have to say by venturing a
conjecture that an insight into the origin, growth, and primitive
workings of the child’s mind will be best obtained, not by the
method of psychological intuition, but—first, by the biological
method of tracing the development of mind gradually from its
first beginnings—that is to say, the development of life into
and in mind, for mind is life and its faculties signify the work¬
ings of life in mind—upwards through the progressive com¬
plications of the reflex structure and action of the nervous
system in the ascending scale of animal organisation; secondly,
by direct observation of the successive formations and associa¬
tions of the child’s movements in their definite relations to
objects and its feelings. For mental apprehensions are based
on motor apprehensions, mental grasps on the grasp of the
object by hand, of its image by sight, of its sound by hearing.

2. Psychophysics .

I pass on now to the second part of my subject, the method
of psycho-physical research and the inquiry what it does, what
it expects to do, and what it cannot expect to do. That is to
say if there be a limit to its expectations ; for some of those who
vaunt its value have spoken of it as if its expectation was
limitless and there was no sun in the psychological sky before
the sun of its day arose.

Beneath all mental acts there are most subtle currents or
undulations of nervous energy of yet unknown nature—physio-
chemical, electric, electro-vital, or what not—along definite
tracts of physical organisation ; they are necessarily therefore
affected by the physical conditions which affect all physical
motions. Sensation has always been known and said to be

Digitized by

Google

418 THE NEW PSYCHOLOGY, [July,

blunt or keen, emotion to be dull or lively, thought quick or
sluggish, and if one reflects on the derivation of the terms of
psychology—such words, for example, as emotion, reflection,
deliberation, and the like—it is manifest that their origin and
primal meaning was essentially physical; the words bespeak a
material origin, are imbued with sense-experience, and signify
in the concrete properties that are material. Nor have varia¬
tions of mental properties in different persons, or in the same
person at different times, been overlooked. Quickness and
slowness of perception of thought, ranging from the swift flash
of cerebral excitement to the slowness or almost standstill of
thought in the oppressed or decayed brain, have attested the
positive effects of changing physical conditions on its rate of
speed. It is well known, too, that causes outside the body, as
well as causes within it, affect the speed of thought and the
quality of feeling. A thunderstorm will clear or a snowcloud
darken the mental as it will the physical atmosphere, nor is
the actual experiment necessary to prove that it would be as
hard for one half frozen on the top of an iceberg to think
nimbly as it would be for him to thread a needle deftly.
Grasp of thought can be just as much benumbed as grasp of
hand, and by the same physical agency, mental apprehension
being, as I have said, a corresponding process to motor appre¬
hension at a higher cerebral remove and subject t© like physical
conditions.

Although these are familiar facts of common experience
embodied by it in common speech, they were quite ignored by
psychologists and their scientific lesson unlearnt, because it
seemed an insult to the majesty of mind to think of it
otherwise than as immaterial, indivisible, invulnerable, outside
natural law of cause and effect, not subject to conditions of
space and time. Descartes, having postulated an absolute
separation of mind and body, because he could conceive a clear
idea of their distinction, and declared mind to be the only
reality, and its study therefore the supreme study of reality,
started philosophy triumphantly on the tack of a pure self-
introspective study of abstract mind which it has pursued since.
His second meditation he actually devotes to showing that it is
more easy to know the mind than the body: a hardly con¬
ceivable proposition to those who cannot think of any actual
human mind except as containing essentially and representing

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

419

the individual body, or imagine how a knowledge of it without
this content could be other than disembodied knowledge.
Now, however, things are changing fast. The exact experi¬
ments made to measure and determine the physical conditions
of sensation and thought inevitably drag psychology down
from the abstract heights of speculation to the positive methods
of observation and experiment ruling in every domain of
true scientific inquiry. Its professors, roused thereby to see
what they had cultivated a stubborn blindness to, show a quite
febrile and almost pathetic haste to set up so-called psycho¬
logical laboratories, and some of them proclaim the avatar of a
new science. That is to go fast. A little more knowledge and a
little wider reflection might perhaps teach that the physiology
of the senses, as treated by Muller in his great work on
Physiology , was in large part psychological, and that the
so-called psychological experiments of to-day are in most part
physiological ; that pain and sensation have always meant
laws not of life only, but of consciousness ; that physiology and
psychology are not actual separations in nature, but convenient
divisions in human thought; and, lastly, that the sun does not
rise for the first time when the last born infant beholds it.

Undoubtedly the demonstrative experiment appealing
directly to touch or sight will teach that which reflection
founded on simple observation fails to teach ; for the experi¬
ment strikes the senses forcibly and provokes reactive appre¬
hension, whereas a process of sustained reflection or logical
reasoning appeals in vain to minds the large majority of which
cannot see beyond one link in a chain of thought. To see any
fact intelligently there must be fit intelligence behind the eye ;
when that is there the observation may be small, but the
teaching of it will be great; when it is not there the observa¬
tion will be overlooked and its lesson not learnt. Now to
weigh, measure, count, manipulate, and to express the results
in arithmetical numbers or algebraic formulas, is a method of
demonstration which cannot fail to impress the general mind,
to bring psychology into touch with realities, and to put positive
meaning into its language.

All this may be admitted without thereupon incontinently
concluding that nothing which has been done hitherto has been
well done, and ignoring the difficulties that lie in the path of the
new method. In the end these psycho-physical experiments

Digitized by VjOOQle

420 THE NEW PSYCHOLOGY, [July,

are physiological rather than psychological. Let it be possible
to fix exactly the time-rates of a mental process apparently
the same in two persons by noting the exact instants of its
beginning and ending in each, it would not then be certain
that it was the same process ; for the same end might have
been reached by different mental paths, and certainly would
have been so reached if the two minds represented two differ¬
ent cultures. Many trains leave London for Edinburgh daily,
two or more of which might chance to start at the same
moment and to arrive at the same moment, yet they may not
have traversed the same route. Even if the thought-waves of
two minds did follow the same lines from start to terminus at
the same rate of speed, the one might be later in arrival than
the other, not because its actual speed when moving was less,
but because it was delayed at a junction ; some inhibitive idea
in the one mind, of which the other was destitute, happening
to give a temporary check to the current and so delay it.
Experimental measurement must reckon the result in terms of
speed-rate simply ; how can it do otherwise, since it cannot
analyse or throw any light on the intermediate process between
start and finish ?

Even more important and less calculable than the com¬
plexity of the mental train-system is the personal equation .
Once this unknown quantity was styled Idiosyncrasy , but the
big word fell into disrepute because, although importing plainly
that every self was a special self, it explained nothing, yet was
apt to be taken for explanation,—as imposing words always
are, especially when spelt with an initial capital letter. Never¬
theless it was a good word as a denotation, when not misused
as an interpretation. For after all a definition need not be an
interpretation ; it may be quite arbitrary, and is good for its
purpose if it distinguish clearly that which it is intended to
mark. Has there been much gain thus far by the substitution
of the term “ personal equation,” which, though it sounds more
algebraic, does not really teach more ? It hardly, perhaps, con¬
notes as much, since it applies to degrees of stimulation and to
quickness or slowness of reaction only, taking no account of
quality , as the old word did when, noting quality, it tried by
its doctrine of temperaments to make some classification of
individual qualities. Here, then, we have an arithmetic working
to do exact sums with an inconstant and unknown number

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

421

among the figures. How devise an experiment to measure
why one person faints if a cat be in the room, though he did
not know otherwise that it was there ; why another is poisoned
by a strawberry; why a third “ if he hears the sound of a bag¬
pipe cannot contain his urine.”

Many painstaking experiments have, I believe, been made to
measure exactly the effects of a dose of opium on sensibility
and motor reaction. Yet it is notorious that an equal dose of
opium, which has little or no narcotic effect on one person, will
act powerfully on another, and in different degrees and even in
different ways on the same person at different times ; nay, that
in one it may cause its usual narcotism, and in another a
violent sickness along with a delirium which I have known to
be mistaken for acute mania. All this without anybody being
able to foretell what will happen, or to give the least reason
why it happens. With such subtle and unknown factors in
the constitution of nerve-element in the background, it is hard
to see how multiplication of mechanical measurements can add
much to knowledge. Though these be multiplied and accu¬
mulated world without end, yet if they remain scattered,
incoherent, fragmentary heaps, they will be only monuments of
sterile industry—monumental mockeries of knowledge.

It may be said, of course, that risk of fallacy and failure is
lessened when the experiments are made on the same person
and averages taken. No doubt if the same person were
always the same person from day to day,—which he never is,—
and if averages taught us anything more than the general direc¬
tion in which we ought to search for the concrete knowledge
we are in want of. The opium-instance I have given is com¬
paratively gross ; far finer problems, of course, are the exquisite
subtleties of individual feeling which, thus far being outside any
knowledge we have, much more any manipulation we can make,
of nervous structure and function, import incalculable possi¬
bilities of fallacy into all minute physical measurements. Set
a man down in the chair of a psychological laboratory with all
appliances and means to boot, in order himself to make, or to
have made on him, an exact experiment with respect to a
particular mental process, the measured result might differ on
different occasions according to the then quality of feeling in
him, of which he himself was perhaps unconscious and the
observer certainly could not take account. An atom gone

Digitized by VjOOQle

422

THE NEW PSYCHOLOGY,

[July,

astray in metabolism may notably precipitate him from a
heaven of joy into a hell of dismal despair ; and the same
impression striking in one mood will produce as different an
effect from that which it produces in another mood as a quite
different impression would do. Add to this obstacle, more¬
over, the possibilities of fallacy inherent not only in the
constant personal equation of the experimenter, but also in his
variable moods ; all the more confounding when it is a self¬
experimenter who, triune being, tries to be at the same time
agent, patient, and impartial judge.

The eager psycho-physical experimenter hardly stays to
consider calmly what it is that he does actually, or what it is
that he does not nor can do. When all is said, it is the
physical substrata only, not the mental state, which the most
ingenious and delicate measurements can attack. To find out
and formulate in arithmetical numbers or algebraic symbols
what degree of stimulus will excite a sensation, pleasant or
painful, or what mixture of stimuli to senses, and in what
proportion, will produce an agreeable or disagreeable percep¬
tion—useful work as it may be—is not to measure the mental
processes. An impassable gulf lies between the measurement
of the perceived energy—that is the objective energy which
can be handled, and for which all the world can agree on a
common unit of measurement—and the subjective state, which
is intangible, and for which no common unit of measurement is
possible. How measure the thrill of a pang of grief? The
heat of a flash of rage ? The corrosion of an envy ? The vibra¬
tion of a ray of hope ? The leap of an inspiration ? How
sound the depths of a sympathy ? or estimate in millimetres
the height of a vaulting ambition ?

No doubt the several feelings have their special underlying
and precedent or concomitant nervous processes, and the dif¬
ferent kinds and degrees of passion their respective measures of
physical commotion, and such underlying activities may be
theoretically measurable; but, having regard to the extreme
subtleties and intricacies of these motions, is it probable that
any instrument will be invented sensitive enough to catch and
measure them quantitatively, even if it be possible to get
effectively at them ? And as to the all-important quality of
the feeling, which goes before in origin and lies deeper in nature
than thought—which is the essential man,—it is obvious, as I

Digitized by VjOOQle

1900.]

BY HENRY MAUDSLEY, M.D.

423

have said, that such method of research can say nothing. Is
it liver-feeling? Is it heart-feeling? Is it spleen-feeling? Is
it genital feeling ? For it is pretty certain that these several
organs do play their essential parts in the constitution of the
present mood, whatever it be. When there is a discordant note
of gloom in the grand physiological orchestra which organ or
instrument is it that is at fault ? The body is not simply a
complex physical machine ; it is a grand organic complex of
exquisitely subtile, rapid, and intricately ordered motions, of
which mind is, or ought to be, the supreme harmony ; it was
no mere idle fable of the Greeks, therefore, which made Apollo
the god of medicine as well as of music, and his son ^Esculapius
the healing restorer of a lost bodily harmony.

If I dared to speak of music—in doing which I should be
no better than a blind man talking of colours—I should venture
a surmise that Paganini’s violin was a better psychometer than
has been, or is likely to be, invented in any psychological labora¬
tory. At any rate I judge so if it were capable of expressing
what Heine rapturously declares that it did express : “ sounds
from whose bottomless depths gleamed no ray of hope or com¬
fort .... melting sensuously languishing notes of bliss!
Tones that kissed one another, then poutingly fled from one
another, and again languishingly embraced and became one
and died away in the ecstasy of the union.” Now these
enravishing sounds are the subjective correspondents or cor¬
relatives of the varieties and combinations of the vibrations of
fiddle-strings under the magic touches of a master’s fingers ;
objective motions which are, I suppose, theoretically measurable,
and in that case infinitely more easily so than the psychophysics
of the human organism.

In the result then, I conclude that man as a whole is a larger
affair, a grander and more mysterious complex, than any single
method of minute inquiry—be it chemical, physical, patho¬
logical, microscopical, or psycho-physical—will ever unfold, and
that there are still abundant room and work for old methods
of observation. The pity of it is that these are not pursued
more steadily and systematically. How little has been done
yet to note accurately the mental symptoms of different bodily
diseases, and the qualities of feeling marking the different
stages of the same disease as it goes on either to recovery or
death; symptoms which differ and are almost as constant in

Digitized by VjOOQle

424 THE NEW PSYCHOLOGY, [July,

relation to the vital changes as the physical symptoms of
which such exact daily note is taken. Then, again, what
a light might not a diligent and systematic observation of
dreams in relation to bodily states throw on mental pro¬
cesses, not in relation to diverse bodily states of transient
disorder only, but also in relation to diverse diseases. Lastly,
there is the vast field of mental pathology hardly yet
seriously explored, in which nature is continually making and
obtruding, and we are continually neglecting, experiments for
our instruction. These paths of inquiry I mention, not because
they are exhaustive, but as being of some special interest to
this Association, and at all events as serving to show that the
methods of the old psychology are not quite spent, nor it
necessarily doomed because of the invasion of its “ impious
younger world.” There is work enough for as many methods
of study of mind as are rationally based ; have the definite aim
of a concrete mental organisation to be studied, and work
definitely and progressively for it by observation of facts ; ex¬
clude not one another, but know that in the end they must
bring and, knowing, strive to bring their results into harmony.

Discussion.

At the General Meeting, May ioth, 1900.

Dr. Mercier spoke appreciatively of the eloquent form of Dr. Maudsley’s
address, but criticised the matter of it as inconsistent, and unduly depreciative of
the labours of others.

Dr. Rivers thought that the study of mental science was not in so deplorable a
condition as Dr. Maudsley seemed to think. Professors of mental philosophy, of
whom Dr. Maudsley had spoken so contemptuously, had often, in the present day,
a very wide acquaintance with the physiological aspect of their subject. In his
remarks on child study, Dr. Maudsley had been unfortunate in drawing his
examples from the wild amateur work which the subject had a tendency to produce.
He had said that the observer “ must inevitably read into the mind of the child
what is in his own mind,” but the tendency to do this, which constituted a recog¬
nised danger of all comparative psychology, could be controlled. One of the
most hopeful lines of psychological investigation was that dealing with mind in
its development in the animal, the child, and the savage, and it was very deplorable
that Dr. Maudsley should lend the weight of his authority to discourage the study
of genetic psychology.

In his remarks on psycho-physical research Dr. Maudsley had unfortunately
not given any indication of the sources from which he had drawn his ideas of the
present condition of the subject. He had eloquently pointed out a large number
of difficulties with which every serious worker was perfectly familiar. The
presence of difficulties was, however, no reason for discarding any branch of
scientific work, and the “ new psychology” only differed from the old in working
under well-defined conditions, and in making its methods as exact and systematic
as possible.

Dr. Hyslop. —I came here hoping to learn what the " new psychology” is,
but I am afraid that even now we are far from obtaining a satisfactory answer or

Digitized by tjOOQle

BY HENRY MAUDSLEY, M.D.

1900.]

425

solution of the difficulty. I appreciate Dr. Maudsley thoroughly; we have all
been students of his writings, and we know what a tower of strength he is in the
domain of mental physiology, but dealing with the question of sociology is another
matter. 1 have no doubt that most of us disagree with his ideas of sociological
problems, and when he deals with mental physiology I think he departs from the
subject of pure physiology. He marshals his facts with the master’s hand, and
one regards him not as being merely a brain physiologist, but as one who deals
with the metaphysical side of the question. As to the new psychology, it seems
to me that at present it cannot explain the whole. We are mixing up a new
psychology and a new physiology. It seems to me to be an attempt to explain
physiological and psychological events which are really beyond explanation.
Dr. Maudsley has himself stated definitely that there are certain brain problems
which we cannot explain; so that, whether new or not, we shall only reach a
certain length and no further. No matter how much we speak of brain events
in physical terms, we shall never be able to explain fully the ordinary workings
of life. At first Dr. Maudsley was rather inclined to define psychology, and he
spoke in terms that almost made us begin to wonder whether we had minds or
not; and then in the second half of his paper he seemed to think that there was
only one thing definite to deal with, and that was the human mind, and that the
brain events were purely hypothetical. Although he spoke in these definite terms,
he said that of these things we knew absolutely nothing; but, at any rate, apart
from his sociological views I am quite in accord with him, and 1 do not think that
the new psychology or new physiology, if it is to be restricted to terms of measure¬
ment, will lead to anv explanation of the phenomena of life or mind.

Mr. Langhorne Orchard thought all would agree with Dr. Maudsley and the
last speaker in considering that one cannot give an account of psychology in terms
of physiology. He maintained that the data were not sufficient. He then, at
considerable length, pointed out fallacies which the seeker after truth must avoid.

Mr. Shadworth H. Hodgson. —The words metaphysic and metaphysician
have been heard in this room this afternoon. I am glad to see that they have
called forth some defence on the part of one or two of the speakers who have
spoken on the occasion of Dr. Maudsley's address. 1 profess myself to be a meta¬
physician, and by that word I mean one who attempts the analysis of facts of
experience from the subjective side, that is, of our knowledge of what we call
reality. Understanding it in that analytical sense, I was very glad to hear the
speaker who addressed us next after Dr. Maudsley pointing out that even measure¬
ments were mental states. In fact, the only knowledge that we have of this real
physical world about us is knowledge, and knowledge is a state or complex of
states of consciousness. We have no immediate knowledge of physical reality ; it
is an inference, and I would also add that the mind is an inference in exactly the
same way. I would therefore, for my own part, begin the subject of psychology
by putting aside such words as mind and soul, and I would draw the distinction
between mind and matter, or mind and what it knows, between consciousness and
its objects. There you have a distinction which is wide enough to embrace all
distinctions which are fundamental in any positive sense. I consider that psy¬
chology is a positive psychology, and by psychology I mean what Dr. Maudsley, I
think, means by the new psychology ; the bringing of states of consciousness into
direct connection with their physical conditions. Instead of speaking about the
mind as a single power having faculties—that I call the old psychology—we now
speak, or ought to speak, of consciousness in relation to its physical conditions or
whatever conditions research and experiment may discover to be the real condi¬
tions of its arising, and of the order in which the states succeed, accompany, and
are combined with one another. There are therefore, to my mind, besides the old
psychology of an entity with its faculties, two new psychologies. There is, first,
the psychology which connects the physics of the brain (physiology that is) with
concomitant states of consciousness, placing them as two parallel series of
phenomena that are concomitant one to the other, the last of which concomitants
you can trace, but without venturing upon any hypothesis as to the relation of
dependence which may exist between them. That I would call the middle or
second psychology. The newest psychology, which I consider is now entering on
its trial, is one which bases itself on some distinct hypothesis as to the relation of
dependence which exists between the physiological and physical action of the

Digitized by VjOOQle

426

THE NEW PSYCHOLOGY.

[July,

brain and consciousness, and that hypothesis can only be that the states of con¬
sciousness depend upon, rise, and succeed one another only in consequence of
changes in the brain, and that changes in the brain are in no way influenced by
changes in the series or complexus of states of consciousness. I simply state that
theory which I consider to be the veritable new psychology, and I think that for
my part, if I were to name among those to whom 1 owe the reflections, which
finally ended in my adopting for my own humble part that view of the matter, I
should name pre-eminently Dr. Maudsley himself in his earlier writings. 1 there¬
fore consider 1 owe a great debt to Dr. Maudsley, but I think that in all these
subjects the large view must be the dominant one, and 1 believe that what I term
the philosophical, or as it has been called this afternoon, the metaphysical view—
considering what the foundation of all knowledge must be—must in all essentials
be considered the dominant point of view. 1 think that metaphysical philosophy
has the largest scope and is the most fundamental of all inquiries that any man
can possibly undertake.

The President. —Before I call upon Dr. Maudsley to reply, I think I may say
that whatever difference of opinion there may be as to the teaching of Dr.
Maudsley’s paper, there can be only one opinion as to the charming way in which
he has presented that teaching. 1 have myself listened to it with the greatest
pleasure, and I am sure that pleasure has been shared by everyone present. ,1
could only wish that Dr. Maudsley would come more frequently amongst us. He
has done excellent work for the Association, and I daresay he thinks it is time for
the young men to do their share, but the young men like the presence and appro¬
bation of the older ones, and if he could find time and opportunity to come among
us 1 am sure he would receive as hearty a welcome as we have given him to-day.

Dr. Maudsley. —I think I shall be suiting your convenience best if I make what
remarks I have to make very brief. In the first place I must be allowed to
express my disappointment that I have not received the illumination which I
asked for. I asked what were the conquests of the new psychology, but while
I have been told of the value of its methods, I have heard nothing of the
fulfilment of them. My paper was critically interrogative, and I described it so on
purpose to elicit such information. Having taken that critical attitude, its
remarks may have Sounded depreciative. They were not intended to be so, bilt
intended only to elicit definitely what the new psychology was expected to do and
could do. But my critics, immediately rushing to the conclusion that I was
denouncing the method, when I was onlpr asking to have it defined and its results
set forth, have treated the matter as if 1 wished to exclude it, which was by
no means my intention. Of course by laying so much stress on the defects, this
may have led to a misunderstanding of my object. With regard to what has
been said as to my quotation of Descartes—that I might have gone further back
—I might have gone back to the Infinite. I quoted him specially because he said
that the study of mind was the only reality, and that mind was something abso¬
lutely and entirely distinct from body, and he devoted his second meditation
entirely to prove that it is easier to understand the mind than the body. I did
not wish to throw scorn upon the method of introspection, but to point out
this: that the mind contains the whole body, and that, in fact, you must combine
all the methods of physiology and introspection. So long as you ignore the body
you cannot satisfactorily study the mind introspectively. Mind, in fact, con¬
tains and essentially represents the body, and, if I might be allowed to say so,
in the presence of one who is far more deeply instructed in Aristotle than I,
I should say that that was the fundamental conception of Aristotle, namely, that
mind was vital structure, function by adaptation making structure. That, I should
say, was at the bottom of the whole system of Aristotle’s Psychology, Ethics, and
Politics. 1 should be prepared to maintain, perhaps wrongly, that consciousness
must necessarily be a thoroughly inefficient instrument for investigation. Con¬
sciousness at its best but reaches surface, penetrates only slightly into the mind.
Coleridge said long ago that consciousness leaves most part of the mind uncon¬
scious, and it is that unconscious mind which is essentially physiological; which
is, in fact, built up through the ages by successive adaptations of function to
changing conditions and a corresponding growth of mental organisation.

Digitized by tjOOQle

1900.] PUPILLARY ANOMALIES IN IDIOT CHILDREN. 427

On Pupillary Anomalies in Paralysed and Non-paralysed
Idiot Children , and their Relation to Hereditary
Syphilis . A Paper read before the Medico-Psychological
Association at the General Meeting, London, 10th May,
1900, by W. J. Koenig, M.D., Dalldorf, Berlin.

I DESIRE in this paper to focus your attention upon certain
pupillary anomalies as observed in a class of patients who in
this respect have not been the recipients of that amount of
attention which to my mind is their due.

The eye-symptoms in insanity and other forms of cerebral
disorder have for many years past been an object of assiduous
study on the part of alienists and neurologists of all countries,
and though their researches have by no means been confined
to adult subjects, but have embraced juvenile cases as well,
more especially the category which Dr. Clouston has termed
“ Developmental General Paralysis,” idiot children, and in par¬
ticular those of the paralysed type, have not come in for their
share of consideration.

A few years since, I published a communication “ On the
State of the Cranial Nerves in Infantile Cerebral Paralysis,”^)
and discussing the oculo-motor symptoms I remarked on the
striking paucity of clinical information extant on that point,
this being singularly true with respect to the motor derange¬
ments of the intrinsic muscles.

My search through literature resulted in the discovery of
three very incomplete and aphoristic instances quoted by Freud
in his well-known monograph.( 2 ) I adduced several examples
from my personal observation, and while pointing out that slug¬
gishness or failure of pupillary action in children was taken by
various authors, notably Oppenheim and Uhthoff, as fairly con¬
clusive of syphilitic heredity, I gave the opinion, based on my
own, if limited, experience, that before laying down a hard and
fast rule it would be expedient to wait for a greater number
of cases. In some instances, I suggested, the predisposing
cause might be a complex, or a different one altogether. In a
second publication ( 8 ) I drew attention to the clinical bond
uniting cases of uncomplicated idiocy and such associated with
paralyses, the link being represented by a series of “ concomi-

XLVI. 30

Digitized by VjOOQle

428 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

tant symptoms ” which could be seen alike in infantile paralysis
and in examples of simple idiocy. As such “concomitant
symptoms ” I regarded epileptiform and hysterical seizures,
involuntary disordered movements of an athetoid, choreiform or
myoclonic type, and finally disturbance of the oculo-motor appa¬
ratus, viz., nystagmoid movements, paresis of the intra- and
extra-ocular adjustments, neuritis, and atrophy of the optic
nerve.

Since publishing the above-mentioned paper I have added
considerably to my experience. On this occasion, however, I
propose to limit myself to the discussion of the pathology of
the internal ocular muscles as the dominant feature in thirteen
cases of idiocy, and shall promiscuously deal with paralysed
and non-paralysed subjects.

Among so many hundred cases of children, I have been en¬
gaged in during the last ten years, thirteen observations of
pupillary anomaly represent a very small minority. Their
sparse occurrence is explanatory of the small number of
references met with in medical literature.( 4 ) Fuchs ( 6 ) in a recent
work giving notes of a hundred cases of infantile cerebral
paralysis does not in one instance mention any deficiency of
pupillary reaction ; and only in one he reports inequality of
pupils, in my experience a feature by no means uncommon,
and comparatively insignificant as long as there is readiness of
reaction.

For practical reasons I shall divide my material into three
groups, the first two including one case each.

The first instance has been fully reported by me in a previous
writing,( 6 ) and I therefore intend restricting myself to an out¬
line account setting forth the main points. This case is unex¬
ampled, and distinguished from all the rest by the manifestation
of a pupillary phenomenon the rarity of which is unanimously
acknowledged by neurologists and oculists on the Continent.
The essence of this symptom is a more or less frequent alter¬
nate dilatation of the right and left pupil. This “ alternate
mydriasis,” as we may translate the German term “ Springende
Mydriasis,” has chiefly, and for a very long time exclusively,
been observed in general paralytics and tabetics (by Hirschberg,
Mendel, Oppenheim, Siemerling, v. Strumpell, and others), and
fourteen years since, when last the prognostic value of this
symptom formed the topic of an animated discussion in the

Digitized by VjOOQle

1900.]

BY W. J. KOENIG, M.D.

429

Berlin Medical Society,( 7 ) the common teaching was to regard
alternate mydriasis as a sign of distinctly evil foreboding.
Notably Mendel and Hirschberg urged its ominous import on
the strength of two observations in which they had noticed the
phenomenon precede the actual onset of general paralysis by
five and twelve years respectively. Later on examples of
alternate mydriasis in patients suffering from functional nervous
disorder were reported by various authors. Pelizaeus ( 8 ) records
notes of six cases of neurasthenia in which the symptom was
observed. The value of this communication had not been
adequately appreciated until I drew attention to it, and urged
that these observations compelled us to somewhat qualify
the unfavourable prognosis alternate mydriasis had hitherto
seemed to imply.

Now it is a well-known fact that progressive paralysis in its
initial stages not infrequently resembles neurasthenia, and, bear¬
ing in mind the above-mentioned observations of Mendel and
Hirschberg, the question arises whether these cases of Pelizaeus
have been followed up long enough as to be absolutely con¬
clusive in respect to their functional nature. One case at all
events will satisfy the most sceptical critic. It is of a well-
known member of the medical profession in Berlin, still in
practice, who as long as seventeen years ago placed himself
under Dr. Pelizaeus’s care exhibiting unmistakable symptoms
of neurasthenia and alternate mydriasis. Pupillary action, as
in all Pelizaeus’s cases, was brisk. This gentleman has never
quite got rid of his nervous complaints, but up to the present
day there has been no indication of organic mischief.

This instance is of fundamental importance, affording proof
conclusive that under certain circumstances alternate mydriasis
and a favourable forecast of the case are not mutually ex¬
clusive.

Before entering into a discussion of the special nature of these
circumstances, allow me to put before you the broad facts of
my only observation of alternate mydriasis in normally reacting
pupils.

H. V—, male, aet. 17, admitted on January 3rd, 1898. According to
information given by patient’s mother, his father died of some pul¬
monary affection. Mother enjoyed good health all through her life, and
there was no neuropathic heredity in either parent. Complete ignor¬
ance was professed as regards syphilitic antecedents. There were nine

Digitized by VjOOQle

430 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

pregnancies, the third and ninth being miscarriages at third month; the
rest were full-time children, two of whom died in infancy, one from lock¬
jaw and the other from general debility; three children are doing well,
mentally and physically. Of the four survivors, patient is the second
child. Pregnancy natural; infant not asphyxiated; was suckled by
mother. Patient was congenitally weak-minded. He did not attempt
to talk or stand on his feet till more than three years old. He never
spoke properly, and was always clumsy in walking. During his first
year he was twice attacked with fits, which have not since recurred. At
the age of ten he contracted an illness, the exact nature of which could
not be elicited; informant only remembers the patient lost conscious¬
ness for the space of a week.

On examination, patient is mentally dull and slow: there is a very
bad stammer and slowness of speech, and he frequently drops the final
syllables; in repeating difficult test-words his language is next to in¬
comprehensible. There is, however, no nasal twang in his voice, and
his speech on the whole does not resemble that of a general paralytic.

Patient is undersized, cranium fairly symmetrical, gait somewhat
spastic; now and then his knees will suddenly give way, but he never
falls. Genua valga; marked rigidity on attempting passive movements
at knee- and hip-joints. Knee-jerks increased; double ankle-clonus;
no evidence of ataxia, double club-foot, athetoid movements in oral
muscles and toes. Condition of upper limbs presents nothing note¬
worthy ; circulatory, respiratory, urino-genital systems unaffected. Sen¬
sations all over the body good. Fields of vision roughly examined are
of natural extent; no oculo-motor anomalies save slight insufficiency of
the internal recti; central vision uncorrected, R. V. f, L. V. Snellen.

Oculisfs report .—Slight post-neuritic optic atrophy, extreme pallor
of discs, arteries small and tortuous; pupillary reflexes lively; pupils of
medium size, the left slightly the larger.

The next day the right pupil was noticed to exceed the left in width,
and this fact prompted us to subject patient to continuous observation
for a period of three months. The result of our effort, briefly sum¬
marised, was that the exchange of the mydriatic condition from one eye
to the other frequently occurred as often as three or four times a day;
then at other times the same pupillary state was maintained up to three
days. At various times there was equality of pupils, and it was not
infrequently noticed that after a period of pupillary equality the previous
condition was re-established instead of being reversed (e, g. R. > L.,
R. = L., R. > L., and not L. > R.). Since the last notes were taken the
clinical aspect of the case has been unaltered.

Summing up, we have alternate mydriasis associated with
normal pupillary reaction in a young subject affected with pre¬
sumably congenital organic disease of the brain, the clinical
symptoms of which consisted in mental reduction of a non¬
progressive character, spastic paraparesis, athetoid movements
of oral muscles and toes, and post-neuritic optic atrophy.

This is the first instance on record of alternate mydriasis in

Digitized by VjOOQle

1900.]

BY W. J. KOENIG, M.D.

431

a case of organic cerebral disorder where normal pupillary
sensibility to light has not only been present but retained for
quite a number of years.

We are not aware as to when the alternate mydriasis first
put in an appearance ; it might be congenital or acquired ; and
it will be a matter of some importance and great interest to
watch the further progress of the case.

Three courses of development are conceivable. Either the
present condition will be maintained to the end, or the symptom
of alternate mydriasis, being of a transitory character, will dis¬
appear, or lastly the final issue will consist in loss of pupillary
mobility.

The case goes to show that alternate mydriasis and normal
reactionary activity of pupils may for a period of many years
co-exist with organic disturbance of the brain.

Viewed in the light of the above observations presented to
you, we come to the following conclusions with regard to the
prognostic significance of alternate mydriasis :

(1) The symptom of alternate mydriasis is of particular
import only when associated with normal pupillary sensibility,
the presence of even slight impairment of light-reflex, with or
without alternate mydriasis, being sufficient to put us on our
guard against taking a sanguine view of the case.

(2) In cases of natural pupillary reflex, other indications of
organic trouble being absent, the appearance of alternate
mydriasis is not necessarily a sign of evil omen. We will, how¬
ever, carefully exercise a wise discretion in estimating the sig¬
nificance of the symptom, with regard to the fact that general
paralysis in making its approach frequently simulates neuras¬
thenia ; and bearing in mind this, as the foregoing example
proves, normal pupillary action, combined with alternate
mydriasis, may persist for years in spite of orgaiflc changes in
the brain.

Prior to proceeding to the next case let me call your
attention to another phenomenon, self-evident, and not at all
remarkable in itself, but which by the uninitiated, and on a
cursory examination, may be mistaken for alternate mydriasis,
and which I have suggested to denominate “ Pseudo-Alternate
Mydriasis.” This mock-symptom is seen in pupils of unequal
width and reflex-irritability, when under the influence of light
varying in its brightness. Hence it follows that pseudo-alternate

Digitized by VjOOQle

43 2 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

mydriasis will be seen at its best in instances of uniocular loss
of light-reflex.

Supposing L. > R., L. being fixed to light, the width of R.,
with accommodation at rest, will vary with the increase or
decrease of daylight, and present a more myotic or mydriatic
condition accordingly. With advancing darkness dilatation
will ensue, R. equalling L., and finally exceeding it, the result
being R. > L., apparently an instance of alternate mydriasis,
while in point of fact no actual exchange of the mydriatic
condition has obtained, the size of R. not having undergone
any alteration. Increase of daylight will re-establish the first
state.

I have myself been temporarily deceived in a case of a
general paralytic confined to her bed and facing the window,
the varying intensity of light thus having free play.

The second case I have to narrate is likewise a solitary
observation, it is one of transitory pupillary sluggishness, asso¬
ciated, it is true, with external ophthalmoparesis and conse¬
quently not strictly within the limits of this paper, but interesting
enough to justify my making brief mention of it.

M. W—, female, £et. 8. Patient’s family and personal history could
not be procured.

Condition on first examination (November nth, 1897).—Patient is a
complete idiot Circumference of head 47*5 cm. Traces of hypertonia
in lower limbs on trying abrupt passive movements; knee-jerk markedly
exaggerated on both sides. State of other systems healthy.

On October 3rd patient became ill, with an acute attack of diarrhoea;
two days later she manifested complete right ptosis; the drooping eye¬
lid cannot be raised; no conspicuous over-action in the corresponding
half of the frontalis, and pupils contracted readily to light. No chance
of testing accommodative reflex. Both eyes could be freely moved in
all directions. Ophthalmoscopic appearance natural.

On October J8th there was an extremely marked divergent paralytic
squint of right eye; state of levator unchanged; there is distinct in¬
sufficient mobility of the eye in all directions, the upward and down¬
ward movements being particularly affected. External rectus acts well;
there is slight prominence of eyeball (paralytic exophthalmos). Right
pupil of moderate size, larger than its fellow, responding sluggishly to
direct and indirect light stimulation. No retinal changes; condition
of left eye healthy.

On the nth there was indication of beginning recovery, the internal
muscles and the levator being the first to regain activity. By the 30th,
about three weeks after the onset of the trouble, all the symptoms had
disappeared. There has been no second attack. The question
naturally arises as to the causation of this transient ophthalmoplegia.

Digitized by VjOOQle

1900.]

BY W. J. KOENIG, M.D.

433

We know of the frequent occurrence of passing oculo-motor affections
in luetic subjects. About the antecedents of the above case we are
entirely in the dark; no perceptible stigmata of venereal disease were
seen on the body, but this negative finding naturally does not authorise
us to exclude hereditary syphilis with anything like confidence. Per¬
haps toxins produced by the micro-organisms of the intestinal catarrh
affected the oculi-motor cells, or vascular irregularities within the ocular
nuclei may have had a similar effect Anyhow we are not in a position
to make any definite assertion on this point.

The third group comprises eleven cases presenting a chronic
state of irregular pupillary activity.

I propose to first give a brief clinical history of each instance,
adding a short account of the pathological changes where a
post-mortem examination has been made.

Case i. —P. B—, male set. 9.

Family history atid previous health .—Mother single, father has been
lost sight of; there is a probable history of maternal syphilitic heredity,
but no definite proof can be adduced. Patient bom at full term ; labour
not instrumental, and of normal duration. When eleven months old
patient was seized with convulsive attacks and subsequent right hemi¬
plegia : after a free interval of five y£ars he had a second convulsive
period.

Condition on admission .—Intellectually, very far below par. Right
spastic hemiplegia, the paralysed limbs exhibiting trophic lesion.
Pupils unequal, L. > R., acting sluggishly to light, while during con¬
vergence there is vigorous contraction. Fundi and discs of healthy
appearance.

Case 2.—P. K—, female set. 7.

Antecedents .—Father died an inmate of Dalldorf Asylum; he had
been a general paralytic with a clear history of specific disease. Patient
is the last child of seventeen. It was not noticed that there was any¬
thing the matter with her legs till she began to walk at three years. No
history of fits.

Present state .—Pupils dissimilar, L. > R. Right pupil fixed to light
and upon convergence; left but faintly responsive to either stimulus;
optic discs healthy; all ocular movements well carried out. The two
sides of the face quite symmetrical in their aspect and movements.
Tongue deflected to right on protrusion. Spasticity of all four
extremities, less marked in the upper limbs. Knee-jerks exaggerated,
left greater than right. Left foot-clonus, gait spastic.

Case 3.—A. S—, male set. 12.

Family history and personal antecedents .—Parents were first cousins.
Father presented a likely history of luetic infection. Patient is the
third child. Labour tedious, and instruments had to be used. Child
asphyxiated when bom. He never ailed till up to the age of nine, when

Digitized by VjOOQle

434 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

a first convulsive seizure occurred, leaving the right side paralysed.
After a quiet intermission of six weeks, he had a second paroxysm with
ensuing left hemiplegia. After a lapse of another four weeks a third
and last attack came on, since which patient’s mental condition rapidly
deteriorated.

State when first examined .—Complete absence of language, hyper¬
tonicity of muscles of all limbs. Right extremities more paralysed than
left; double genu valgum. Gait of the spastic-paretic type. Pupils
unequal, R. > L., reaction to light and convergence gone in right eye,
very deficient in left. Ophthalmoscope reveals nothing abnormal.

Death took place from independent causes.

Pathological summary .—Thickened and milky appearance of pia-
arachnoid, with matting of the superficial layers of cortex. Pia does
not peel without tearing of brain substance. General convolutional
atrophy. Lateral ventricles much distended with serous fluid, ependyma
thickened and highly granulated.

Case 4 . —E. S—, male aet. 14. Illegitimate child ; family history
otherwise unimportant. Mother experienced a good deal of worry
during pregnancy. Delivery natural and easy; infant delicate. When
six weeks old he took convulsions, and, coming out of them, could not
move his right side. In the course of the subsequent eighteen months
the paralysis gradually subsided. At twelve years he had an apoplectic
fit, after which he increasingly failed in his walking power, and com¬
pletely lost his speech.

When first seen, his language was almost unintelligible, and he
scarcely appreciated the simplest remark. Thyroid gland slightly
enlarged; heart-beat accelerated in a rhythmical manner, the number
of contractions being about 120 per minute. Weakness of right lower
face. Tongue, when protruded, curves to the right. There was utter
inability to walk or even stand without extraneous aid. When sup¬
ported during progression, he brings his limbs forward in a spastic-
ataxic way, swinging his right foot round with a semicircular movement.
Myoclonic jerkings are present in various muscles all over the body,
and athetoid movements in right toes. All four extremities are in a
spasmodic condition, more marked on the right side. Right knee-jerk
excessive. By a single tap on the Achilles tendon, three to four
contractions are readily obtained. Double patellar clonus and right
foot-clonus.

Post-mortem record .—Meninges thickened and adherent to cortex.
Ventricles greatly extended and granular. Yellow patches of old
haemorrhagic softening on surface of caudate nucleus, i£ cm. antero-
posteriorly by 1 cm. laterally. Basal arteries atheromatous.

Case 5.—E. B—, male 12 years. Born out of wedlock; birth
natural and easy. When eight days old was taken with fits. Attacks
kept on occurring at varying intervals during the next five months ; after
ceasing for eighteen months the spells returned. In his fourth year had
measles and supervening pneumonia. Pupillary irregularity was only
noticed when he was five. No definite statement could be obtained
with regard to onset and duration of paresis. Of late patient is said to

Digitized by VjOOQle

1900.] BY W. J. KOENIG, M.D. 43 5

develop occasional violent outbursts of temper and reckless impulsive¬
ness.

State on admission .—Cranium oxycephalic. Dissimilarity of pupils,
R. > L.; both irresponsive to light. Action during convergence
lost on right eye and a mere flicker on left. No ophthalmoscopic
changes. Doubtful weakness of left lower face and hypoglossal nerve.
Slight spastic paresis of left arm and faint evidence of rigidity in the
other limbs. Patellar tendon-reflexes increased. Tachycardia. Frequent
occurrence of major epileptic attacks.

Autopsy .—Milky aspect of pia-arachnoid. Sclerosis of right posterior
central gyrus. Ventricles greatly dilated, and ependyma coarsely
granular.

Case 6.—A. M—, female set. 12. Father very alcoholic. Rather
mentally enfeebled, her state being strongly suggestive of incipient pro¬
gressive paralysis. Patient is the fifth child, and was naturally delivered
after easy labour. Her intellectual powers up to the age of eight of
average quality. In her seventh year she had an attack of convulsions,
and at eight took measles. Since that time she has been weak-minded
and subject to vertigo. At the same time she began to be awkward in
walking, and since her tenth year involuntary jerky movements are
manifest.

When admitted her pupils were widely dilated and unequal, the right
the larger one, both fixed to the strongest light, and failed to act upon
convergence. Ocular movements perfect. Optic discs somewhat pale,
without presenting definite existence of atrophy. Nothing abnormal,
cardiac or pulmonary. Slight spinal lordosis, and there was consider¬
able rigidity in arms and legs. Tendon jerks of the clonic type, double
knee- and ankle-clonus. During progression patient plants her feet
widely apart, very slightly stamping her legs, not throwing them strongly
forward as in ordinary ataxy, on account of a very marked stiffness.
Great reduction of voluntary power in lower limbs. Choreiform move¬
ments are seen in muscles of trunk and extremities. Condition of arms
otherwise natural. Fatal termination in January, 1899, from intercurrent
pulmonary affection.

Autopsy (twenty-four hours after death).—Heart-muscles soft, pale,
fatty; valves healthy. Old pleural adhesions of left apex. Left lung
studded with tubercles, caseous nodules, and cavities. Broncho-pneu-
monial patches in inferior lobe of right lung. Enlargement of spleen ;
kidneys show evidence of parenchymatous degeneration. Liver fatty.
Mucous membranes of the lower intestines injected and swollen. No
signs of old syphilis. Skull thickened, sutures ossified, sinuses contain
clots of blood. Dura natural. Pacchionian bodies not unusually large.
Pia-arachnoid opaque and thickened, more especially on either side the
longitudinal fissure; strips with undue ease, and without laceration of
cortex. Ventricles perceptibly distended; ependyma smooth, healthy.

On slicing brain is moist, and there is no undue multiplication of
puncta cruenta. Naked-eye appearance of spinal cord good.

Case 7.—E. G—, male set. 8. Father incurred specific infection
previous to marriage, recovering under antiluetic treatment, but evidently

Digitized by CjOOQle

436 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

communicated the disease to patient’s mother, who shortly after marriage
exhibited venereal symptoms. At present moment apparently in
enjoyment of good health.

First pregnancy resulted in abortion at three months. Patient the
second child. Labour difficult, protracted, necessitating instrumental
interference. When four months old patient was taken with an attack
of convulsions terminating in paresis of right arm and slight weakness
of right leg. Since then seizures have periodically occurred. No
attempt to speak or to walk has ever been made.

Present state (March 17th, 1899).—Patient is quite demented. He
can neither stand on his feet nor walk without assistance. Head and face
asymmetrical; voluntary action of facial muscles equally powerful on
either side; right hemiplegia with contractures; left limbs in a state
of slight rigidity; knee phenomenon in excess, R. > L., Achilles-
reflex brisk. Pupils equal, perfectly immobile to the stimulus of even
focal illumination; reaction upon convergence and accommodation
could not be tested. Retinoscopy shows both discs to be of a palish
white-grey, with blurred edges (post-neuritic atrophy). Patient died
from intercurrent broncho-pneumonia (July 8th, 1899).

Brief summary of post-mortem notes .—The main feature of the finding
was atrophy of the left hemisphere, and a gummatous growth originating
in the meninges of the left hemisphere and spreading over the parietal
lobe, including both ascending convolutions in their entire extent and
the first temporal gyrus. The specific growth had penetrated into the
white matter, and was separated from the lateral ventricle only by a thin
layer of natural tissue.

Case 8.—K. K—, male set. 10. Parents dead. Family and previous
history unobtainable. When admitted (October 10th, 1899) patient
showed little intellectual development. His physique was fair; hori¬
zontal circumference of cranium 46 cm. Facial asymmetry; pupils
wide and do not contract to light; accommodation reflex could not be
tested. No change of fundi or discs. Knee- and Achilles-jerks exagge¬
rated ; no ankle-clonus. When maintaining the dorsal decubitus patient
draws up his legs; he can, however, extend them at will with apparent
ease. There are no contractures, and no rigidity is felt in effecting
sudden passive movements of legs. Patient is unable to walk by him¬
self. When assisted stands with a broad base, and in stepping scrapes
the right foot along the ground. Patient is subject to occasional epi¬
leptic paroxysms. Died January 1st, 1900, from pneumonia.

Autopsy (four hours after death).—Dura adherent to skull. Between
the dural membranes a thin layer of fluid blood. Pia intensely opaque
and thickened, particularly so over right Sylvian fissure. Ventricles
moderately dilated, ependyma a trifle thickened. Heart muscle fatty;
lungs congested, show evidence of grey hepatisation.

Case 9.—C. P—, female set. 7. Both parents are inmates of Dalldorf
Asylum, and suffering from progressive paralysis.

Father according to his own story contracted a hard sore followed by
rash, and underwent a course of antivenereal treatment. He could
make no definite statement as to whether he had infected his wife.

Digitized by

Google

BY W. J. KOENIG, M.D.

1900.]

437

The latter denies ever having had syphilis, but owing to her very
enfeebled state of mind not much weight attaches to her report.

Patient is the only child, and there were no miscarriages. Maternal
grandmother, when interviewed by me, stated that when patient was bom
her finger-tips and soles of feet were covered with a vesicular eruption
(pemphigus ?). After this had cleared off, patient’s mental progress and
general health were satisfactory up to her third year, when she all of a
sudden developed a squint and found difficulty in walking, by degrees
becoming quite unable to guide her steps. At the age of five she was
seized with epileptiform spasms, and during three days lay in a comatose
state. She made a gradual recovery, but never regained the power of
locomotion. No recurrence of fits.

Notes on admission .—Mentally very imbecile; double pes talipes;
knees flexed. On striking the patellar tendon there was a clonic
response. Doubtful comparative weakness of left lower face. Pupils
semi-dilated, equal in size, insensible to light, and very sluggish during
convergence. No abnormality of fundi. Tongue non-tremulous, pro¬
truded in middle line. When both arms are simultaneously raised
above the horizontal there is a distinct retardation of movement in the
right extremity. Movement of fingers in both hands awkward.
Plantars on tickling the soles of feet show extensor response. Pin¬
pricks cause patient to draw back her legs in a lazy fashion. Sensations
and special senses unimpaired. Patient is incapable of standing or
walking except when supported. When standing she rests on the balls
of her toes, and the heels are drawn up from the ground; hip and
knee-joints slightly flexed. The other systems of the body are not
affected.

Case 10.—W. L—, male aet. 9. According to the information
received from the child’s mother there is no neuropathic heredity,
and both parents have never been ailing. Venereal infection and
abuse of stimulants denied. There were eight full-time children, of
which patient is the last, one stillborn, and one miscarried at second
month, four children died. The survivors are in good health and
mentally bright. Mother went through pregnancy and labour without
any drawbacks; child was normally developed when bom, and was
brought up by bottle. At five months convulsions came on, recurring
at intervals till he attained his fifth year. Mental faculties below par
from birth.

On first examination (January 1st, 1898) he exhibited a high degree
of mental obscuration. Head of hydrocephalic shape. Corneal
opacities in both eyes. Left pupil of medium size, its margin a trifle
irregular through anterior adhesions. All reactions present. Right
pupil widely dilated, iris annular, non-adherent, direct and indirect
light reflex abolished, accommodative reflex faintly retained ; eyes can
be readily moved in all directions. Normal condition of optic nerves.
The other functions of the body are regular.

Case ii. —F. B—, male aet. 15. The following history was given
by patient’s maternal grandmother and his father.

Father of alcoholic habits (was intoxicated when interviewed), has had

Digitized by VjOOQle

43 » PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

a soft sore, no secondary symptoms, and was treated locally. Patient’s
mother died of “ spinal syphilis ” (tabes ?). She had five pregnancies.
First was an abortion at fourth month ; patient the second child; third
child died twenty-four hours after delivery; fourth and fifth children are
delicate. Grandmother noticed unnatural dulness in patient at the age
of six weeks. Later on he frequently exhibited hasty temper on slight
provocation. Did not get on at school.

On admission he was of very weak intelligence; physically fairly
strong, and had a good deposit of subcutaneous fat. His speech diffi¬
cult of comprehension, but in nowise resembling that of a general
paralytic. Slight cranial asymmetry. Right palpebral fissure compara¬
tively narrow. Ocular movements perfect. Horizontal nystagmus.
Pupils L. > R. All reactions extinguished. No facial palsy, or para¬
lysis of extremities. Knee- and Achilles-jerks exalted ; at times right
ankle-clonus can be obtained. Right plantar reflex of the extensor type.
Gait awkward, not distinctly pathological.

Analysis .

The eleven cases included in the third group consist of
eight boys and three girls, their ages at the time of admission
varying between seven and fifteen years. I do not mean to
enlarge on the preponderance of the m^les, the higher per¬
centage being in all probability accidental. To arrive at a
proper estimate as to the real proportion of males and females
we would have to be in possession of larger figures. Nine
cases were clinically of infantile cerebral paralysis, one of them
proving on post-mortem examination to be caused by gummy
meningo-encephalitis, and two were cases of uncomplicated
idiocy. In all instances but three the children were mentally
deficient from birth, or were noticed to be wanting in normal
intelligence before the close of the first year.

In three cases only the intellectual condition was stated to
have been normal till the third, eighth, and ninth year re¬
spectively.

All patients were more or less demented on admission. In
all cases language was either absent or impaired, but there never
was any resemblance to the articulatory disorder of general
paralysis. There was, moreover, no instance of abolished knee-
jerks, the very converse obtaining, as in all cases a more or
less exaggerated condition of the tendon-reflex was found.

All patients but one had a history of convulsive attacks at
some time or other of life, paralysis and mental enfeeblement
frequently being ushered in by the first seizure.

Digitized by VjOOQle

1900.] BY W. J. KOENIG, M.D. 439

In six cases post-mortem examinations have been made, to
which I shall recur presently.

Turning now to a study of the two points taking front rank
in our interest, the pupillary anomalies and their bearing on
syphilitic heredity ; the former show two types, a binocular
and a uniocular one. Of the latter I have only our example
to record, viz. light reflex extinct, and accommodation slow.

Cases of one-sided deficiency of pupillary action are not of
very frequent occurrence in the adult, and evidently exception¬
ally rare in mentally affected children.

As regards the binocular examples we have—

(1) All reactions lost in two cases.

(2) Pupils fixed to light, action during convergence could
not be tested in three cases.

(3) Pupils rigid to light, and sluggish upon convergence in
one case.

(4) Light reaction gone, convergence reflex sluggish in one
eye, normal in the other, in one case.

(5) Contraction to light and convergence absent in one eye,
slow in the other, in two cases.

(6) Light reflex deficient in both eyes, action upon con¬
vergence and accommodation being vigorous.

We have, therefore, in eight instances double loss or de¬
ficiency of light reflex, and in four cases additional double loss
or deficient reaction during convergence and accommodation.
In one example only did contraction on convergence show
natural briskness.

In three observations mobility during convergence and
accommodation could not be tested, and in one child all
reflexes, with the exception of convergence action in one eye,
were abolished.

In six instances there was double affection of all reactions.
One salient feature of these observations will not have escaped
your notice, /. e. the great frequency of simultaneous deficiency
of all reactions, this being the reverse of the condition in
general paralysis, where in a large proportion of cases reaction
to convergence is retained. This remarkable difference of
pupillary behaviour is probably due to diversity in the extent
of nuclear changes ; the reason, however, for this diversity is as
yet in abeyance.

Approaching the question of syphilitic heredity, we must

Digitized by VjOOQle

440 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

bear in mind that outside of venereal disease there are quite a
number of other factors playing a recognised predisposing or
even aetiological rble in the history of idiocy as well as infantile
cerebral palsy, the most prominent among them being—con¬
sanguinity of parents, illegitimate birth, premature birth,
ancestral alcoholism, severe nervous shock or bodily injury of
mother during pregnancy, the fact of the child being the last or
one of the last of a long family, difficult and protracted labour,
asphyxiated birth, head injury, and acute infectious diseases.
In the overwhelming majority of cases we shall encounter a
plurality of predisposing agents, and the difficulty we ex¬
perience in trying to fix the blame on one ultimate cause is
very often insurmountable; we must then be content to state
a joint responsibility of several predisposing factors, leaving the
question of the exciting cause, the actual aetiology, an open one.

In searching out our cases for predisposing and aetiological
elements we note :

In Case I : ( a ) Presumptive history of maternal syphilis ;
(< b ) illegitimate birth.

In Case 2 : (a) Clear history of paternal syphilis, father
died a general paralytic ; (b) patient the seventeenth child.

In Case 3 : {a) Father presents likely history of syphilis ;
(< b ) father and mother first cousins ; {c) labour tedious ; ( d )
child asphyxiated.

In Case 4 : (a) Illegitimate child ; ( b ) mother experienced
much worry during pregnancy.

In Case 5 : ( a ) Illegitimate child, no further history.

In Case 6 : (a) Father intemperate; ( b ) mother’s mental
state suggestive of incipient general paralysis.

In Case 7 : (a) Both parents give a definite history of luetic
infection.

In Case 8 : (a) No history.

In Case 9 : ( a ) Father with syphilitic antecedents and a
general paralytic ; ( b ) mother a general paralytic ; (c) child
born with presumably specific eruption.

In Case 10: (a) Patient the eighth child, family history
otherwise good.

In Case 11 : (a) Father very alcoholic; (b) father gives
history of soft sore not followed by secondary symptoms ; (c)
mother died of spinal syphilis (? tabes).

From the preceding groupings of predisposing factors it will

Digitized by

Google

1900.]

BY W. J. KOENIG, M.D.

441

be readily seen that only in one example (10) syphilitic
heredity may with likelihood be excluded. Of the remaining
observations one (8) is minus any history at all ; and in three
(1, 4, 5), the patients being illegitimate children, syphilitic
ancestry naturally cannot be negatived, particularly in Case 1,
where the mother presented a likely history of venereal disease.
The same applies to Case 6, where the mother’s mental condi¬
tion suggested incipient progressive paralysis ; to Case 3, in
which there was a presumptive previous history of paternal
infection ; and to Case 11,—mother succumbing to a specific
disorder of the spinal cord, and father having had a soft
chancre.

In a considerable number of the cases of conceivably or pre¬
sumptively syphilitic origin we have several of the “predisposing”
elements. Only in two instances the (etiological connection
between ancestral syphilis and infantile cerebral trouble is
absolutely obvious and non-contentious, viz. in Cases 7 and
9. In the former both parents owned to previous infection,
whilst no ulterior predisposing factor could be traced, and the
post-mortem revealed gummy meningo-encephalitis. In the
latter there was likewise a luetic history and development of
general paralysis on part of both parents, and the new-born
infant exhibited what may be assumed to have been a specific
exanthema.

The family history of this case likewise bears out the
relationship between syphilis and progressive paralysis of the
insane, whilst the case itself may be considered as intermediary
between infantile cerebral palsy of specific origin and develop¬
mental general paralysis.

For Case 2 paternal syphilis has very probably to answer, as
w r ell as for the two last-mentioned instances, only that the
presence of another predisposing element—patient being the
seventeenth child—prevents us from quite unhesitatingly accept¬
ing syphilis as the immediate cause.

The lesson to be learnt from the above considerations is that
finding as we do ancestral syphilis in the majority of cases of
early dementia with impairment of pupillary reaction, either as
the -proximate cause or as one of several predisposing elements,
deficiency or loss of pupillary action in cases of infantile mental
enfeeblement must necessarily point to syphilitic heredity.
Our present knowledge, however, does not allow us to negative

Digitized by VjOOQle

442 PUPILLARY ANOMALIES IN IDIOT CHILDREN, [July,

the existence of other causes outside of syphilis. In advancing
this view I am in harmony with Babinsky and Charpentier,( 9 )
who in a recent writing discussed the broad question of
pupillary symptoms in their relationship to syphilis.

In concluding this paper let me briefly touch on the pathology
of the six cases in which a post-mortem examination was made.
In five instances autopsy disclosed a naked-eye condition such
as we are accustomed to find in the advanced stages of general
paralysis, viz. thickening of pia-arachnoid, adhesions to cortex,
distended and granular ventricles. In addition to these changes
Case 4 showed atheromatous basal arteries and small patches
of yellow softening in the caudate nucleus, Case 3 very marked
general convolutional atrophy, and Case 5 sclerosis of the
ascending parietal. The latter is the only example in which a
microscopic examination of the cortex has been carried out,
for which I am indebted to Dr. Navratzki, one of our as¬
sistant medical officers. Contrary to our expectation the
natural wealth of tangential fibres was present except in the
sclerosed posterior central convolution ; neither did the grey
matter of the central canal manifest any morbid alteration. The
pathological finding of this case calls for special attention, show¬
ing that in spite of macroscopic appearances resembling those
of general paralysis, the microscopic investigation may reveal
an aspect different from what one would be led to expect. A
minute pathological study of a large number of similar and
allied cases is a matter very much to be desired.

Case 7 is the only one of cerebral syphilis; at the same time
one of those instances in which the family history permitted us to
make a likely if not absolutely safe diagnosis as regards the
nature of the anatomical changes. A clear history of parental
syphilis is, as we all know, by no means an infallible guide in
this respect; for in a number of similar instances morbid
alterations of a non-specific kind are met with.

Running our mind’s eye over the heterogeneous mass of cases
of congenital and early weak-mindedness in which parental
syphilis plays a predisposing or the aetiological part, we may
recognise, clinically as well as pathologically, three varieties, the
latter not necessarily, and very frequently not at all, correspond¬
ing to the former.

Of the three clinical groups the first comprehends the cases
of non-paralysed idiot children, the second those of infantile cere-

Digitized by VjOOQle

1900.]

BY W. J. KOENIG, M.D.

443

bral palsy proper, the third those of juvenile paralysis, of which
I agree with Dr. Mott ( l0 ) that we may discern two types. In
every one of these three groups abnormalities of pupillary
action may be present. This may be regarded as the rule in
juvenile paralysis and in many cases of brain syphilis, as the
exception in infantile cerebral palsy proper, and still more so
in ordinary idiots.

Very frequently we shall encounter transition forms not
fitting into either of the three groups, and we must likewise
bear in mind that gummy alteration of the central nervous
system may simulate any of the three types, as well as the
transitory ones. In a large proportion of examples of cerebral
syphilis the diagnosis in relation to the anatomical character of
the morbid changes will have to remain sub judice until after
autoptic inspection.

The most common of the transition cases in my experience
are those intervening between infantile cerebral palsy and
juvenile paralysis (e. g. Case 9). Of the pathological varieties,
the first includes all cases with specific cerebral or cerebro¬
spinal changes. The second is characterised by the typical
findings, macroscopic and microscopic, of general paralysis.
The third embraces all cases not to be classified under the first
two heads (< e.g . Case 5).

It will be the business of pathologists, more especially of
those connected with large asylums, to clear up the pathology
of this third category, and ascertain whether it constitutes a
genuine pathological entity, or whether we must distinguish
further varieties.

Dr. Jones. —I should like to ask Dr. Koenig for an explanation as to one
phenomenon which I have occasionally met with in cases of general paralysis of
the insane, and which has been called the “ paradoxical ” pupil. The eyes are
closed, and when opened again instead of the pupil contracting it dilates. It is an
unmistakable occurrence, and it has appeared in my experience in general para¬
lysis only. I am not acquainted with the explanation, and I should be glad if Dr.
Koenig can throw some light upon it.

Dr. KoENiG.-^-In reply to Dr. Jones I would say that, as far as I know, there
has been no definite explanation advanced as regards this paradoxical pupil. A
similar state obtains, I believe, in pupils on opening the eyes in the process of
awakening. The pupils, which during sleep are contracted, expand instead of
contracting to light, as one would suppose them to do. Perhaps this is a similar
condition.

f 1 ) Zeitschrift fur klin. Afedicin, 1896, Hefte 3 und 4.—(’) Die infantile Cere -
brallahmung, Wien, 1897.— ( s ) “ Ueber cerebral bedingte Complicationen, welche
der cerebralen Kinderlaehmung, wider einfachen Idiotic gemeinsam send, sowie
ueber die abortiven Formen der ersteren ” ( Deutsche Zeitschrift fur Nerven-

XLVI. 3 1

Digitized by

Google

444

THE ASYLUM AT PAU,

[July,

heilkunde, Bd. xi).—( 4 ) Since my first publication Tuczek ( Berlin. klin. Wochen-
schrift, 1898, No. 37) has communicated a case in point.—(*) Jahrbuecher fur
Psychiatrie und Neurol., 1900, Heft 1.—(“) Deutsche Zeitschrift fur Nerven-
heilkunde, Bd. xv.—( 7 ) 25, xi, 1886.—( 8 ) Deutsche med. Zeitung, 27, viii, 1889.—
(•) Extr. du Bulletin de la Societe de Dermatologie, stance du 13, vii, 99 ; De
/’abolition des reflexes pupillaires dans ses relations avec la syphilis .—( l0 ) Archives
of Neurology of the London County Asylums, 1900.

The Asylum at Pau , a Self-supporting Public Asylum .

By A. R. Whiteway, Barrister-at-Law.

The Asile St. Luc at Pau is indeed an Institution which
deserves to have its story told. Through the kindness of the
authorities this story is now for the first time made public. It
is in effect that, starting with a capital of £ 12,000 and a small
farm of some twenty acres, a nearly perfect asylum with 900
inmates and a staff of over 100 assistants has been built up
by degrees, now not only self-supporting but last year showing
a profit of £2000, spent mostly in structural improvements
and additions and in the purchase of adjoining land. The
Medical Superintendent has a free hand, being responsible only
to the Conseil-G£n£ral of the Department, who, as they find
him no funds, merely exercise a benevolent supervision. How
such a satisfactory state of affairs has been brought about it is
the purpose of the present article to briefly indicate, by way
of an object lesson in asylum management.

History. —In the year 1838 the French Lunacy Act was
passed, which in theory compelled the erection of a separate
asylum in each Department throughout the kingdom. There¬
tofore syphilitic prostitutes, sick prisoners, and lunatics in chains,
treated as dregs of a society of which they are but necessary
bye-products, were herded together in one building in Pau in
the care of a concierge, and daily visited by a doctor appointed
for the purpose. Notwithstanding the Act of 1838, it was
not until 1868 that the Department of the Basses Pyr£n6es
began to carry into effect the provisions of this statute as to
constructing a proper asylum for the insane alone. The old
maison de force , now the Museum, was sold for fr. 300,000
to the town of Pau. With this sum upon a farm of twenty

Digitized by VjOOQle

1900.]

BY A. R. WHITEWAY.

445

acres two miles off, which had been for long allotted to and
worked by the patients, the present Asylum of St. Luc was
commenced.

There are in France various kinds of asylums for the insane :
(i) State establishments strictly so called, of which there is now
in fact but one, namely that at Charenton ; (2) Departmental
asylums such as that we are describing, of which there may be
forty-five in all ; (3) Communal asylums , perhaps fifteen in
number, nominally annexed to hospices ; (4) Private asylums ,
perhaps twelve in all, of which that of M. Miruit, which serves
for both the Departments of Lot and Dordogne, is a good
typical example. There are besides two Autonomies —one at
Bordeaux and one near Lille,—which are entirely self-governing.
If a Department possesses its own asylum, a certain sum per
head per day is paid by it for each indigent patient maintained,
whom the superintendent is obliged to receive at the price
fixed by the Conseil of the Department. At Pau this sum is
8 \d. a day. The problem to be solved is, how to make
this pittance suffice to furnish the fr. 1 40 c. worth of food,
clothing, and share of general expenditure entailed by the re¬
ception of each person, in compliance with the uniform minimum
scale fixed by the Minister of the Interior, which can, however, be
modified by the Pr£fet in each Department. The way this is
brought about at St. Luc is by bargaining to take patients from
two adjoining Departments, neither of which has as yet faced
the initial cost of buildings of its own. These are the Hautes
Pyr6n£es and the Landes. For the last ten years they have
paid at the rate of fr. 1 18 c. a head ; but after April next,
under a new contract, they are to give 3 c. less during the next
twenty years. Besides indigent patients from the three De¬
partments already mentioned, there are a very small number
from other sources, such as the Army and the Prison Service,
who pay about fr. 1 30 c. All these belong to the Fifth or
Indigent Class. Even so at first sight there is a loss of 20 c.
a head a day on each of these better paying guests. The de¬
ficit is made up in three ways: (1) By taking about 120 still
better paying patients mainly from the same three Departments,
one at fr. 8000 a year, who has a house to himself with two
servants found by the establishment; thirteen at fr. 8 50 c. or
fr. 6 50 c. according as they have three rooms or only one each,
with fr. 2 50 c. for a male or fr. 2 extra for a female servant;

Digitized by VjOOQle

446

THE ASYLUM AT PAU,

[July,

sixteen at fr. 4 50 c.; seventeen at fr. 3 50 c., and sixty at fr. 2
50 c. a head a day. All these patients have to find their own
clothes and tobacco. (2) By the labour of some 450 of the indi¬
gents male and female for a portion of say 300 days each year.
These practically do everything necessary for the working of
the establishment under proper foremen, and work on the sixty
acres of garden, farm, and grounds belonging to the Institution.
(3) By taking adequate measures to prevent any waste in the
food and clothing of patients a saving of about 13 c. a head a
day is computed to be brought about.

Dr. Girma, the present Director, sees that a sufficiency of food,
including 257 grammes of first-rate meat on every jour gras ,
warm clothing and breathing space is allotted to each inhabitant,
while none are overworked. No restraint is used except isola¬
tion, the strait waistcoat having been discarded now for two
years, while outdoor air and exercise are the chief medicines
that the patients are compelled to take. The Institution struc¬
ture has been built up bit by bit as occasion demanded, and
the marvel is that it presents so harmonious an appearance.
What strikes the visitor is the practical character of every
detail of the establishment. The windows looking south, though
protected, are nowhere rendered repellent by unsightly bars.
The lay element and the religious sisters are said to work in
their service of mercy in perfect accord. Having regard to the
excellence of climate and situation at St. Luc, it is to be re¬
gretted that no thorough open air treatment has as yet been
attempted for the phthisical, such as has been for years in full
work at Villejuif, but the splendid corridors and balconies,
chiefly facing due south, afford opportunities for getting air and
exercise at all seasons under exceptionally hygienic circum¬
stances. The treatment by keeping agitated patients in bed with
the view of affording perfect rest and quiet is here carried out
with success.

The Staff consists of two doctors, two supervisors, and a suf¬
ficiency of male and female attendants and sisters, making with
the foremen of shops and farm and clerks a staff of over 100
all told. The chief attendant has been at St. Luc from the
foundation of the Institution, and worthily hands on its tradi¬
tions to his subordinates. Although there is no regular school
for probationer attendants, they are said to learn their duties
easily and efficiently, great care being taken in the initial selec-

Digitized by VjOOQle

1900.]

BY A. R. WHITEWAY.

447

tion from among the fifty usually on the list for each vacancy.
The secret of success is that they have an exceptionally com¬
petent head, who gets matters into the right groove to start
with, and by constant watchfulness afterwards prevents them
from ever getting off the rails.

Available Labour. —As some eighty patients on an ave¬
rage belong to the class of dements with faulty habits, fifty to
the agitated, sixty-five to the epileptic, i oo to the invalid, and
120 to the paying boarder element, making up nearly half of
the entire insane population, only about the other half, or 450
pairs of hands, are available for work of any kind. The value of
their labour differs indefinitely, and from day to day. Still,
taken as a whole it suffices, with that of efficient foremen, for
the general service. The men and women patients being about
equal in number, half the workers are male and half female.
In the shops the estimated profit upon the men’s work is
fr. 10,000 ; while that upon the labour of the women, chiefly in
making and repairing clothes and in washing, may be taken at
about fr. 17,000 each year. The aggregate value of the
services of those who undertake the agricultural duties of the
farm and gardens is reckoned at about fr. 20,000 annually. As
far as possible those who work together in any common occu¬
pation are placed in separate dormitories, e. g\ the agricultural
labourers, and those employed in scavengers’ duties. Thus
their getting up at hours necessary for their respective employ¬
ments disturbs none of their fellow-patients. Extra food and
small payments stimulate each worker to do his or her best for
the common good, while the interest taken by each in the daily
toil is no doubt of individual personal benefit as a physical,
mental, and moral restorative. The shops in which men are
employed may be roughly classed as those of painters, glaziers,
carpenters, masons, builders, tailors, cart-makers, shoemakers,
blacksmiths, and wheelwrights.

Labour. —Thus, with the exception of that afforded by an
administrative staff of a dozen persons, of forty-four attend¬
ants, and twenty-eight chief workmen and labour superintend¬
ents, all the labour at St. Luc is obtained from twenty religious
sisters, who get but their food and ^8 a year each for clothes
and from the indigent patients. Besides sufficing for the work of
the establishment, such labour produces food, clothes, and other
articles, which taken together effect a saving of over fr. 47,000

Digitized by

Google

448

THE ASYLUM AT PAU,

[July,

annually, and in addition much of the indigents’ work goes in
making structural additions and improvements, which at the
end of the next ten years will be no more required. After
that period it will be utilised in the manufacture of carpets or
some other articles for sale to the general public, as fortunately
competition of this kind has not yet been objected to in
France, as is prison labour in Britain and America.

Economic Arrangement. —This consists in the rigorous
application of two principles, buying in the cheapest market,
and producing as far as possible what is consumed in the
establishment, as well as in effectual prevention of waste by
adequate elasticity in commissariat administration. No objection
having been raised by jealous contractors, cattle are purchased
by an official in the neighbouring markets, and killed on the
farms without being fattened there, and good meat thus obtained
at a saving of ioo per cent. The meat each patient eats daily
costs 2\d .; if bought in the open market it would cost 5 d.,
and not be nearly so good. Best joints are consumed by the
private patients, and other parts by the State-supported. The
skin, bones, and refuse are sold. Pigs, fowls, and rabbits are
bred on the estate. In bread the saving is only in the superior
quality of the home-manufactured article, the price being the
same. Corn is purchased from the farmers, ground and made
into bread on the premises, while more than sufficient fruit
and vegetables are grown in the extensive gardens. Waste is
prevented by each day preparing a careful list of the food that
will as a fact be eaten by the population on the following day,
and not as usual by the purchase and preparation of a
constant quantity every day for each inmate, whether it can be
eaten or not. If a patient is on the sick or infirm list he has
some delicacy suitable to his condition, and not the regulation
food, much of which in his case would necessarily be wasted.
It is here, perhaps, that the excellence of the management is
most strikingly in evidence, and here also that the greatest
saving is effected without detriment and indeed with benefit
to patients. The same economy is observed in the matter of
clothes, which are all manufactured on the premises, the old
ones being sold at the end of the year for what they will
fetch.

Buildings. —The asylum is built on the detached block
plan, and, notwithstanding the large area covered, the dis-

Digitized by

Google

1900.]

BY A. R. WHITEWAY.

449

tribution of food and stores is easily effected in trucks readily
wheeled along corridors connecting kitchens and wards. All
dormitories are well ventilated, and while adequately warmed
in winter are yet cool in summer, by reason of the excellence
of the verandahs, shutters, and blinds protecting the southern
exposure from the sun. Overcrowding is .the danger to be
feared, as the population increases by leaps and bounds year
by year. But this is as yet capable of being readily coped
with, owing to the growing habit of sending back to their
homes or elsewhere, on probation, all suitable unrecovered
cases. There is an objection to removing patients far from
home and friends. They are then cut off from the advantage
of visits from relations, which alone prevents defectives from
becoming outcasts, by keeping them ever in touch with their
original family life. Although manifest disadvantages exist in
sending a lunatic with a small subsidy back to his family, such
as the fact that he may not improbably there be treated as an
inferior, and also afford a bad object lesson in heredity to his
brothers and sisters, nevertheless many compensatory advan¬
tages co-exist side by side ; the cost is less, and the substantial
kindness shown him will probably be greater than among
strangers.

But whenever the return of patients on probation to their
homes is impracticable or undesirable, an enlightened boarding-
out system among peasants is the best substitute for the relief
of overcrowded institutions, and this method will no doubt be
found to work well likewise at St. Luc.

Pauper Lunatic Boarding-out System. —This system
in England is being applied to about 6000 cases, in Scotland
to 1019 patients in their own homes, and to 1658 with
strangers ; in Belgium at Gheel and Lierneux to a large extent;
and in France at Dun-sur-Auron in the case of more than 500
inoffensive lunatics. Home treatment has also been found
suitable in Russia, Germany, and the United States. The
approximate sum paid in Scotland is 1 id. y at Gheel fr. 1 38 c.,
at Dun fr. 1 40 c. a day, 20 c. of this being here the estab¬
lishment charge, and at IIten 93 c. In the Basses Pyr£n6es
about 50 c. is usually a sufficient subsidy.

Accounts. —Asylum accounts are kept with a detail such
as is only to be found in France, which is pre-eminently the
land of statistics. They go to show the mean cost of indigent

Digitized by VjOOQle

450 THE ASYLUM AT PAU, [July,

patients to be nominally fr. i 40 c., and in reality through the
prevention of waste but fr. 1 27 c. a day, and that of boarders
about fr. 1 50 c. But this result would seem to be arrived at
without bringing into account the rental value of the establish¬
ment, which taken at 3 per cent, upon the prime cost amounts to
over fr. 70,000 per annum. If this sum were brought strictly
into account, the outgoings per day in connection with each
description of patient would be further increased by about
20 c. A somewhat more serious error appears to result from
estimating the yearly profit made by the asylum at ,£2000,
which, if we have rightly apprehended the true inwardness
of the accounts, or “ compte moral,” as they are quaintly termed,
is arrived at by taking credit for the farm and garden produce
at market prices, without allowing anything for indigent labour,
nor for that employed in making and mending the clothes of
patients, or for washing and such like, except as lumped in
this profit of about £2000 a year. Surely great part of this
profit should be considered as having been expended on behalf
of, and so a$ forming part of the expenses that ought to be
divided among, the total number of patients, all this labour
having been in effect essential to their maintenance at the
prices charged , and in the existing comparative comfort, which
is mostly referable thereto. The requisite free labour could
not be had at much more than double the cost, having regard
merely to the necessary expenditure in wages ; and thus if this
contention be correct, and indigent labour were not forth¬
coming, the prime cost of each class would have to be still
further increased by perhaps another 20 c. a head a day. The
work of 450 persons, even if insane, under proper foremen for
any material part of 300 days a year, must be worth more
than £2000.

Expenditure, such as that upon food and clothing, manifestly
varies according to the markets; while general expenses and
rent are constant. Thus the establishment charges can fairly
be divided into two categories:— (a) Food, clothing, and
tobacco ; ( b ) pocket-money of labourers, general establishment,
fixed charges—such as salaries, lighting, repairs, and estimated
rent. These, divided by the number of days the total number
of patients have passed in the asylum (318,455), give the
approximate cost per head per day of each, boarders and
paupers alike. And when this quotient has been increased by

Digitized by

Google

1900.]

BY A. R. WHITEWAY.

451

the addition of the proportionate fraction of rent fairly attribu¬
table to each, as also by his proper share in the very underpaid
available labour, the result will be a truer estimate of the cost
per head per day, viz. fr. 1 27 c .,plus 20 c., plus 20 c., viz. fr. 1
67 c. in all ; or perhaps more accurately still, by entirely ne¬
glecting the value of the labour as well as the fictitious profit,
and considering the establishment as not much more than self-
supporting, and by assessing the all-round cost at something
more like fr. 1 40 c., without labour a head a day for each
indigent patient. In this way of regarding the case the profit
of 17 per cent, on the farm is a purely paper one ; but none the
less, given the institution as a going, concern for which no rent
but only low interest upon construction moneys is to be
reckoned, and the subvention paid in the case of indigents, and
“ pension ” in that of boarders, we have here an undertaking
that is clearly somewhat more than self-supporting, inasmuch
as it is able to keep going, and also by its own earnings and
labour to increase its proportions year by year, according as
occasion requires. The same can hardly be said of any other
public undertaking, handicapped as it is in the price at which
more than three quarters of its inmates have to be taken, the
half of which latter are but mere dead weight, through being
unable to aid by any work that they can do in the general
upkeep of the institution.

Movement of Population. —On January 1st, 1891, 885
lunatics resided at St. Luc, of which 766 were indigent, 392
men and 374 women, and 119 boarders. During the year
1 56 were admitted for the first time, 24 had been there before,
and 5 came by transference from other asylums, making 18 5
in all. Of these 71 were discharged improved and 25 re¬
covered, while 1 escaped and 10 were sent away for various
reasons—numbering 107 in all. Moreover 98 died, 49 men
and 49 women. On the 31st December in the same year the
numbers were respectively 398 indigent men and 309 women,
or together 757, besides 108 boarders. In all 1070 patients
passed through the establishment in the year 1898, 497 from
the Basses Pyr£n£es, 210 from the Hautes Pyr£n£es, 201 from
the Landes, and 7 from other places. The boarders—of whom
but three are English—belonging to the six classes (the sixth of
which fare as do the indigents) were 10, 10, 18, 23, 63, and
31 respectively. The proportion of 25 recoveries, 27 relieved,

Digitized by

Google

452

THE ASYLUM AT PAU

[July,

98 deaths, and 1 escape out of 1070 patients compares very
favourably with other asylums, such as Villejuif for example,
in whose floating population of 2600 there were 400 deaths,
and only 7 per cent, of recoveries, with 10 per cent, of relieved,
perhaps by reason of its less genial climate and surroundings,
and also no doubt owing to the fact that the patients there
are chiefly of Parisian, and not of healthy peasant extraction
as at St. Luc.

As Departmental Property. —The land and buildings,
which have cost the Department of the Basses Pyr£n6es
nothing more than the price of the old tnaison de force y are
now worth about fr. 2,500,000, and have a debt of only
fr. 300,000 upon them, that will be paid off in some twelve
years’ time by amortisation. By an expenditure of the
fr. 500,000 more that has been already sanctioned, though
only to be incurred bit by bit, according to precedent as
requisite money is earned, an asylum calculated to contain
1000 patients will then have been completed, and become the
unencumbered property of the Department, though this may
perhaps take ten years to accomplish entirely. Not only must
this ultimately be the case, but the Basses Pyr£n£es will be
able to get its insane perfectly cared for there at 8 \d. a head
instead of at fr. 1 20 c., which is the minimum cost that would
otherwise have to be met. No other asylum in France is
running so successful a course, and it is only in Loz&re that
boarders are taken more cheaply (fr. 1 10 c.), and at Avignon
that the departmental subsidy is slightly less. By being its
own landlord, allowing only 3 per cent, for rent, viz. fr. 73,350,
a saving of 20 c. a head a day is effected, whereas otherwise
the actual cost would be about fr. 1 40 c. This might be
increased further by 25 c. a head if the asylum were not its
own grazier and butcher in the matter of the 80,000 kilos, of
meat consumed each year, and further still by 20 c. a head a day
if indigent labour were not obtainable for the entire service of
the institution. Even then good milk would have to be got
at 20 c. a litre, and all provisions purchased in the best possible
market. As has been said before, this prosperous state of
affairs has been brought about by careful utilisation of the labour
of inmates, and by taking boarders, with the result that the total
income in 1898 was fr. 656,798 94 c., including fr. 101,847 34 c.
brought over from 1897, and the outgoings fr. 499,357 42 c.,

Digitized by VjOOQle

1900.]

BY A. R. WHITEWAY.

453

extraordinary expenses fr. 34,520 5 1 c., and supplementary ones
fr. 5 8,000 1 c., leaving a balance to be carried over to next year’s
account of fr. 117,000. Placing the balance brought over from
1897 on one side, the extraordinary expenses (being in fact
interest and sinking-fund instalment) added to the surplus
income to be carried over this year together amount to
fr. 50,000 or ^2000, which represents pretty fairly the true
profit of the asylum, taken as an unencumbered going concern,
with a fair average amount of patients and tied labour.

General Observations. —Practice as opposed to theory is
the underlying principle of management at St. Luc. Everywhere
a benevolent administration shows itself at work. The place is
more like a large family, where as many as may be day by day
go forth to their work and to their labour for the commonweal
until the evening. No mechanical restraint is used to econo¬
mise attendance, nor more opiates than are indispensable. If
there are rather more separate jingle rooms (which are match-
boarded and not padded) than would seem quite necessary, there
is yet a garden with which these communicate, and thus some
open-air exercise is possible even for those thus unfortunately
secluded. The southern peasant is so natural and abstemious
in his habits that the class of insanity mostly met with at St.
Luc’s is as a rule not difficult to treat, nor are the patients for
the most part unhealthy in body or difficult to cater for. The
food is excellent and both well cooked and served, but the
quantity would seem insufficient even for a Parisian, and still
more so for the carnivorous man of the North.

Although there is no wall surrrounding the property, nor any
efficient system of sentinel attendants, hardly any escapes take
place, or outrages or accidents of any kind. This shows the
individual attention daily given to the condition of each inmate.
The cubic space allowed in the dormitories is sufficient, and
their arrangement satisfactory, while the light and cheerful as¬
pect of the day-rooms may perhaps be mainly owing to the
situation. Even with a population of excitable southern French,
St. Luc gives the casual visitor more the idea of an English
country workhouse, from the great number of its old and feeble
inmates, than a hospital for mental cases properly so called.
There are but three children patients. When it is remembered
that there is little or no State supervision, and that the County
Council of the Department is mainly interested in getting their

Digitized by

Google

454

THE ASYLUM AT PAU,

[July,

lunatics looked after at the lowest possible rate, it is matter for
wonder that the development of so elaborate a concern has
progressed thus speedily, due regard being had to the limited
means at the command of its originators. With respect to the
administration of St. Luc, it remains only to apply the words
of Krohne, the prison director : “ If you have a good head, even
with inferior methods, all goes well; but with the best methods
and a bad head everything very soon gets out of joint.” The
only improvement there is to be desired is more attendants and
a slightly more liberal diet; and there, as in France generally,
the overlooking of a Minister or court of lunacy to relieve the
pr^fets of the care of the insane in their districts, as well as
legal authorisation for the frequent exeats given to patients for
the purpose of returning to their homes. In brief, it is too
easy to get out of lunatic asylums in France, for it is no one’s
especial business to keep doors barred at which so many are
ever knocking for admission. Moreover, as no one is personally
interested in compelling insane patients to come under restraint,
too many are at large, not only on leave, but never having been
officially treated as lunatics at all.

Without doubt what is done at St. Luc is done well and
humanely. The only question is whether this conforms exactly
with the true requirements of the increasing regional insanity,
with which, in the imperfect state of the French poor laws, it
is impossible adequately to cope. The boarding-out system
may be the most useful stop-gap. In any case it is a progres¬
sive and not a reactionary measure—an altruistic attempt to
bring the sheep that was lost home to the flock, so as not to
segregate him in a separate pound along with others afflicted
with similar unfortunate propensities for the term of his natural
life. For the rest, the insane of Pau may no longer cry as
before 1868, “ Who enters here leaves hope behind!”

Digitized by VjOOQle

Appendix I.

Copy of a Daily Statement showing the number of Mouths to Feed .
Asile Public d*Alien£s de Pau.—Tableau No. i.

Articles 20 et jp du Rkglement inttrieur. Bulletin de la population d nourrir le
cTapres la population constate la veille au soir.

1900.]

BY A. R. WHITEWAY.

455

Digitized by VjOOQle

Appendix II.

Copy of Dietaries for a particular day .
Regime alimentaire du -.

456

THE ASYLUM AT PAU.

[July,

- 3

4) V

— t/i

O £

in ~

l CO ”

£ £ 2
c *+•
(S o V

O °*3
^ C

u o

'JJ U

* «

a> v 4 > u
C^no

3 ^

~ «2
« S

« S o g

O0S cl©

c8 E-S

o «

. U
• 4>

V'D V
CffTJ
£3 »

*3 «" 6

a> aJ O

g-S “•
° E-S
m O „

g .*.■§

•- JS

*3 **“ 4>

« 3 D

10’S

0 -z;

w c2

c J ti

2 E fc
So a; J 2
2 “^-3
•<« I s s

4) u 3 c
a-U« .a* I

C /3

t/)

‘55
3 *t 3

Pfl u

■g So

53 8 3

IS - 1/5 1
<S c 3.!
0.0
aT 4,
bo— c
Pfl u u

“*-1 8
0 “

4i u 3

ffl

u c -
3 O

V) V)

(/) .

s' 2

o 05
8ed
c

z o

V) o

2 s

^ c

C u

o w

^ -S 02

a7 4> 3

s&8„

•P « " "

(3 .£ v> 9

"nJ *

rt.5 ? x

bo > «.3
^3u

o> «« cr n»
"o Ml -fl

c /3

-o

02 3 j 5

3 rt "o
8 nd «

VM O **

*t « -C S
“ M o-S

5 £
3! o
*Q

h 3 .

03 •*

52 cfl u

JX — 3 4)
0 3 & a

■3

'SJ

’ra

8 «.* g

«CO
U re »J

4 )

‘So

I 6

b© O

'a.

Digitized by

Google

1 The thick cabbage soup of Beara.

* /.#. the servants are fed as if belonging to the 4th class, but they have in addition eggs and beans, and cheese and potatoes on this occasion.

1900 .] REMODELLING OF AN OLD ASYLUM.

457

The Remodelling of an Old Asylumf ) By Ernest W.

White, M.B.Lond., M.R.C.P., Medical Superintendent,

City of London Asylum ; Professor of Psychological

Medicine, King’s College, London.

It not infrequently happens that the senior assistant medical
officer of a modem institution for the insane is elected medical
superintendent of an old asylum. Such was my lot when early
in 1887 I was chosen by the Court of Aldermen of the City of
London to fill the post of chief officer to their asylum at Stone,
and I entered upon my duties with no light heart, because it
was early apparent that many structural and administrative
changes would be necessary to bring this institution abreast the
times. The asylum is constructed on the gallery or corridor
plan, in linear form, extending from east to west, with projec¬
tions north and south at several points. This linear form is
modified by semi-detached laundry and workshop blocks, which
are connected by covered ways to the central administration
situated midway between these blocks, and at right angles to
the line of the wards, which it intersects as it runs north and
south. The style of architecture is Gothic, of white brick
with Suffolk quoins, stone mullions, and dressings to the gables ;
the roof is of Broseley tiles. There is a handsome tower of
white brick and stone with embattlements ; the central portion
of the tower is an iron smoke shaft, the part intervening
between this and the outer wall being a heated extraction shaft
for removing the foul air from the galleries and single rooms.
The buildings are of two stories, except to the south of the
central administrative block, where there is a third story for
the old chapel (now being converted into a recreation hall), and
for some of the staff bedrooms of either side. The estate com¬
prised in 1887 thirty-three acres.

What were the defects of this institution, and how have they
been remedied ? The chief structural defect was undoubtedly
the existence of a dividing wall extending the whole length of
the main building from east to west on both ground and first
floors, which so split up the space that the wards, which were
separated by glass screens, were small, with connecting galleries
and through traffic on both floors on the south side, and the

Digitized by

Google

458 REMODELLING OF AN OLD ASYLUM, [July,

dormitories small and stuffy, and on both floors on the north.
Where was the through ventilation which is so necessary?
The w.c.’s were all on the south side, and communicated
directly with the wards. They were deficient in number (only
one third the proper proportion), often offensive, especially when
the sun was upon them in the summer-time, and on the male
side there were a sufficient number of stall urinals adjoining
the w.c.’s for a railway terminus ! These were an ever-present
nuisance. With two exceptions there were no w.c.’s connected
with the dormitories for night use. The nurses* and attendants’
rooms were all on the north side, damp and cheerless, never
brightened by sunshine. There were no proper ward sculleries ;
the washing up was done in the lobbies of the w.c.*s, where
sinks had been fitted, and on the male side these adjoined the
urinals. There were no ward store-rooms. The stock was
kept in small wardrobes and in cupboards, suitable for brooms
and brushes only, under the stairs. As regards lavatories,
three or four single rooms had in a similar number of wards
been fitted up with basins, but apart from these the ablutions
were carried out in basins in the dormitories, or in the lobbies
attached to the w.c.’s, where basins had been fixed. Each ward
had a single bath-room, too small for any dressing accommoda¬
tion. The patients were therefore obliged to undress and dress
in the open wards, a very objectionable practice. There were
no general bath-rooms for the proper supervision of the
bathing and inspection of the patients for bruises or skin
eruptions. The walls of the wards, dormitories, single rooms,
and staircases throughout the asylum were unplastered, but had
been distempered a blue colour with a light drab brown painted
dado, a red line intervening. This rough surface harboured
dust and germs, and made the surroundings of the patients cold
and comfortless. I should add there were no slop sinks, no
boot and cloak rooms in any of the wards, and no proper
broom and bucket closets. The day-rooms were badly lighted,
on one side only—the south,—stuffy and ill-ventilated, with no
cross air current. They were, moreover, small and difficult to
manage, being on both floors, therefore requiring a large staff.
The same objections applied to the dormitories, only more so,
as they faced the north, never received any sunshine, and
always looked damp and comfortless. The single rooms were
nearly all on the north side of the galleries, which on both

Digitized by VjOOQle

1900 .] BY ERNEST W. WHITE, M.B. 459

floors were used for through traffic and as day space. All the
day-rooms were of a size, although they had to accommodate
very different classes of cases. There was an excellent system
of ventilation, but it was incomplete and partly defective. The
inlets were at the floor level of the galleries, the air being
warmed on admission by passing in air-ducts over hot-water
pipes, part of a circulating system, of which there were three in
all, one on the male and two on the female sides, with corre¬
sponding stoke-holes and saddle boilers. In the winter those
of the female side necessitated the frequent trucking of coals
and coke through the female grounds, an undesirable arrange¬
ment. The air, after admission into the galleries near the floor
level, passed from the south side across the corridors, over the
doors of the single rooms near the ceiling, and was extracted
from near the floor level on the north side of the single rooms,
and taken to the central shaft already described. The day-
rooms and dormitories had similar inlets on the south and
north sides, but no outlets for vitiated air. These had been
overlooked by the architect. In most of the day-rooms addi¬
tional artificial heat was obtained from hot-water coils in the
bays on the south side, which, being encased, harboured dust
and the d/bris of food pushed through by patients.

A word next regarding the sewerage system. The w.c.'s
were of the old Jennings type with side handles. The bottoms
of the pans were frequently broken by the slops being emptied
into them, and the water valve was often defective. The soil
pipes passed out on the south side and were not ventilated on
egress. The sewer pipes were not laid on concrete, and being
on gravel and sand, they kinked and leaked at almost every
joint. Their course was close to the buildings, along the entire
south front, therefore just under the windows of the day-rooms
and galleries on the ground-floor, then round the west end
to the north of the asylum, where they delivered into a large
tank of 120,000 gallons capacity, situated at a distance of only
two hundred feet from the administrative centre. There was a
short ventilating shaft to this about twenty-five feet high. The
sewage was there stored and underwent fermentation. It was
pumped from this tank back to the engine-room in the centre
of the asylum, and then driven to a higher level beyond the
cottage hospital, and delivered on a 9-acre field, distant
about 120 yards from the main buildings. The tank was
xlvi. 32

Digitized by VjOOQle

460 REMODELLING OF AN OLD ASYLUM, [July,

always a nuisance to the asylum residents, and the 9-acre field,
which had become sewage sodden by being irrigated by the
fermented sewage, was a constant nuisance to our neighbours.
The inner airing courts were like rough playgrounds, devoid of
flower-beds or paths, and in them the patients were congregated
in large numbers daily for exercise, but few being employed
outside, for there was no farm, and but 9 acres (the portion
which received the sewage) under cultivation as kitchen-garden,
the remaining 24 acres of the estate being covered by the
buildings, airing courts, cricket ground, and cemetery. The
small extent of the property was therefore a great drawback to
the proper treatment of the patients and working of the
institution. There were no greenhouses belonging to the
asylum, and flowers were not cultivated. The workshops for
the tailor, upholsterer, and shoemaker and their patients were
small and dark, with windows only on one side, and no super¬
vision from without. The special observation dormitory on the
female side was much too small, badly lighted, and badly
ventilated ; that of the male side was of recent construction
and free from objection. The floors of day-rooms, galleries,
dormitories, and single rooms were worn and warped, and
allowed percolation beneath when scrubbed from day to day.
They had become very insanitary from long use and the faulty
habits of patients. The buildings generally were very deficient
in alternative exits for use in the event of fire. The arrange¬
ment of the outside hydrants was satisfactory, but those inside
were stowed away in cupboards, round comers, and not readily
supervised, therefore the nozzle or hose would often be missing
when required. The water-supply of the asylum was from a
central well near the engine-room and boiler-house, which were
in the centre of the administrative block. The supply had
never failed, but in the event of fire involving the engine-room,
no water would have been available. The well is 120 feet
deep in chalk, with a central boring of 100 feet below this;
the quality of the water is excellent, but with 17 grains per
1000 hardness. A rain-water storage system had been
arranged originally for collecting the rain water in a 120,000-
gallon tank near the laundry, for use there and in the engine-
room, but many of the stack pipes were blocked and leaked,
and the collecting system of pipes had settled in the gravel and
sand, and the pipes were filled with sediment, kinked and leaky,

Digitized by VjOOQle

1900.]

BY ERNEST W. WHITE, M.B.

461

and even in some instances broken across, so that but a very
small portion of the rainfall on the buildings reached the tank ;
most of it percolated the ground near the stack pipes to the
detriment of the foundations. There were no mess-rooms and
no nurses* recreation room. The administrative department was
very defective. There were no central ground-floor stores ; the
attendants, nurses, and servants had to pass down a common
staircase to the basement stores at the centre, and these stores
were damp and unsuitable for dry goods. There was no vege¬
table room connected with the kitchen department, and we had
no housemaid’s pantry. The laundry was very old-fashioned,
all the work in it done by hand, and the hand machines were
very out of date. The drying power was glaringly deficient.
There were but four horses ! The foul washing was done in
an annexe to the general washhouse. There was no staff
laundry. The clothes of both divisions were received in the
general washhouse, and there was but one small general
delivery room. Moreover the male washing had to be brought
through the female division, and returned by the same route.
There was a central dining and recreation hall, but without a
permanent stage. In the winter months a temporary stage
was fitted in this hall for dramatic entertainments ; it was made
up of the dining-hall tables tied together, and stage fittings ; it
took us the best part of a week to erect, and when up filled a
third of the hall, therefore greatly curtailed our dining accom¬
modation for the time being. The sick came off very badly as
regards their surroundings. There were no hospital wards
proper. Small cheerless dormitories on the north side of the
terminal day-rooms on the ground-floor were allotted to the
sick. These dormitories held from six to eight beds, but the
cubic space was very insufficient, and on the male side there
were no padded or single rooms off the dormitory ; they were
at the north side of the gallery adjoining the day-room. In
both divisions the slops and stools had to be taken through the
day-rooms—which were also dining-rooms for the sick—to the
w.c.’s, a most objectionable arrangement. The mortuary was a
very old-fashioned building, and adjoined the laundry, which
was most undesirable. The asylum was lighted throughout by
gas supplied by the Dartford Gas Company; the gas was often
of inferior quality, and the light bad in the evening from
defective pressure.

Digitized by VjOOQle

462 REMODELLING OF AN OLD ASYLUM, [July,

Such, then, were the chief structural and other defects of this
institution. It is now my pleasing duty to record how, by means
of the support of the Visiting Committee and the energetic
action of that Committee during the past thirteen years, the
following remedies have been effected.

(1) The land question .—In December, 1887, we purchased
by private treaty, at £74 an acre, the adjoining Stone Lodge
Farm of 107 acres, which, added to the 33 acres of the original
estate, made 140 in all; but we did not get possession of this
land until April, 1890. Last year two additional acres were
bought to round off the west end of the farm. We therefore
have 142 acres of freehold land in all. At the present time
no land in the parish of Stone can be purchased under £200
an acre. The advantages of the acquired land are as follows :
—eighty-six acres adjoin the original estate to the north and
east, and have a gradual fall of 96 feet towards the Thames.
This portion was admirably adapted for surface sewage irriga¬
tion on the intermittent system by the natural force of gravity.
In ‘the marshes to the north are 21 acres of pasturage for cows,
and excellent watercress beds which have been long established.
The value of this farm for the employment of patients as a
remedial agency cannot be over-estimated.

(2) The alterations of structure .—These were commenced in
1887, and are now approaching completion. The wall already
mentioned, which extended the whole length of the main
buildings from east to west, and separated day-rooms from
dormitories on both floors, has in every case been removed, the
dormitories on the ground-floor have been added to the day-
rooms, and upstairs the day-rooms have been added to the
dormitories. We now have through ventilation of both wards
and dormitories. By night the windows of the former can be
kept wide open, and by day those of the latter. The super¬
vision of the patients is also considerably improved by this
arrangement. Properly necked cross-ventilated sanitary spurs
have been built to all the wards and dormitories thus formed
on the north side. These spurs are of white glazed brick with
terrasco floors, and have on the ground-floor 4 pedestal w.c.’s
(1 to 12 patients) with Doulton’s Simplicitas pans and special
pulls, also each spur has a slop sink. On the top floor are
slop sink, w.c., and a clothes-room for the patients’ clothes at
night. The old w.c.’s on the south side have been converted

Digitized by VjOOQle

1900.]

BY ERNEST W. WHITE, M.B.

463

into nurses' and attendants' rooms all along the line. The
single bath-rooms in most of the wards have also been fitted as
nurses' and attendants' rooms, of which we were very short.
Proper sculleries have been made near the north or dining end
of those wards in which patients dine, and suitable lavatories
have been fitted to all the wards and the dormitories needing
them. In some wards single rooms have been converted into
store-rooms. Connected to others new store-rooms have been
built. Boot-rooms and broom and brush cupboards have been
made where necessary. All inside urinals were abolished in
1893, since which time the pedestal closets have supplied their
place. General bath-rooms, central for either division, have
been erected in white glazed brick, with pale green crystopal
dados and terrasco floors. There are six baths, a shower and
needle bath, and a large dressing-room on the female side, and
seven baths on the male side, with shower and needle bath and
dressing-rooms also. The baths are of porcelain of the best
Stourbridge pattern (Rufford's), and fill and empty in twenty-five
seconds. The wards, dormitories, and single rooms are being
plastered, and the floors renovated throughout. Light has been
introduced in every direction. All doors have glass panels
excepting where contra-indicated ! Those of the nurses' and
attendants' rooms have also spring blinds inside. This change
was largely effected in 1888 ; much light was thereby borrowed,
and better supervision ensured. We have since realised that
the more glass you have in an asylum the less you have broken !
The system of ventilation has been improved by extracting the
impure air from the single rooms near the ceiling line, by with¬
drawing it also from the wards and dormitories near the ceiling
line to the central extraction shaft, and by the introduction of
Boyle's mica flap ventilators into all the chimney breasts which
are not used for fires. We are also constructing in both
divisions ventilating filches with electric motor fans for
removing the impure air by ducts from the dormitories of the
main building, where the present arrangements are insufficient.
The workshops have been enlarged by throwing a wide passage
into them, and their lighting improved by the introduction of
intervening glazed screens. The female special observation
dormitory now allows of 56 patients, split up into three
divisions, being under complete observation by one stationary
night nurse. Four additional alternative exits for use in the

Digitized by

Google

464

REMODELLING OF AN OLD ASYLUM [July,

event of fire have been added to the upper story on the female
side, and three on the male. Those of the laundry and work¬
shop blocks are stone staircases. All inside hydrants are now
unencased and kept coupled up. An alternative water-supply
from the West Kent Waterworks to the main tanks has been
added for use when needed. Mess-rooms on both sides, with
sculleries attached, have been erected, and on the female side a
suitable nurses’ recreation room. Central ground-floor stores
with hatchways opening on to the m&le and female general
corridors have been formed over the old .engine-room, and a
dairy, vegetable room, and housemaids’ pantry added to the
kitchen department.

Three new laundries (general, officers’, and foul) have been
constructed, and the old laundry has been rearranged ; the
finishing room becomes the sewing and mending room, the
old sewing-room the laundry day-room, and the dormitories
above remain but little changed.

A housekeeper’s cutting-out room and laundrymaids’ mess-
room, with staff* bedrooms overhead and cross-ventilated sanitary
spur, are added to the old buildings, and the washhouse is
absorbed in the new central power station. The three new
laundries are of white glazed bricks, with salt glazed dados,
and are very complete, with separate receiving and delivery
rooms (male and female), washhouses, drying and finishing
rooms, etc. Electric motor fans ventilate the various sections.
Corridors connect the laundries to each other and to the day-
room, sowing, and mending room. The laundry machinery is
supplied by Manlove, Alliott and Co., Tullis, and Bradford’s,
and fitted by the last-named firm. It is worked by electric
motors from the subways, therefore free from noise, nuisance
of oil, and danger of shafting and belting. It will also be
more economical to work, because it can be used in sections.
The laundries will appear unnecessarily large to public asylum
officials, but one third of our patients are of the private class,
which will explain the apparent redundancy of this depart¬
ment. The new general power station, which I have said
above adjoins the laundry, consists of a boiler-house, engine-
room, accumulator-room, water-softening house, coal-store, etc.
These are largely of white glazed bricks. The three boilers
are 30 ft. x 7 ft. 6 in., of the Galloway type, with forced
draught added. The flue is connected with the old central

Digitized by VjOOQle

1900.] BY ERNEST W. WHITE, M.B. 465

smoke shaft in order to preserve the original ventilating system,
which has stood the test of time.

The Atkins modification of the Porter Clark process is the
one adopted for water softening. All the stoke-holes of the
several heating centres of the buildings and greenhouses are
done away with, and the heat supplied as live steam in the
form of calorifiers from the central power station. These heat
the several hot-water systems in the air ducts. From this
station also cables go to the electric motors, which work the
well pumps and the machinery of the bakehouse and work¬
shops at a distance of more than 100 yards. The station also
supplies the electric motor power for the laundries and the
various ventilating fans throughout the asylum. It moreover
furnishes the hot-water supply of the institution, and will give
the electric light, the fittings for which are almost completed.

The old engine-room and boiler-house will be converted into
a central Turkish bath.

A new mortuary has been erected to the north of the
laundries, to replace the old one pulled down during these
extensions. Its interior is of white glazed bricks throughout.
It has male and female divisions, a well-lighted post-mortem
room, with white porcelain revolving table and pathological
laboratory.

The new detached chapel is built of faced flint and Portland
stone, with tiled roof, and is on the north side of the adminis¬
trative centre and to the east of the new laundries. It is a
Gothic building of the early Decorated period, and accommodates
about 350 persons. It consists of nave, chancel, and transept
for the organ and vestry. The floor of the nave is of wood
blocks, that of the chancel of tiles. The roof is of English
oak on the hammer-beam principle, and the seating of oak
also. The windows are of stained glass. Those east and
west were the gift of members of the Corporation. The old
chapel over the dining hall is being converted into a recreation
hall, and a stage and dressing-rooms are being added to it on
the north side over the kitchen.

Male and female hospitals have been erected. The female is
new throughout, and attached by corridor to the west end of
the female division. It consists of a central day-room and
galleries facing the south, with nine single rooms (two padded),
six nurses’ rooms, lavatories, and sanitary spurs to the north of

Digitized by VjOOQle

466 REMODELLING OF AN OLD ASYLUM, [July,

the galleries, and other administrative offices beyond. At
right angles to the galleries at the east and west ends hospital
wards extend to the south, with a good view and cross¬
ventilation. This hospital accommodates fifty patients.

That of the male side is at the east end of the main building,
and very similar to the female, except that only one half is
new, the other half being the old male infirmary gutted and re¬
arranged ; part of it is therefore on the first floor. It will also
accommodate fifty patients. A view of the Thames has been
obtained for those in the sick ward, by removing the boundary
wall opposite the hospital and replacing it by railings. We
have also an infectious hospital beyond the cricket ground for
twelve patients, six of either sex.

(3) The sewerage system ,—In 1890 it was decided to adopt
a new method of sewage disposal, by abolishing all storage and
pumping, and by distributing the sewage fresh, before fermenta¬
tion had set in. A twelve-inch main, 370 yards in length, was
laid from opposite the administrative centre where the sewage
entered the old tank, to a natural gulley on the new farm land
to the north-east, in a perfectly straight line with a fall of one
foot in ninety-six. It passes under Cotton Lane at a depth of
1 o feet from the surface, and at one spot is 14 feet 6 inches
from the ground level. There are four manholes for inspection
and flushing, and you can see daylight through its entire length.
There is no storage ; the sewage is delivered fresh on the hill¬
side, where some 2 5,000 gallons daily can be directed over
from thirty to forty acres of land by gravity. The heavier
solids are removed every day at the outfall, where there are
gratings in a shallow tray-like arrangement for separating them.
They are mixed with sifted dry earth and cinders and used as
manure. A system of open earthenware channel pipes and
moveable galvanised gutter piping, which taps the liquid sewage
at various points, ensures its distribution over a different portion
of land daily. There is no effluent; the subsoil is gravel, sand,
and chalk, and therefore highly porous. All the soil pipes from
the building to the main have been ventilated with full diameter
pipes on egress on the north side. They were relaid on concrete
in straight lines, and have junctions only at manholes.

The old sewage tank of 120,000 gallons capacity has been
cleaned out, and is now used as a second rain-water tank for
the engine-room and boiler-house. The rain-water system has

Digitized by VjOOQle

1900.]

BY ERNEST W. WHITE, M.B.

467

been relaid throughout on concrete, and now collects to two
tanks of equal size, the original one supplying the laundry.
Friction between the two departments regarding rain water
will therefore case.

As regards the grounds, the inner airing courts have been
properly laid out as gardens, and the outer courts planted and
developed. Glass houses have also been erected for the pro¬
pagation and storage of hothouse plants for the wards.

The plans for the new buildings and the remodelling of the
old were made by the City Surveyor from my suggestions.
The total cost will be about £80,000. The original asylum
cost about an equal sum.

The chief advantages claimed for our remodelled asylum
are—

(1) The wards are all on the ground-floor, face the south
with one exception, and have through ventilation. As they
are only separated by glass screens in the main building there
is thorough supervision, and they are easily worked.

(2) The upper story consists of dormitories only, and
through ventilation can be ensured all day. It is possible, also,
by master-locking off the upper story on the male side, for the
beds of that division to be made by female patients, who can
cross over to it by a gallery through the dining hall.

(3) All w.c.'s and soil pipes have been removed from the
south to the north side only, and the w.c.'s are in necked
and cross-ventilated spurs. All inside urinals have been
abolished.

(4) Most of the nurses' and attendants' rooms are now on
the south side.

(5) The necessary offices have been added to the wards and
dormitories.

(6) We have hospitals for the sick and infirm, general bath¬
rooms, new laundries, a separate recreation hall, with stage,
etc., a detached chapel, and a new mortuary, all equal to our
requirements.

(7) By the centralisation scheme all stoke-holes are abolished,
and heat, motor power, light, and the hot and cold water
supplies are derived from one general power station.

(8) We have an alternative water-supply from the West
Kent Waterworks for emergencies, such as a fire involving the
pumping station, well contamination, etc.

Digitized by VjOOQle

468 REMODELLING OF AN OLD ASYLUM. [July,

(9) The sewage disposal is devoid of all storage (we have
not three inches anywhere), therefore fermentation cannot occur,
and the farm benefits by the irrigation.

There is one matter I should like to allude to before con¬
cluding ; I am strongly in favour of a central dining hall when
the wards are handy to it. We find the sexes like to be
associated at all meals, and for quite ten years past we have
given them music during dinner. It aids digestion, and going
to the hall is a pleasant break in the day’s monotony. The
windows of the wards can moreover be then thrown open, and
proper ventilation ensured.

With full knowledge and experience it is comparatively
easy to plan a new asylum. To remodel an old one, and have
a full and paying house all the time, is a more difficult task.
If we have succeeded our reward will be in the Approbation of
those best qualified to judge, and in the improved surroundings
of those committed to our charge.

(*) Read at the South-Eastern Division of the Medico-Psychological Association
at Dartford, 25th April, 1900.

Discussion

At the Spring Meeting of the South-Eastern Division, April 25th, 1900.

Dr. Percy Smith, who had taken the Chair owing to the departure of Dr.
Beach, expressed the thanks of the meeting to Dr. White for his able paper.

Dr. Thomson said he understood from personal experience the many difficulties
a medical superintendent had to encounter when, after having been trained in a
new asylum, he was elected to an old one. He considered Dr. White was entitled
to great credit for what he had accomplished.

Dr. Bower and Dr. Richards drew attention to several matters which specially
deserved favourable comment, and they very heartily congratulated Dr. White on
the results of his labours.

Dr. White, in reply, thanked members for their criticisms. With regard to the
Kent Water Company, he explained that an agreement was made to connect their
supply at a cost of £37 10s., and the Asylum then paid £$ per quarter as a
minimum rate for a supply not exceeding 120,000 gallons. Above this supply
10 d. per 1000 gallons was charged.

Digitized by tjOOQle

1900.]

CONTINUITY OF WORK.

469

Continuity of Work under Altered Conditions . By the

Rev. H. Hawkins, late Chaplain Colney Hatch Asylum.

The time at last comes when, sooner or later, the old work
has to be given up—work of various kinds in different cases.
But the special sphere of occupation referred to is that in which
the Journal of Mental Science is chiefly interested.

One cause or other, failure of health, age limit, fresh employ¬
ment, or other occasion, brings to an end the active work
carried on, perhaps, during many past years. The change of
habits and routine, which have become a second nature, is in
view, and has to be faced.

The purpose of this brief paper is to suggest the question
whether, on retirement from the long-continued work of asylum
life, in one or other of its departments, a cessation of interest
in the employment of former years is preferable, or whether,
under altered circumstances, a continuity of the work which has
been the responsibility and happiness of a lengthened period in
the past is desirable and practicable. In one aspect the con¬
tinuity of professional, as of private life, is not altogether
optional.

Whether voluntarily or not, memories are revived, the scenes
of former labours, e.g . infirmaries, wards, etc., present them¬
selves to the “ mind’s eye.” Old familiar forms and faces,
many of valued friends, are vividly recollected, and at times
memorable events in the past official years are recalled.
Though the old vocation has been laid aside, its remembrance
cannot be, nor should be, altogether effaced. In any new
phase of life there should not be a hiatus as regards the em¬
ployments of past years.

New occupations to a certain extent take the place of old,
according to individual tastes and opportunities, but there should
not be, even if it were practicable, entire severance from the
work of past professional life.

The case comes to recollection of a distinguished surgeon, a
President of the College, who passed his latter years in the
country improving his property, regularly visiting London from
time to time to fulfil some special medical engagement. It
seems almost unnatural, on the termination of the active duties,

Digitized by

Google

470

CONTINUITY OF WORK.

[July,

e.g. y of asylum life, even to wish abruptly to cut off communica¬
tion with the past, to turn one’s back upon the scene of past
labours and varied associations without any desire henceforward
to take some part under new conditions in former occupations,
and still to maintain kindly associations with days that are no
more.

Of course any sympathetic interest shown in the work taken
up by a successor, any slight service rendered in furtherance of
objects which formerly engaged one’s attention and energies
year in and year out, would become on retirement the service
and interest of an extern, an outsider, standing aloof but not
unconcerned.

Reviewing past errors, deficiencies, neglects, etc., an outgoing
official would discover ample cause for suppression of self-com¬
placency, and maybe for frank recognition of greater efficiency
in his successor’s administration.

But the main purpose of these lines is to consider whether,
and in what directions, there may be continuity of the kind of
work referred to under altered conditions. And here the
question presents itself whether, in the case of those officials
whose retirement is accompanied with a pension, the honorarium
would not to many be more pleasant and welcome if it were
viewed not merely as a recognition of past service, but also as
a motive and stimulus for continued interest in former work,
and as an acknowledgment of the graciousness of rendering
some quid pro quo on the part of the recipient. Moreover an
honourable feeling would be cherished in the pensioner of still
being, in a degree, an active, and not a mere sleeping partner
of the corporation.

A few suggestions may be allowable as to some ways in
which useful interest may be shown in work no longer actively
engaged in. Real pleasure would often be given to an intelli¬
gent patient by the receipt from some former member of the
staff with whom, perhaps, the inmate has been in daily com¬
munication, of some slight but valued memorial—letter, news¬
paper, book, memento of a birthday or season of the year. A
sympathetic visitant of an asylum ward often becomes a patient’s
friend, a relationship which should be sustained after separa¬
tion ; and some kindly token, indicating “not forgotten,” would
pleasantly respond to the question which may have arisen,
“ Does my old friend remember me ? ”

Digitized by VjOOQle

1900.]

BY THE REV. H. HAWKINS.

471

Looking along his bookshelves volumes may catch the eye,
books which are never taken down for the owner’s perusal, and
which might be profitably forwarded for the instruction or
recreation of the inmates of asylum wards. By such contribu¬
tions continuity of interest and of service might in a very useful
way be maintained. And some books not considered likely to
be appreciated might find interested readers.

A late distinguished alienist was once referred to as the
historian of his speciality. The learned leisure of retired
members of his profession might, perhaps, oftener (it is respect¬
fully suggested) find congenial occupation in contributing to
the cure or relief of mental maladies by means of treatises upon
the writer’s speciality, and of communications to professional
journals—the valuable result of wide and ripe experience.
Such literary employment would be for a certain class of former
asylum workers congenial continuity of service.

Again, associations on behalf of the infirm in mind, and of
those who minister to them (“after-care,” “asylum workers,”
etc.) would become better known, and rendered more efficient
by the attendance on their committees, and by the counsels
of former asylum officials, who, prevented from being present at
meetings even kindred to their official work during the labori¬
ous years of acting and exacting professional life, might yet
have both leisure and inclination to do so in a subsequent
period of comparative leisure.

Not unremembered by the friend who once was in daily
communication with them, are many patients who miss his or
her familiar presence or kindly greeting on departure ; might
not sympathy with mental patients be extended by endeavours
to induce (it has been done successfully) kindly disposed persons,
here or there, to befriend, by visits or through the post, lonely
inmates of asylums ? Not only would the lives of these be
brightened and cheered, but also the desire to relieve one of
the saddest of maladies might be communicated to others. This
is certain, that kindly intercourse (of course, under due regula¬
tions) between selected patients and friends outside the walls
would result in mutual advantage.

Another example of “ continuity ” may be instanced. Both
the harmonious management of asylums and the well-being of
their patients largely depend upon the character and efficiency
of the main body of the working staff—the attendants and

Digitized by VjOOQle

472

CONTINUITY OF WORK,

[July,

nurses. Few persons would be better judges of the suitable¬
ness of young men and women in quest of such employment
on the staff of an asylum than former officials in the service.

Occasions might arise when an applicant with aptitude for
the special work might advantageously be introduced to the
management, and thus a double service, both to the staff and to
the candidate, rendered.

“ Continuity ” of work from a religious point of view would
be valued by many. Not a few of the afflicted in mind in
asylums—there to remain, perhaps, during life’s residue—have
become familiar friends to former members of the community

Some of these, on retirement, would wish to preserve remem¬
brance, before God, of those to whom they had become attache^
The words of a graceful living writer are suggestive : “ You go
over the dear names, sweet beads of the heart’s rosary, telling _
one by one to God, with their several wants and needs.” No
doubt there may be more especial reference to a closer relation¬
ship than exists between an official and a patient. Yet there
are those who appreciate, in its degree, the relationship.

The foregoing suggestions may perhaps serve feebly to illus¬
trate the design of this paper to plead for continuity of service,
with particular reference to one branch, under varied conditions
and altered circumstances.

It would be appreciated as partial compensation for the in¬
evitable discontinuance of the daily routine which afforded in
bygone years active employment for mind and body.

Moreover, continuation in some shape of former work would
diminish the feeling of professional isolation . In retirement there
would be agreeable consciousness of still being “ in touch ” with
the work and workers of other days. And though more recent
interests and occupations would take their place in the fore¬
ground, yet, by the continuity referred to, the completeness of a
career would be better maintained.

No doubt the prospect of severance from former companion¬
ships and associations is to some natures exceedingly painful.
After very many years of service an honoured medical superin¬
tendent described his withdrawal from office as a “screw-wrench.”

Might it not be the wiser course, in many cases, on retire¬
ment from official life not to acquiesce in entire estrangement
between past and present, but, in entering upon a fresh phase
of existence, which well employed brings its own special bene-

Digitized by VjOOQle

1900.] ANALYSIS OF ONE THOUSAND ADMISSIONS.

473

fits in their season, to endeavour to be still of some slight use
on the field of former labour by “ continuity of service under
altered conditions ” ?

An Analysis of One Thousand Admissions into the City
of London Asylum.Q ) By Arthur E. Patterson,

M.D., Senior Assistant Medical Officer, City of London
Asylum, Dartford.

It is obvious that it would be quite impossible within the
short limit of time at our disposal to enter into a full and com¬
plete account of all the data collected with reference to these
admissions, which commenced on January 1st, 1892, and ter¬
minated on December 31st, 1899 ; I will therefore confine my
remarks to the more important features presented by them.

The very great majority of rate-paid patients admitted here
have previously been found wandering in the City of London,
having come not only from various parts of England, but from
all quarters of the globe ; and they therefore show the most
diverse and interesting forms of mental disease, whilst almost
every nationality is met with amongst them.

We first commenced to take private patients on January 1st,
1892, and the first patient of this class—a lady who is still
with us—was admitted the very next day. The reception of
private patients has been attended with marked success, and
there can be no doubt that the accommodation for them is
highly appreciated, as is proved by the fact that we often have
to refuse cases simply from want of room ; this taking of the
private class also tends very much to elevate the general tone
of the asylum, and not only acts beneficially on the rate-paid,
but instils greater interest in those responsible for their care.
Whilst on this subject it may be of interest to state that during
the eight years under notice 120 males and 158 females were
admitted as private patients, 33 males and 7 females being
subsequently transferred from the rate-paid to the private class,
making a total of 153 males and 165 females, or 318 of both
sexes under treatment as private.

Digitized by

Google

474

ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

Of the 1000 cases under consideration 620 belonged to the
male and 380 to the female sex, and of these 44 males and
26 females were re-admissions, of whom 34 males and 18
females had previously been discharged as recovered from this
asylum in the following years: males—1 in 1881, I in 1884,
1 in 1886, 3 in 1888, 3 in 1889, 2 in 1890, 4 in 1891, 1 in
1892, 4 in 1893, 1 in 1894, 3 in 1895, 4 in 1896, 5 in 1897,
1 in 1898.

Of the females 1 had recovered here previously in 1883, 1
in 1886, 2 in 1887, 1 in 1890, 2 in 1891, 4 in 1893, 1 * n
1894, 2 in 1896, 3 in 1897, and 1 in 1898.

Two males and one female had previously been admitted on
three occasions, whilst two females had also had two previous
attacks. These relapses occurred most frequently in those
having a history of heredity and drink in addition to the
former attack, and this applied equally to both sexes.

The forms of mental disorder have been classified as simply
as possible to prevent needless confusion, and for this reason
such a class as delusional insanity has not been put under a
distinct and separate head, but those cases which might have
been so classed have been placed under the division of mania
or melancholia according as the predominant symptoms were
those of excitement or depression.

The forms of mental disorder are as follows :

Amentia , by which is meant idiocy or imbecility, whether
complicated by epilepsy or not. There were comparatively
few of this class admitted, and all of these have been imbeciles,
8 of whom were males and 14 females, total 22. Two of each
sex suffered from epilepsy, which was therefore associated with
about one fifth of the total cases of amentia.

The aments of the City of London are sent to Leavesden
Asylum, and do not come here.

Mania , which has been subdivided, as has the class of melan¬
cholia, according to the duration of the attack on admission ;
thus all cases which have lasted for three months or less before
coming here have been considered acute ; if the mental dis¬
order has lasted more than three but less than twelve months,
subacute ; and if more than twelve months chronic.

Of the total admissions 291 males, or 46 per cent., and
181 females, or 47 per cent., came under the class of mania,
and these are subdivided as follows :

Digitized by VjOOQle

1900.]

BY ARTHUR E. PATTERSON, M.D.

475

Males.

Females.

Acute

198

Subacute .

Chronic

Mania a potu

Senile mania

291

181

Amongst the males rather more than twice as many suffered
from acute mania (under three months’ duration on admission)
as from all the other forms put together, whilst of the females
the acute class was small, and the chronic proportionately
larger. Although only fourteen males and four females were
included under Mania a potu y or transient attacks due to
drink, these figures represent but a small proportion of those
admissions in which drink was a very potent factor in the
production of the mental disturbance, as will be shown later on,
when the common causes of insanity are reviewed.

Melancholia. —Of the total admissions 185, or* nearly 30
per cent, of the males, and 147, or nearly 39 per cent, of
the females were melancholics, and these were again subdivided
as follows :

Males.

Females.

Acute

• 134

Subacute .

1 7

Chronic

Senile

185

147

Amongst the males nearly three times as many cases of
acute melancholia were admitted as all the other forms put
together, whilst amongst the females only 7 more were in the
acute class than in the others, whilst the chronic section was
again a large one.

Mental stupor was the form of insanity in 3 males and 2
females.

Epileptic insanity , of which there is little to be said beyond
that 32 males and 13 females, total 45, or about 4 per cent,
of the entire number of admissions, came in under this head.
xlvi. 33

Digitized by VjOOQle

476 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

Dementia. —In this class 24 were of the male, and 8 of
the female sex, giving a total of 32, or 3 per cent, of all
admissions. In 4 males and 2 females the dementia was
associated with epilepsy, whilst old age was the cause in 7
men and 2 women. There was no instance of primary de¬
mentia.

The above groups have presented little or nothing of special
note, and no useful purpose would be fulfilled by their further
analysis, but the divisions now to be considered are more
important, and present features which are interesting, and
worthy of more detailed attention.

Puerperal insanity .—Only 7 women, or roughly speaking
1 *5 per cent, of the total female admissions, have come in
suffering from insanity the result of the puerperal state. The
reason for this small proportion is not far to seek when one
remembers that very few women at the child-bearing period of
life are resident in the City of London, and it is therefore
not surprising to find that of the cases met with no less than
4 belonged to the private class, and were brought here from
a distance.

All these patients were women under the age of thirty, the
youngest being a mere child of sixteen years, whilst the two
eldest were aged twenty-nine. In 5 of the 7 the woman
was a primipara, and in every instance the attack of insanity
was the first from which she had suffered.

Result of treatment. —Three, or 42 per cent., have recovered,
two were discharged relieved, one to the care of her husband,
and the other on transfer to another asylum : the latter has
since died. The remaining two are still here.

As regards the length of residence in those recovered, one
was with us for two months, another for four, and the third
for one year.

General paralysis of the insane. —Of the 620 male admissions
76, or 12 per cent, have been general paralytics, and of the
380 females 8, or nearly 3 per cent The proportion of males
to females was as 6 to 1.

Amongst the males 43 were married, 30 single, 1 was a
widower, and in 2 the condition as to marriage was unknown.
Of the women 4 were married, 3 widowed, and 1 single. It
will thus be seen that the disease was met with more frequently
in the married than the single, which is generally accepted.

Digitized by

Google

1900.]

BY ARTHUR E. PATTERSON, M.D.

477

Only 2 males were under thirty years of age, 34 were
between thirty and forty, and 30 between forty and fifty,
whilst 10 were aged between fifty and sixty. These figures
show that no less than 64 out of the total 76 were between
the ages of thirty and fifty.

All the females with one exception were between thirty and
forty.

Taking the males first, in 13 no cause could be ascertained.
Of the known causes syphilis heads the list, there being a
distinct history of this disease in 18 cases, or 28 per cent.,
whilst drink is the next most frequent cause, the two being
associated in 8 instances, whilst drink alone occurred in 9.

Mental anxiety and worry was responsible for 15 cases, and
the remaining causes in the order of their frequency were 8
from blows on the head, 4 from hereditary predisposition, and
3 from sexual excess. In one case influenza alone was given
as a cause, whilst in two others it was associated with plumbism
and with syphilis respectively.

Amongst the females drink appeared as a cause four times,
in one of which it was associated with syphilis, and in another
with influenza. Mental anxiety and heredity were each given
in one instance, and in the remaining two cases no cause could
be elicited

Previous attacks of mental disorder were noted in 6 male
general paralytics.

There can be no doubt that a very large number of general
paralytics have syphilis to thank for the cause of their illness,
and personally I am confident that if we could get at the
true history of the obscure cases which come under our care
this disease would be much more frequently found than it is
at present; but for obvious reasons it is often quite impossible
to get reliable information on the subject.

With reference to those cases of general paralysis attributed
to blows on the head, the usual history given is that the injury
was sustained some years before—often many years before—
the onset of the symptoms, and may therefore fairly be classed
as a predisposing cause.

Of the 76 male paralytics no less than 67 presented sym¬
ptoms of mania, 5 only were melancholic, and 4 were dements.
Of the 8 females 2 were melancholic, and the remainder
maniacal.

Digitized by VjOOQle

478 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

Fifty-three males and two females have died of this class.

The average duration in the males has been slightly over
two years in the asylum, in the females very much longer.

In the whole history of the institution only one patient was
found to be not insane on admission.

Bodily health on admission .—The very large proportion of
573, or 57 per cent., were in an unsatisfactory physical condition
when they came in, thus proving that over half of those suffer¬
ing from mental disease are below par as regards bodily
health.

Out of the thousand admissions, extending over a period of
eight years, only 6 males and i female have died of tuber¬
cular disease, and a study of these deaths is very instructive, for
it shows that of the males 2 had cavities and 2 marked
consolidation of the lungs on admission, whilst in the remain¬
ing 2 alone were the lungs normal. The i female had
slight affection of the right apex when admitted, and died of a
severe attack of haemoptysis—a very rare event here. When it
is noted that 118 males and 37 females have died from all
causes, of whom only 2 males succumbed to phthisis developed
after admission, there can be no doubt that the proportion of
deaths from this disease is by no means large.

It may perhaps be argued that a certain number of deaths
amongst these admissions have occurred in which active tuber¬
cular mischief was present though the certified cause may have
been some other disease ; but this is not the case, for it has
long been noticed that tubercle in this asylum is conspicuous
by its absence as a cause of death, and is found in a much
smaller proportion of cases than obtains in many other similar
institutions.

Many patients are admitted here with undoubted symptoms
of pulmonary tuberculosis in whom the physical signs clear up
during residence. That confirmed phthisis runs a long course
with us is evidenced by two females, who were admitted in
1891 and 1894 respectively with marked pulmonary mischief,
in both of whom little progress has been made by the disease.

The reasons for the comparative absence of tubercle here is
to be found in the healthy site, the system of ventilation, and
the free lighting of the wards (all of which face the south) by
the introduction of glass wherever possible, thus permitting

Digitized by

Google

1900.]

BY ARTHUR E. PATTERSON, M.D.

479

ready access to the sun, the most formidable antagonist with
which the tubercle bacillus has to deal. It has been suggested
that the desiccating influence of cement works in the neigh¬
bourhood may have a beneficial effect on pulmonary disease,
and this material can certainly often be recognised in the
atmosphere.

It may be added that the milk has been scalded on reception
from the farm for the past seven years.

Continuing to review the bodily health on admission, the
condition of the heart now calls for attention.

Cardiac disease in one or more of its many forms has been
frequently met with in those admitted into this asylum, as the
following data will show.

Of the 620 males, 52, or 8 per cent., had heart affection, and
of these 32 suffered from the valvular form ; whilst of the 380
females, 75, or 19 per cent., were similarly affected, of whom
54 showed valvular mischief, making a total in both sexes of
1 27, or nearly 13 per cent, of all admissions.

Mitral disease was most often associated with symptoms of
mania in males and melancholia in females, whilst aortic
disease was noted in these two forms of mental disorder about
equally in the two sexes.

In only 6 general paralytics—all males—was there heart
disease, and these were valvular, 3 being mitral and 3 aortic.

In but 1 out of 45 epileptics of both sexes was there any
sign of cardiac disorder. The sole point which is noteworthy
in the foregoing remarks is that heart disease has occurred
rather more than twice as frequently in women as in men, and
I am strongly of opinion that not only cardiac but general
vascular degeneration is commonly developed amongst female
patients during their residence in asylums as a result of the
sedentary lives which they lead.

The causes of insanity in those admitted, in order of fre¬
quency, have been previous attacks, intemperance in drink,
hereditary predisposition, mental anxiety and worry, adverse
circumstances, influenza, and the climacteric in women.

Drink was twice as frequently associated with symptoms of
mania as with those of melancholia. One fourth of the total
number of general paralytics had a history of intemperance,
but in these it was probably far oftener a symptom than a
cause, and was frequently associated with syphilis.

Digitized by

Google

480 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

Hereditary predisposition was encountered as a cause in 114
males and 97 females, total 211, or 21 per cent., and was pro¬
portionally far oftener met with in women than in men, and
the great majority of these females were melancholic.

The degree of heredity was as follows :

Males.

Females.

Direct .

• 5 i

Collateral

• 55

Remote

114 97

Mental anxiety and worry gave rise to insanity in 28 males
and 21 females, and 11 of the former were general paralytics.

Adverse circumstances were responsible for the admission of
16 males and 9 females, and in these mania was twice as fre¬
quently met with as melancholia.

Nineteen females have suffered from insanity associated with
the change of life y and the average age at which the symptoms
appeared was forty-seven years. Of these 12 were melancholic
and 7 maniacal, and only 2 have recovered. This small pro¬
portion of recoveries goes to prove that this particular form of
insanity is not a very hopeful one.

The last cause of mental disorder to which I would ask your
attention is the very important and interesting one of influenza ,
and perhaps I may be allowed to consider it in more minute
detail than those which have already been mentioned.

Influenza, as it appeared in epidemic form, was an acute
affection running a specific course, and a considerable amount
of evidence goes to prove that its virus or poison when once
introduced into the system acted primarily, and in many cases
chiefly on the nervous system, showing its presence by a feeling
of bodily malaise with mental depression, accompanied by more
or less pyrexia. As the nervous system was so frequently
affected it does not appear strange that the epidemic was
followed in a certain percentage of cases by mental breakdown,
and in my experience insanity has broken out much more
frequently after influenza than after all the other fevers put
together; thus 25 of the admissions here had a previous
history of influenza, whereas only 6 followed other fevers, 3 of
these appearing after enteric. This form of mental disease has

Digitized by VjOOQle

1900.] BY ARTHUR E. PATTERSON, M.D. 481

been more frequent in females than in males, the proportion
being 4 to 1. The percentage on the total admissions was
4’3 for women, and 17 for men. As regards age there was
little or no difference in the two sexes, the average in males
being thirty-seven and in females thirty-five. All the patients
with the exception of 3 were aged between thirty and forty,
and none were met with under twenty, and it would therefore
seem that the mental disturbance usually appears during the
prime of life.

Heredity plays a very considerable part in the production of
post-influenzal insanity, and was present in 1 o out of the 2 5
cases, or 40 per cent.

Previous attacks of mental disorder had been recovered from
in 2 cases, in both of which that produced by influenza exactly
resembled the former illness.

Though any form of insanity may occur as a sequel to
influenza, melancholia was the most frequently met with, and
sleeplessness with refusal of food was common, the latter more
particularly in women. Hallucinations of hearing and delusions
of poisoning predominate. Suicidal propensity was found in
3 women and 2 men.

Influenza preceded general paralysis in 4 males, but has
not been met with as the starting-point of epilepsy.

The length of time which usually elapses between the attack
of influenza and the onset of the mental symptoms is almost
impossible to ascertain with any degree of accuracy, but the
balance of evidence goes to prove that where influenza alone is
the cause these come on soon after the feverish attack is over,
and are then maniacal in nature; but such cases are com¬
paratively rare, for other causes are generally met with in
addition to the influenza, the chief of which are heredity,
mental anxiety, syphilis, and drink. It may fairly be assumed
that influenza by itself is not a frequent cause of insanity, but
gives rise to mental disturbance in those having other causes in
addition.

We now come to the consideration of those discharged from
the asylum.

Recoveries .—The proportion per cent, of recoveries to admis¬
sions in the 1000 cases under notice has been 40 per cent,
for males, 37 per cent, for females, and 39 per cent, for both
sexes ; this does not include 21 males and 12 females who

Digitized by VjOOQle

482 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

are deemed curable and are still in the asylum. Amongst the
males, of those suffering from acute mania 51 per cent., or
about one half, recovered, from subacute mania 58 per cent,
from acute melancholia 48 per cent., and from subacute melan¬
cholia 50 per cent. In mania a potu ever}" case save one
recovered, as did 2 out of 3 of mental stupor.

Amongst the females the recovery rate for acute mania was
49 per cent., for subacute mania 40 per cent., for acute melan¬
cholia 5 1 per cent., and for subacute melancholia 30 per cent.
Here, again, every case of mania a potu with the exception of
one got well, as did 3 out of 7 suffering from puerperal
insanity.

An endeavour to ascertain the relation of the number of
recoveries to the duration of the mental disorder before admis¬
sion shows that in the two sexes 45 per cent, with acute mania
and 41 per cent, with acute melancholia get well when the
symptoms have lasted for less than one month on reception ;
this coincides with the general experience, that the earlier the
patient enters the asylum after the onset of the attack the
better is the chance of recovery.

Mania a potu gives by far the highest recovery rate, and all
cases except one female came in within a week of the appear¬
ance of the first symptoms.

Of admissions suffering from acute mania in males and acute
melancholia in females about half recover, and of those which
have lasted under one year on admission 48 per cent, get well.

The average period of residence in those recovered under
the various forms of insanity was as follows :

Males.

Females .

Acute mania

6 $ months

124 months

Subacute mania

Mania a potu

Acute melancholia

Si „

6 „

Subacute melancholia

Females seemed to take twice as long to recover from the
acute forms of mania as males, whereas acute mental de¬
pression in women was recovered from in half the time required
for a similar result in men. The average period of residence
for all acute attacks which recovered was months for both
sexes.

Digitized by VjOOQle

1900.] BY ARTHUR E. PATTERSON, M.D. 483

Mania a potu was of shorter duration than any other form
of insanity.

Chronic melancholia was occasionally recovered from after a
long residence, extending into several ^ears.

In puerperal insanity the average period of residence in the
recovered was six months.

The great difference in weight of patients on admission and
on leaving the asylum as recovered was often very striking.
Many of the people admitted here are in a thin feeble state,
and it is no uncommon thing for them to lay on weight, even
to the extent of two or three stones, during a residence of
a few months.

The average increase in weight in recoveries from mania
has been 12$ lbs., and from melancholia 11 lbs. Of the entire
number of those recovered only 7 males and 3 females showed
a decrease in weight on discharge, and in these the loss was
small.

Relieved and not improved. —During the past eight years
87 males and 55 females, total 142, have been sent out
relieved, and 11 males and 20 females, total 31, not improved.
Of the above 78 have returned to the care of friends, whilst
95 have been transferred to other asylums. A total of 47
patipnts of the chronic class have been discharged to the
Metropolitan Asylum at Leavesden, under Sect. 25 of the
Lunacy Act, 1890.

Deaths. —Of the 1000 admissions 118 men and 37 women,
total 1 5 5, or 15 per cent., have died. The large preponderance
of male deaths was attributable to general paralysis of the
insane, which accounted for 53.

The six most frequent causes of death in the order of their

frequency were—

Males. Females.

Total.

1. General paralysis of the insane

• S 3 2

2. Heart disease .

. 8 7

3. Exhaustion from mania

. 10 5

4. Exhaustion from epilepsy .

• 8 4

5. Senile decay

• 8 3

6. Exhaustion from melancholia

. 4 2

Our death rate has never once in the history of the asylum
reached the average public asylum death rate.

Digitized by VjOOQle

484 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

One hundred and twenty-one post-mortem examinations
were made. Of these 95 were on males, and 26 on females.
It must be remembered that the friends of private patients and
those of the Jewish faith frequently object to allow any
examination to be held.

The only inquest held during these eight years was upon the
body of a man aet. 38, who was admitted in a state of wild
mania, with great bodily exhaustion. His death took place
within thirty-six hours of admission, and the verdict of the
jury was exhaustion from acute mania, the result of an accidental
kick of a cab horse about ten years ago.

The only subject which remains to be dealt with is the
treatment , which will be briefly considered under two heads,
moral and medicinal. Of these the former is the more im¬
portant in promoting the recovery of those under our care.

The systematic employment of the insane is one of the best
methods of treatment at our disposal. Attached to this asylum
is a farm of 120 acres, and a considerable proportion of our
male patients are daily employed there, and in the gardens
and grounds surrounding the institution ; in addition many
work as printers, carpenters, tailors, painters, and in other
capacities. Altogether as many as 70 per cent, of the men
are usefully engaged in some work or another.

The women are employed in the proportion of 60 per cent,
in the laundries, kitchen, dormitories, and wards, and we are
about to supply the quieter patients of this sex with light
garden tools, so that the flower beds in the proximity of the
female wards may be tended by them under proper supervision,
thus giving them an interest outside the ordinary routine.

Exercise in the grounds and by road walks is enjoyed by
both sexes, and the amusements are many and varied, including
dances, concerts, picnics, athletic sports, cricket matches, tennis,
bowls, etc.

Restraint and seclusion are practically unknown in this
asylum, although we receive a large proportion of acute cases,
which require constant supervision and attention ; these are
sent out daily for a short time in the grounds under the care
of special attendants and nurses, unless their physical condition
is such as to contra-indicate it.

In those cases where forced feeding is inevitable, through the
persistent refusal of food, the oesophageal tube is generally used

Digitized by VjOOQle

1900.]

BY ARTHUR E. PATTERSON, M.D.

485

here, the patient where possible being placed in the sitting
position so as to allow of the action of gravity in the flow of
the nourishment, which is not so decided in the lying-down
posture. In certain cases the nasal tube comes in useful, but
the stomach-pump or Higginson’s syringe is never employed
for forcible feeding.

In certain cases of melancholia, where food has been refused
for some time, I have used lavage of the stomach with benefit.

It is just possible that a certain amount of the benefit arising
from this method of treatment is due to its unpleasantness, for
patients do not express the most unbounded delight at the
procedure.

A most important and useful means of treatment in suitable
cases is that by shower-baths; these are largely employed at
this asylum, where there is a special shower-bath book for
each division, in which is entered the name of the patient in full,
the reason for the bath, the date of commencement, the dura¬
tion, when discontinued, and the result. No shower-bath is
ever given to any patient over fifty years of age, and a careful
medical examination of the chest is made before the first bath
is administered, whilst the chief of each division is present
during the operation. The baths recently erected and now in
use are a combination of shower and needle, and answer well.
The usual duration ordered for each bath is twenty seconds.
The best class of cases for treatment by this method are the
young of both sexes, especially those who are dejected, listless,
and apathetic, and of faulty habits ; the mental and bodily
improvement in such is often very marked. Certain cases of
maniacal excitement coming on in youth also derive great
benefit.

Whilst on the subject of baths it may be mentioned that it
is proposed to convert the old engine-room into a Turkish bath
for use by both divisions.

A special bedsore paint is in use here, consisting of equal
parts of Tinct. Catechu and Liq. Plumbi Subacetatis, B.P., and
this has kept us free from bedsores for many years past.

With reference to strictly medicinal treatment, we have a
great aversion to keeping patients under chemical restraint by
means of the bromides in combination with chloral.

The sheet-anchor in the treatment of melancholia in this
asylum is the morphia and ether combination first advocated

Digitized by VjOOQle

486 ANALYSIS OF ONE THOUSAND ADMISSIONS, [July,

by Huxley, the former superintendent at Barming Heath.
Erythrol tetranitrate has been employed in certain cases of
melancholia, and there can be no doubt that in this drug we
possess a very efficient and rapidly acting vaso-dilator; in one
case a series of very instructive sphygmographic tracings were
obtained, showing that its action is well established within half
an hour of administration. By the reduction of arterial tension
sleep is promoted, and it certainly allays the restless agitation
of melancholics. The great drawback to its use is the headache
often induced by it, which is sometimes very intense, and the
cause of such bitter complaint that in several instances the drug
had to be discontinued.

In the treatment of epilepsy the bromides are useful, but have
to be carefully watched. A combination of bromide of potassium
and belladonna has been found of service in diminishing the
number of fits, but it must not be forgotten that all bromides
tend to hasten the onset of dementia.

In status epilepticus the bowels are relieved by enemata, the
head raised to promote the return of venous blood by the force
of gravity, and the liquid extract of ergot, in half-drachm doses,
given with a little brandy and water, or the citrate of ergotinine
by hypodermic injection.

As an hypnotic trional is much to be preferred to sulphonal.
We have found its action much improved when administered
on alternate nights with paraldehyde , and it is a very good rule
to “ ring the changes ” in the use of all sedatives.

Bro?nidia has not proved of any great service, and is a remedy
of doubtful value.

Thyroid extract was given a trial here but abandoned, as the
results were by no means satisfactory, all those subjected to it
complaining of headache and rapidly losing flesh ; and this form
of treatment for the cure of mental disease now seems to have
fallen into disrepute, but in one case of myxcedema admitted
here its effect was so marked and beneficial that perhaps brief
reference may be made to it.

The patient, a Jewess, married, aet. 39, was admitted in
January, 1896, suffering from melancholia with hallucinations
of hearing. After a residence of some months, during which
she showed no sign of mental improvement, it was noticed that
her speech was measured and hesitating, her ideation slow, and
her expression heavy and stupid. Myxcedema was diagnosed,

Digitized by • 3 °&

1 900.] PATHOLOGICAL WORK OF IRISH ASYLUMS.

487

and she was ordered thyroid tabloids daily, when she at once
improved, and was discharged recovered four and a half months
after the commencement of the treatment.

She was readmitted here exactly one year after with all the
symptoms well marked : the skin was now dry and rough, the
hair of the head thinned ; she was dull, apathetic, and slow in
thought and movement ; she spoke languidly and deliberately,
articulation was thick and rather blurred, and her voice mono¬
tonous ; her expression was heavy and stupid, whilst her memory
was defective. On admission she was at once put on thyroid
treatment, when she rapidly lost all these symptoms, and was
sent out recovered after being with us four months.

(*) Read before the South-Eastern Division of the Medico-Psychological
Association held at Dartford on April 25th, 1900.

The Best Method of dealing with the Pathological Work
of the Irish Asylums . By W. R. Dawson, M.D.

The modem conception of asylums as hospitals for the
treatment of those diseases whose salient phenomena are
mental, and the fact that insane patients are peculiarly liable
to be attacked by ordinary physical diseases, for which they
must be treated in asylums, render it essential that these
institutions should in their organisation and equipment be
approximated to general hospitals as closely as their peculiar
circumstances allow. In general hospitals nowadays the
pathological department takes a position the importance of
which is increasing every year, owing to the extraordinary pro¬
gress in all branches of pathological science, and it is just as
important that this department should be efficiently worked in
asylums. Its functions may be said to be twofold, clinical and
what we may roughly call anatomical.

The common operations of clinical pathology, such as ordi¬
nary urinary examinations and the staining of sputum for
tubercle bacilli, are now expected to be within the powers of
every medical man, and their carrying out will devolve as a rule
upon the younger members of asylum staffs. But even as
regards these simpler processes difficult cases arise from time to

Digitized by VjOOQle

488 PATHOLOGICAL WORK OF IRISH ASYLUMS, [July*

time where wider experience is needed, and many procedures,
such as the detection of unusual bodies^in the urine (hsemato-
porphyrin, for example), determination of the presence or absence
of diphtheria bacilli in the mouth-secretion, the examination of
blood for micro-organisms, and the like, demand an amount of
time and experience, and a laboratory equipment, such as few
asylum officers have at their disposal. Yet all these procedures
are absolutely essential from time to time if the patients are to
be properly treated. The prosperity of such institutions as the
Clinical Research Association shows how widely this necessity
is felt by the busy members of the general profession, and
surely medical officers of asylums must find it not less urgent.
In a few fortunate instances, it is true, where there is a school
of medicine in the vicinity, the aid of an outside laboratory may
be available, but in the vast majority of instances no such aid
is available, and in any case a public institution should not be
dependent on the charity of outsiders in carrying on its work.

When we come to deal with post-mortem pathology the need
for special skill and experience becomes increasingly evident.
Ordinary naked-eye and even microscopic examinations may be
and are efficiently made by asylum officers, but questions often
arise which no ordinary asylum officer can in the nature of things
be competent to settle. Take one instance. A patient is found
post mortem to have a number of ribs broken. Is this due to
morbid fragility of the bones, or does it indicate violence ?
Obviously, in some cases at all events, this point requires in¬
vestigation of a kind beyond the scope of any but an experi¬
enced pathologist. Again, the occurrence of epidemics in
asylums, such as beri-beri, requires pathological investigation,
and one might easily multiply instances of various kinds. But
most of all is the need for special knowledge, skill, and experi¬
ence obvious in dealing with the central nervous system, the
organs in which as alienists we are chiefly interested. The
brain is the most difficult and complex of all organs, and to
appreciate its changes in disease requires a minute knowledge
of its normal anatomy and physiology, such as few men have
time to acquire. Its investigation, again, can only be carried
out by some of the most difficult, complicated, and lengthy of
all the methods at the disposal of the investigator, while the
mass of work being done all over the world necessitates an
acquaintance with foreign languages, and a large amount of

Digitized by VjOOQle

1900.]

BY W. R. DAWSON, M.D.

489

time devoted solely to keeping up with the literature of the
subject. It is therefore clear that to deal adequately with
asylum pathology specially trained pathologists are necessary,
working in properly equipped laboratories, and devoting all
their time to the subject. No outside pathologist could give
the necessary time, even if he had the requisite degree of
knowledge.

Hitherto I have merely dealt with ordinary asylum work, but
I need hardly say that this is not all, and that our hopes of a
real knowledge of the conditions of insanity, and consequently
of a rational treatment of it, centre in original research directed
to its pathology in the wide sense, albeit in conjunction with
enlightened and scientific clinical observation. For such re¬
search, more than for any other branch of pathology, special
knowledge and skill and much time are absolutely necessary,
and we must see that they are available if we do not wish to lag
behind other countries in this department of scientific progress.
But I need delay you no longer with arguments, which, indeed,
seem almost superfluous, for a proposition so self-evident as the
need for special arrangements for dealing with the pathology of
asylums. Let us see now what means are elsewhere in existence
for meeting this want.

In many of the English and Scottish asylums there is a resi¬
dent pathologist, who has a laboratory at his disposal, and is
responsible for the pathological work of the institution. But
he is, as a rule, simply the junior assistant, and is expected to
combine with his pathological duties a not inconsiderable
amount of clinical and administrative work ; and even if it were
not so, there being little prospect of advancement in his par¬
ticular line, he usually after a year or two, just as he has
acquired a useful amount of knowledge and skill, accepts pro¬
motion to a higher assistancy, and drops to a large extent his
pathological studies. Such an arrangement, therefore, hardly
fulfils the conditions which I have laid down ; but even if it did
so, in this country it would, for financial reasons, be out of the
question. The clinical and administrative departments of our
Irish asylums are none too well manned, and therefore their
Boards could scarcely be expected to offer an adequate salary
for a resident pathologist in each, or even in a majority, of the
institutions.

Even across the Channel, however, there is a wide-spread dis-

Digitized by VjOOQle

490

PATHOLOGICAL WORK OF IRISH ASYLUMS, [July,

content with the existing arrangement, and as long ago as
1892 the London County Council took steps to introduce a
better order of things in the seven asylums under their control,
and accordingly, after inquiries both in England and abroad,
they established a central laboratory at Claybury Asylum,
splendidly fitted out for its purpose, and placed over it a scien¬
tific man in every way competent to fill the post, Dr. F. W.
Mott, F.R.S., with an adequate salary and two assistants. This
experiment has been a complete success. Not only has most
excellent work been done, as shown by the first number of the
Archives of Neurology, published from the laboratory, but, as
Dr. Mott stated in his first report, his “ appointment appears to
have been an incentive to pathological work at other asylums,”
a very important point. I need only just mention the magnificent
central laboratory of the New York State Hospitals for the Insane
with its eight departments, each in charge of a specialist, which
has been established since 1895, and turn to what is, for our
purpose, the most useful example of such institutions, the Con¬
joint Laboratory of the Scottish Asylums. Stimulated by the
success of the London County Council, a number of these
institutions combined in 1896 and started a laboratory in
Edinburgh under the control of Dr. Ford Robertson, who was
already known for his work in the field of cerebral pathology.
He receives £400 a year as salary. The duties of this post
and the objects of the laboratory are as follows :

I. To carry on original researches upon the pathology of
insanity.

II. To examine pathological material sent from the asylums,
and to furnish reports.

III. To give instruction free of charge to* members of the

medical staff of the associated asylums in the
pathology of mental diseases and in laboratory
methods.

IV. To assist members of the medical staff of these

asylums in original research by {a) suggesting sub¬
jects, ( b ) collecting material, ( c ) advising as to
methods, ( d) assisting with reference to literature,
(< e ) providing “ demonstration sets ” of microscopic
specimens to be sent round to the asylums, (/)
visiting the associated asylums at intervals with
reference to their pathological work.

Digitized by VjOOQle

1900.]

BY W. R. DAWSON, M.D.

491

V. To form a library of books and journals bearing on the
subject.

Seventeen of the twenty-four Scottish asylums have now
joined the scheme, contributing to the support of the laboratory,
in proportion (nominally, at all events) to their death-rate, a
total sum which last year amounted to £650 10 s. The ad¬
ministration is in the hands of a General Board, composed
of the superintendents of the associated asylums, together
with lay governors from each when desired, from which
General Board a smaller Executive Committee of nine is annu¬
ally elected.

This scheme has now been working for several years, and
has been strikingly successful. Numerous papers have appeared
in various scientific journals by which our knowledge of cere¬
bral pathology in relation to insanity has been extended, and
Dr. Robertson is about to publish an important work covering
the whole ground, and embodying his researches on the subject.
Medical officers of asylums have received instruction, patho¬
logical work has been stimulated elsewhere, and, in short, the
programme of the undertaking has been pretty fully carried
out. So successful has the laboratory been that, as we learn
from the last report, it is proposed to extend it by the establish¬
ment of a separate department for pathological chemistry
under a specialist in this subject.

We are therefore led irresistibly to the conclusion that the
establishment of a central laboratory in this country is not only
the best, but is the only way at our disposal for dealing with
the pathological work of our asylums. On the whole, a scheme
modelled on the Scotch institution, though with certain modifi¬
cations, would seem to be the most practicable. Thus the
mode of control, and management, can hardly be improved on,
but the duties of the pathologist should not, I think, be
restricted to the nervous system. They might be defined as,
first, to examine and report on all material, both clinical and
post-mortem, sent to him from the associated asylums. Secondly,
to give pathological instruction free of charge to medical offi¬
cers of the associated asylums. Thirdly, to act as pathological
consultant to the associated asylums in all other matters (such,
for example, as instruments and laboratory fittings) on which
his advice may be sought by them, and perhaps to visit them
at intervals with this object in view. Fourthly, to carry on

XLVI. 34

Digitized by VjOOQle

492

PATHOLOGICAL WORK OF IRISH ASYLUMS, [July,

original research in the pathology of mental and nervous
diseases. Whether any attempt should be made to form a
neurological library is a matter which must depend on the
success of the project in other respects.

Lastly, we have to consider whether such a scheme is financially
practicable. The first point is as to the laboratory itself and its
equipment, and here I venture to think we are peculiarly fortu¬
nate. At the Richmond Asylum in this city, and therefore at a
spot easily reached from any part of the country, there already
exists one of the most commodious and best-equipped asylum
laboratories in the three kingdoms. If, therefore, the Richmond
authorities can be induced to place this at our disposal, it
seems to me that, for the present at all events, we need go no
further. The next point is with regard to the raising of the
sum necessary for the maintenance of the laboratory and the
pathologist’s salary. It seems to me that in order to induce a
competent man to give his whole time to the work we should
offer not less than the salary paid by the Scottish asylums, viz.
^400 a year. Setting down the working expenses at £100,
this means £500 a year to raise. There are in this country
twenty-three district asylums, in addition to which there is the
Central Criminal Asylum at Dundrum, the Stewart Institution,
St. Patrick’s Hospital, and a number of private asylums, some
of which would no doubt contribute. If we might put down
the combined quota of all the asylums other than district
asylums at £40 a year, this leaves only £20 a year to be contri¬
buted by each of the latter. Furthermore, the conjoint patholo¬
gist might also act as pathologist to the Richmond Asylum, and
in this case the Governors of that institution might be in¬
duced to give a much larger proportion than £20, say ^100 a
year, which would still further reduce the contributions of the
other asylums. There are one or two other ways in which money
might be raised, but I think I have said enough to show that
the scheme is well within the range of practical politics, and,
indeed, is not only the most effective but the most economical
mode of meeting the difficulty. Be it understood that what I
have said about the financial and other arrangements are only
thrown out as suggestions designed to show how the scheme
might be worked out. The arrangements would, of course, rest
with the General Board.

It may be said that such a laboratory would not deal with

flzed by

Google

1900.]

BY W. R. DAWSON, M.D.

493

the whole pathological work of our asylums. It would not,
and it is neither necessary nor desirable that it should. Assist¬
ant medical officers are quite capable of doing the routine patho¬
logical work, especially if they have had a course of instruction
at the central laboratory; while all questions of unusual diffi¬
culty, importance, or interest, would be referred to the conjoint
pathologist for solution. Indeed, the establishment of a com¬
paratively well-paid post of the kind would doubtless tend in¬
directly, as well as directly, to increase the efficiency of asylum
officers, by acting as an incentive to assistants to devote more
attention than they have hitherto done to the study of patho-
logy.

In conclusion, I may perhaps be allowed to say that when
the point was mooted by me in the Presidential Address at
the opening meeting of the University Biological Association
last November, it met with emphatic approval, not only from
the guest of the evening, Dr. Aldren Turner, of London, but
subsequently from the Lancet in a notice which that journal
inserted in its columns. A few weeks ago the question was
again brought before the above Association, on which occasion
the speakers were unanimous in their approval of the scheme,
and a resolution was passed to the effect “ that in the opinion
of the Dublin University Biological Association it is desirable
to establish a central laboratory for the Irish asylums, devoted
to the study of pathology in relation to nervous and mental
diseases.” From these indications and others I think we may
take it that our project is sure of the sympathy and support of
all enlightened members of the outside profession, a support of
which, in its influence on the lay boards with whom the success¬
ful starting of the scheme finally rests, we should gladly avail
ourselves.

Discussion.

At the Quarterly Meeting of the Irish Division at Dublin, April ioth, 1900.

When he had read the above paper Dr. Dawson proposed the following
resolution :—“ That, for the better carrying on of the pathological work of the
Irish asylums, and for the encouragement of original research in the pathology of
nervous and mental disease, it is desirable to establish a central laboratory
devoted to these special ends, under the management of a competent pathologist,
who shall give all his time to this work; and that a Committee of five asylum
superintendents be appointed to take steps tp give effect to this resolution.”

Dr. Nolan in seconding the resolution said: After the very able manner in
which Dr. Dawson has dealt with the subject it is absolutely unnecessary for
me to say anything except to formally second the resolution. To my mind
the question is not one for argument, but it is one for apology, and 1 think

Digitized by

Google

494

PATHOLOGICAL WORK OF IRISH ASYLUMS. [July,

the superintendents of the Irish asylums are rather late in the day in trying to
carry out what has so long been in operation elsewhere. 1 am afraid if they do
not do something, outside influences—professional and lay—will place them in an
exceedingly awkward position, in consequence of the large sums of money lunacy
is costing in this very poor country, if it can be said that the money is going to
little more than hotel keeping. We have been subjected to the reproach that
superintendents of asylums are something between hotel keepers and jailors.
It appears to me that we should do more than speed the parting guest, and I
think our work should certainly not end at the mortuary door. I am convinced
the treatment of the insane will derive from pathological research aid of a most
practical and useful character. It would weary you uselessly to labour this
point. We all feel that it is absolutely essential. The details of the scheme
will be, of course, difficult, but these difficulties are not insurmountable. There
has been an absolute necessity for it for years, and I hope it will rouse
enthusiasm now. If properly and energetically worked by the Committee, a
result will be attained sufficient to initiate this project, and I am sure it will
then find support for itself. In the London County Asylums, where you know a
similar project has been successful, the pathologist originally appointed at
£700 has got an increase of .£300 a year to his salary. Dr. Dawson has referred
to New York, but the scheme carried out there is perhaps too ambitious. The
Scotch scheme is one which should appeal to us, and it is the duty of every
superintendent in Ireland to support that.

Dr. Finegan said: I think the resolution is most excellent. There is one
point, however, which I would suggest as an addition to it. This matter does
not rest so much with the Association as with the controllers of superintend
dents—the committees of management. I am quite satisfied all superintendents
in Ireland would be only too anxious to advance the matter in every way in
their power.—and the Association would strengthen the hands of the superin¬
tendents by having a copy of the resolution sent to each committee of manage¬
ment of Irish asylums, in order to get an expression of opinion from them.
The superintendents would, of course, educate the committees on the subject.

Dr. Mercier.— The resolution would carry weight with the laity if a state¬
ment were added to it, referring to the work done in the pathological
laboratories started on this plan and the great advantages reaped therefrom.
Such a memorandum should point out how pathology aids treatment, and how
great public advantage would be gained by a shortening of the period of stay
in asylums, which would not be an improbable result. If you are asking a
public body for money you must show a fair reason for the employment of
that money, and demonstrate that its effect will be to save money in the
future.

A prolonged discussion ensued. Drs. Donelan and O’Mara expressed a fear
that the foundation of a central laboratory might rather check individual patho¬
logical work elsewhere. Dr.Dawson pointed out that such had not been the result of
a similar scheme in Scotland. Drs. Lawless, Donelan, and Nolan suggested that
the co-operation of the inspectors should be sought in the matter. Dr. Nolan
and the Chairman suggested that some difficulty might be experienced as to
obtaining contributions from the local committees, for work not directly and
solely under their control in each case; and the Chairman pointed out that the
Lunacy Amendment Bill (England), now passing through Parliament, contained
a special clause empowering the committees of different asylums in that country
to combine, not only for the purpose of constructing an asylum, but for the pur¬
pose of erecting and equipping a laboratory for pathological purposes. This is a
Government bill, and the Government are by it committed to the principle of
permitting combination for the purpose. A bill for the amendment of the
recent Irish Local Government Act had been announced, and it was suggested
that the Government be requested to permit the addition thereto of a clause
legalising such combination among the Irish district asylums. It was deemed
that this matter should be immediately taken up by the Committee about to be
formed. After further discussion as to how the details of the scheme could best
be carried out, the resolution was put to the meeting and unanimously adopted.

Dr. Nolan then proposed, and Dr. Lawless seconded, “ That the following
members be appointed as Committee to carry out the objects of the foregoing

Digitized by LjOOQle

THERAPEUTICS OF INSANITY.

495

1900.]

resolution, namely, Dr. Dawson, Dr. Woods, Dr. Graham of Belfast, Dr. Conolly
Norman, and Dr. Finegan, and that they be given power to co-opt further
members in case of vacancies occurring, or to add to their number.” This resolu¬
tion was adopted unanimously.

The Therapeutics of Insanity . By Harrington

Sainsbury, M.D.

This subject is of such magnitude and it presents so many
aspects that it would not be possible to develop it at all satis¬
factorily within reasonable limits, if one were to attempt to
deal with it comprehensively. I shall therefore be excused if I
pass very cursorily over certain systems of treatment which do
not, and dwell more upon certain others which do fall within
my competence. The selection will by no means represent
the order of importance.

That which may be called the sociological treatment of the
unsound of mind depends upon the recognition of the rights
of citizenship as still belonging to the imbecile and the lunatic,
however much these rights may be limited or qualified ; the
question to be answered in each individual case is “ How much
freedom ? how much restraint ? ” On this subject Emminghaus
( Virchow's Jahresberichte , Jahr xxxiii, sect. “Psychiatric”) refers
to BottigePs views on the treatment of the insane in colonies
( Ueber die coloniale Behandlung von Geisteskranken ). Bottiger
maintains that this system of treatment gives the best results
because of the beneficial effects of occupation upon the mental
state, and because also of the wide range of liberty which the
system places at our disposal.

In the carrying out of the treatment the colonies may stand
either as independent foci, or they may be in more or less close
connection with the asylum as a centre.

According to Bottiger at least one half of all the inmates of
the asylum are capable of treatment in the “ colony.” He ad¬
vises that where the asylum, as parent institution, has affiliated
daughter colonies, these should be situated near the asylum,
and that whilst the latter should retain the hospital character the
colonies should partake of the nature of groups of dwelling-houses.

He sums up the advantages which the “ colony ” system

Digitized by VjOOQle

496

THERAPEUTICS OF INSANITY,

[July,

offers as follows:—(i) Favourable sanitary conditions; (2)
greater facilities for apportioning to each case the required
measure of freedom ; (3) greater opportunities for varied
occupation ; (4) lessened cost of establishment and mainte¬
nance.

Bottiger insists that all forms of psychosis are suitable for
this treatment during longer or shorter periods.

To the important subject of the industrial training of imbeciles
Dr. Shuttleworth contributes a paper in the July number of the
Journal of Mental Science . Shuttleworth draws attention to
the great value of schools in the development of imbeciles, the
object in view being always the choice of an occupation for the
individual.

On account of the limitations of mental development the
acquisition of manual dexterity is most important, and accord¬
ingly instruction in the handicrafts should constitute an essential
feature of the training. The development of the muscles by
suitable gymnastic exercises will be of value to the same end.

For male imbeciles out-of-door occupation in the fields,
gardens, etc., is desirable, and for female imbeciles light field
work is likewise to be encouraged.

Those imbeciles unsuited to agricultural work should be busied
with domestic work or occupation in workshops, not in factories .
Suitable occupations are bootmaking and mending, tailoring,
mat weaving, brushmaking, etc.

In any case individualism is all-important. I)r. Shuttleworth
is in favour of a system of small rewards in institutions for im¬
beciles as a means of arousing zeal.

At times a considerable amount of taste is to be found among
the feeble-minded, and the cultivation of pow ers of drawing,
painting, etc., in particular among the better classes, will be
then called for.

Passing from the general to the special, we m ay first consider
the subject of suggestion in the treatment of ps /choses . In the
Centralblatt f Nervenheilkunde und Psychiatr 'e , April, 1899,
Prof. Bechterew, of Petersburg, writes on the “Treatment of
Chronic Alcoholism by the Simultaneous Use o Hypnotic Sug¬
gestion and other means.” His experience on he value of sug¬
gestion in this disease will be probably in acc rd with that of
most other workers in this field ; but the point t > be accentuated
here is the combining of this treatment with ot er remedies de-

Digitized by VjOOQle

1900.]

BY HARRINGTON SAINSBURY, M.D.

497

signed to meet the damaged state of the bodily health. Thus he
prescribes, in addition, the use of baths and rubbings, the seda¬
tive employment of bromides with codeia, of heart tonics, such as
digitalis and adonis vernalis, of general tonics, in particular
strychnine. As he insists, chronic alcoholism involves not only
a psychosis, but also a number of morbid bodily states, and hence
he urges that it is most reasonable to apply remedies to these
latter when we are attacking the disease as a whole. The ultra¬
scientist may exclaim against composite treatment, but the
practical man will not be deterred.

Von Bechterew contributes to the February number, 1899,
of the same journal, an article on the “ Treatment by Suggestion
of Sexual Inversion and of Masturbation” His first article,
which certainly gives the impression that this is a new thera¬
peutic departure, brings down upon him the heavy hand of Dr.
v. Schrenck-Notzing, of Munich, who shows clearly that as
far back as 1889, v. Krafft-Ebing, Ladame, and he himself
had published reports of treatment of these conditions by sug¬
gestion ; a bibliography which he adds enforces his case.

Admitting this correction, v. Bechterew’s cases do not lose in
their value as additions to our knowledge of a department of
pathology in which any and every means of alleviation or cure
is welcome.

In these cases, also, v. Bechterew counsels the employment
of other means, baths, bromides, etc., besides suggestion.

Among the most satisfactory of all the methods of treatment
of mental cases are the hydropathic, when they are effective ; in
the treatment of insomnia this holds notably. Dr. Ernst
Beyer therefore earns our thanks for his paper on “ The Appli¬
cation of the Prolonged Bath to the Cure of Mental Disease ”
(CentralbL f Nervenheilk . u. Psychiatrie , Jan., 1899). He
says with truth that in spite of the general recognition of the
warm bath, this variety of bath has received but little at¬
tention.

The technique of the prolonged bath, though very simple,
must be sought in Dr. Beyer’s paper. The temperature of the
water is maintained at 95° F. The patient divides his life
between the bath and the bed ; in the morning into the bath,
in the evening into the bed, and so on for days and weeks
together ; the meals are, of course, administered while in the
bath.

Digitized by

Google

498

THERAPEUTICS OF INSANITY,

[July,

The many precautions upon which some insist, the careful
examination of pulse and respiration, and of the general powers,
etc., all these are as a rule unnecessary. The treatment is to
be regarded as adapted for most patients without hesitation
and without fuss. Experience of the daily routine of these
baths in the Heidelberg Clinique, where constantly half a dozen
such are in use, has convinced Dr. Beyer of the simplicity and
safety of the practice, and he even goes so far as to regard
these many precautions and observations as contra-indicated,
because interfering with the quieting influence of the treat¬
ment.

Constant supervision is a necessity of the method, and one
attendant to every two or three patients will be requisite: to
supervise being his sole occupation. An abundant supply of
easily accessible baths is also essential, and to each section
allotted to noisy and dirty patients there must be one bath¬
room, in which must be one bath to every two or three patients.
Herein may lie the difficulty of adapting the system to large
establishments, for there should not be many baths in the same
room or the sedative influence will be interfered with ; indeed,
even in smaller number it is advisable to separate the baths
from each other by partitions, which, however, need not be
complete.

We must pass over other details and proceed to consider
the kind of patient suitable for this treatment. All cases with
bedsores are indicated, and we are to note that sores of all kinds
heal well in the bath. Cases of excitement generally are in¬
dicated, and particularly cases which are dirty, or which, if
suffering from bedsores, cannot be treated, the patient fouling
the wound or pulling off the bandages.

Difficulty in keeping the patient in the bath is experienced
much less often than would be thought likely, and mechanical
means of restraint are never employed ; but a dose of hyoscin
may in certain cases be required to start the baths.

The prolonged bath has proved most successful in the ex¬
citement of acute mania, less so in that of dementia praecox,
though more extended experience has not differentiated so
markedly between these conditions as appeared likely from
earlier observations. The excitement of paralytics has been
little amenable, but that of alcoholics and epileptics has been
successfully treated.

Digitized by VjOOQle

1900.]

BY HARRINGTON SAINSBURY, M.D.

499

In conclusion the writer considers that the routine use of
these baths will prove one of the most important advances in
the treatment of the insane.

The feeding of insane patients often requires the most careful
and anxious attention. It must be approached from two
points of view, viz. (1) the state of the digestive organs; (2)
the nature of the food supplied. We are apt not to pay suffi¬
cient attention to the former of these, and hence the importance
of such contributions as that of Dr. Greenwood on “ Lavage in
the Refusal of Food by the Insane” (Journal of Mental Science ).
According to Greenwood the refusal to eat often depends upon
the presence of an acute gastric catarrh, and he has obtained
marked and often surprising success from the use of repeated
lavage in such cases ; the measure of the success being shown
by the return of the appetite for food or the voluntary taking
of food, or by an improved digestion (should there still be
refusal) as shown by a gain in weight. The common sense of
this procedure will not fail to commend it.

The food suitable for insane patients who are ill nourished is
a subject the importance of which need not be emphasised.
We would here draw attention to the numerous forms of
artificial foods, such as somatose, sanose, nutrose, eucasein,
tropon, etc. These are employed as nutrient adjuvants ; they
are preparations of casein or of animal and vegetable albumens,
and are generally administered in doses of one drachm to half
an ounce two or three times a day, according to age. They
are for the most part without or with very slight taste, and
hence can be admixed with milk, cocoa, coffee, beer, wine, soups,
or other foods. Some of them are soluble in water or emulsify
in the same. Important papers on these preparations have
appeared in several journals, note in particular that of Strauss
on “Tropon ” ( Therapeutische Monatssch ., May, 1898), and of
Biesenthal on “ Sanose ” ( Therap . Monatssch ., April and May,
1899). One important advantage of tropon over other like
preparations is its relative cheapness, a very solid advantage,
Tropon, like its congeners, is readily digested and assimilated,
for though it is insoluble in water it peptonises readily, the
whole of its 90 per cent, of albumen passing into soluble
peptone (see also Merck's Report , published March, 1899).

The advantages which this class of food offers may be

Digitized by VjOOQle

THERAPEUTICS OF INSANITY.

500

[July,

summed upas—(1) high nutritive value; (2) ready assimila-
bility ; (3) ease of administration because of tastelessness.

In certain mental states profound depression of the vital
powers develops with rapidity. In these states much as food
may be needed it may cease to be assimilated, though pre¬
sented in the most digestible form. Here the one indication
for the performance of any function, digestive or other, is
to whip up the flagging powers, and, as a novel means
of so doing, we may refer to the treatment of the typhoid state
by tfce hypodermic injection of salines of which mention was
made in the last number of the journal of Mental Science . It
will be noted there that to stimulate the vital powers generally,
small injections of some three or four ounces are given and
repeated ; whilst much larger injections, up to a pint or even
more, are indicated when the vital failure is mainly in the
circulation. Of the marvellous recuperative power of saline
injections in collapse from shock or other cause, we have
abundant evidence in ordinary medical practice.

Binswanger (Virchow's fahresbericht f 1898, art. “ Psy¬
chiatric,” Emminghaus) recommends as a treatment for psychoses
with exhaustion , hypodermic injections of an entirely different
kind, viz. of bouillon cultures of the bacterium coli. The cultures
are first killed by means of a 1 per cent, formalin solution, then
in the dose of O’5 to 10 c.c. they are injected with due antiseptic
precautions. The injections are continued until the production
of fever, but on this attaining 39 0 C. (102° F.) the treatment is
intermitted till the temperature has fallen again. During two
years fifteen cases were thus treated, with result four cures, two
alleviations, and in nine cases no change.

The volume of these injections, 0*5—10 c.c., is quite too
small to make it probable that mere bulk plays any part in the
effect, as in the previously mentioned saline injections is
probably the case.

Passing to the medicinal treatment of insanity we come to a
region of exceptional and confounding activity—the past tense
would perhaps describe this more fitly. In three directions we
may observe this activity, first in the extension of the long list
of hypnotics, secondly in the development of new opium deriva¬
tives, and thirdly in the production of new bromine compounds :
these all concern the alienist directly.

Of new hypnotics, Dr. Ernst Schultze, of Andernach, writes

Digitized by VjOOQle

1900.]

BY HARRINGTON SAINSBURY, M.D.

SOI

in the Neurologisches Centralblatt (March, 1900) concerning
dormiol , a product of the combination of chloral with amylene
hydrate. Despite the numerous introductions by the chemist,
the older hypnotics—chloral hydrate, sulphonal, trional, paralde¬
hyde, amylene hydrate—maintain their superiority, and among
these for certainty and readiness of action chloral hydrate comes
first. On the other hand, chloral hydrate is regarded by many
as poisonous even in moderate dose, and the idea of combining
chloral with amylene hydrate was to keep, if possible, the
chloral effect without its drawbacks.

Dormiol is a colourless limpid liquid with a pungent menthol¬
like odour and burning taste. It mixes in all proportions with
alcohol, ether, chloroform, benzol, fats, and the ethereal oils.
It shows a peculiar behaviour to water, but can be made to
dissolve in it in all proportions if certain precautions are
observed ; to obviate difficulty, however, a 10 per cent, solution
of dormiol in water can be obtained commercially. The taste
is no serious drawback, and only two out of sixty patients refused
it for this reason ; moreover, if need be, it may be administered
in gelatine capsules. Sleep followed the dose within the hour
in the majority of cases, very often within thirty minutes ; it
lasted five, seven, eight hours. Dormiol was effective in about
75 per cent, of the cases. In the event of refusal to take the
drug it may be administered per rectum admixed with some two
or three drachms of mucilage of gum acacia ; thus given it in no
case caused irritation.

The cases most suited to dormiol were of melancholia, of
depression, and of hypochrondriasis. In the excitement of
mania and of general paralysis, and even in that of epilepsy, it
failed for the most part. The dose given was in general
about 20 grs., but in some few cases it had to be raised to
45 grs. ; if this dose failed the drug was not indicated. In
other cases 12—15 grs. would suffice.

Unpleasant after-effects were practically absent, and in no in¬
stance was there any serious disturbance of respiration or circu¬
lation. The appetite was not impaired, or less so than with other
hypnotics. Habituation was not observed, nor delay in the
appearance of the effect, as may be noted, particularly in the
case of sulphonal.

In the administration care was taken not to repeat the dose
on two consecutive nights.

Digitized by

Google

502 THERAPEUTICS OF INSANITY, [July,

Dormiol may be confidently recommended as an efficient
and therefore useful hypnotic.

In the Attnales Midico-psychologiques Dr. Viallon, of Dijon,
discusses the merits of tribronio-salol as a hypnotic, and he
comes to the conclusion that it is not suited to alienist practice :
(i) because of its slight and inconstant hypnotic action ; (2) on
account of its insolubility ; (3) because of its high price.

It may be given “ in certain special cases where the patients
are docile, and it may advantageously replace bromide of
potassium on occasion .” 14 It was very inferior to other
hypnotics, such as chloral, sulphonal, trional, etc.”

To the sedative value of hyoscin hydrobromide administered
sub cute, Dr. Dorner ( Virchow's Jahresbericht, loc. at., p. 80)
testifies. He recommends it (1) in all cases of acute maniacal
excitement with destructiveness or violence, with the exception
of those cases with vivid hallucinations and delusions ; (2) in
melancholia agitans ; (3) in sleeplessness where other means
have failed.

Dorner does not find hyoscin of use in hysteria or in
psychoses which demand the continued use of sedatives.

The dose may, with caution, be raised to one or even two milli¬
grammes without danger, and be maintained at this level so
long as the heart's action is good and likewise the nutrition of
the patient.

New morphia derivatives .—We owe to Merck in particular
the synthesis of a number of morphia derivatives, upon the
physiological action of which v. Mering reports briefly in
Merck's Report, published March, 1899. Of such derivatives
three in particular have been investigated, viz. dionin or hydro¬
chlorate of ethyl morphine, heroin or the diacetic ester of
morphine, peronin, a benzoyl-morphine hydrochloride. The
first, dionin, as a substitute for morphine, has the advantages of
mildness of action and free solubility; it is, indeed, the most
soluble of the morphia salts or morphia derivatives. It has
been employed in all morbid states in which opium or morphia
are indicated, including mental conditions, though the reports of
its use in asylums are conflicting. It has been specially recom¬
mended in the treatment of morphinism during the withdrawal
of the alkaloid, and the particular value which it presents here
is that it does not produce euphoria, and so tempt the patient
on its own account; further, its free solubility causes it both to

Digitized by VjOOQle

1900.]

BY HARRINGTON SAINSBURY, M.D.

503

act rapidly and to be rapidly eliminated from the body. The
usual dosage of dionin is gr. £—£ repeated two or three times
in the day. Hypodermically the average single dose is from
£—£ gr. In morphinism the dosage is much higher, and as
much as 7—10 or even 16 grs. may be injected beneath the
skin during the course of the day (see Merck's Report, loc. at.).
Fromme prefers dionin to codein in morphinism {Schmidts
Jahrbiicher, 1899, No. 8).

Heroin, combined as the hydrochlorate. Further investigations
with this salt have discovered that it is more active than was first
thought, being decidedly more poisonous than codein, and
exerting a depressant action upon the circulation and respira¬
tion. This has led to a lowering of the dose which, formerly
prescribed in the amount of 0*005—0*02 g rm * GA—£ gr.) two
or three times daily, is now restricted to gr. ^ as the average
upper limit of the repeated dose (see Miinchener med.
Wochenschr., xlvi, 27, 1899, paper by Erich Hamach).

Peronin is not very soluble, and its usefulness is limited on
this account. It has been employed by Meltzer ( Therap.
Monatsh., 1898, p. 317) as a hypnotic in states of mental
excitement. In these states the dosage was £—2 gr., which
quantities were given without any risk {Merck, ibid., 1899).

New bromine preparations. —The prevailing employment of
bromides in all departments of medicine, but particularly in
mental disease, gives importance to any modifications of these
universal remedies. To two of these we would draw attention,
viz. bromalin and bromipin. The former, described in Merck's
1895 Report, has not been much tested till within the last two
or three years. It is an organic compound,—bromethyl formine
by name—and the special advantages which are claimed for it
are that it conveys the influence of the alkaline bromides whilst
avoiding or minimising some of their irritant effects. The
eruptions of bromism and the alimentary disturbances are thus
avoided. The theory of the salt is that it breaks up, yielding the
active bromine and an antiseptic compound—formaldehyde—the
action of which corrects the stomach and intestinal disturbances
called forth by the alkaline bromides. This treatment is an
advance upon that previously proposed by F£r£, viz. the
simultaneous administration of some intestinal disinfectant, e. g.
/3-naphthol or bismuth salicylate, along with the alkaline
bromide, but the object is the same.

Digitized by VjOOQle

504

THERAPEUTICS OF INSANITY.

[July,

Bromalin is easily soluble in water, and may be given either
in water with syrup of orange, or in cachets; the dose is
io—-30 grs. three or four times daily, i. e. about double that of
potassium bromide. Rohrmann reports recently upon its
favourable action in epilepsy, hi% experience being gained at
the Gottingen Mental Clinique.

Dr. Kothe, of Friedrichroda, discussing the treatment of
epilepsy in the Neurolog. Centralblatt of March 15th, 1900,
speaks very highly of the value of bromipin . His own
experience is limited to six cases ; but these, taken with the
reports of Gessler, Dornbliith, Schultze, and Wulff, lead to the
conclusion that in bromipin we possess an agent which has all
the powers belonging to the other bromine compounds without
their disadvantages.

Bromipin is a combination of bromine with sesame oil, a
10 per cent, solution being employed. Of this a daily dose of
from 4—8 or 10 teaspoonfuls (15—40 grms.) is most effective
in removing the seizures and in benefiting the mental state.
A further advantage lies in the nutritive value of the oil, which
is of easy digestion.

When administration by the mouth is objected to the
oil may be given as a rectal injection in the same dose
(15- 40 grms.) and with the same efficacy. When adminis¬
tered in this way Dr. Kothe has always given it as a single
dose shortly before bedtime. In no case did any rectal
irritation arise. In three of these cases Wintermitz examined
the urine and discovered hydrobromic acid in minute quantities,
proving the absorption of the drug from the bowel.

Kothe refers to Flechsig’s method of treating long-standing
cases of epilepsy, refractory to the ordinary bromide cure, by
the use of opium and of bromides in sequence, but, as he says,
this treatment requires very careful watching, and since his
knowledge of bromipin he has abandoned it. Kothe begins
with the dose of 1 5 grms., generally as a rectal injection ; this
he continues, advancing the dose if need be up to 30 Or qven
40 grms. during the next six to seven weeks ; he maintains
the dose at this level for two to three weeks, and then during
another six to seven weeks he gradually reverts to the initial
dose. This cycle is subsequently repeated more or fewer
times according to circumstances. The first course is preceded
by some weeks of rest in bed, but not the subsequent courses.

Digitized by CjOOQle

1900.] PHYSICAL CONDITIONS OF NERVOUS SYSTEM. 505

The successful treatment of epilepsy demands, he insists, a
lengthened course in the case of each and every treatment.

Iodine is in such great use in nervous diseases, in the form of
the iodides, that we may add to these statements about
bromipin that there is a similar preparation of iodine, viz.
iodipin, also in 10 per cent, solution in sesame oil. This
preparation is capable of replacing the iodides (see Merctfs
1898 Report , and those of 1899 and 1900).

A Theory concerning the Physical Conditions of the
Nervous System which are Necessary for the Produc¬
tion of States of Melancholiay Mania y etc . By John
Turner, M.B., Essex County Asylum.

Very perplexing to the student of insanity is the question
as to how states of exaltation or depression arise. On the
physical side to what changes in the nervous system do they
correspond ? And are these changes localised in different parts
of the nervous system in mania and in melancholia ; and, if so,
what is the site whose disarrangement issues in exaltation or
depression ?

To such questions as these the following hypothesis has
been brought forward as an answer :

Even if, as is very likely, it is only a provisional explanation,
it may serve a useful purpose in enabling us to form a concep¬
tion how states of exaltation and depression may arise and be
associated with a nervous system damaged in one or another
way.

It is true that Dr. Be van Lewis ( Text-book of Mental
Diseasesy 2nd edition, p. 167) states that melancholia and
mania are “serial stages in the same disease,” and that the
latter is merely a “ still lower stage of reduction ” to that which
we get in the former; while Drs. Batty Tuke and Woodhead
(see article “ Pathology ” in Diet . of Psychol. Med. y p. 899)
refer the symptoms of mania and melancholia to intensity and
rapidity of onset of the exciting cause, in melancholia the
intensity being less and the onset gradual, whilst the reverse is
the case in mania.

But neither of these assumptions helps us in the least in

Digitized by VjOOQle

506 physical conditions of nervous system, [July,

forming any idea how it is that these states arise in a dis¬
ordered nervous system.

The hypothesis here brought forward seems to me to meet
the facts of the case better than the above-mentioned, and to
enable us to form a more adequate conception of the mechanism
concerned in these states.

Stated briefly it is supposed that whilst both melancholia
and mania are associated with a dissolution of the nervous
system, in the former case the reduction takes place along
sensory lines of the reflex nervous arc, and in the latter along
motor lines.

In the present state of our vocabulary it is very difficult
without using cumbrous phrases to avoid confusing physical
processes with their mental accompaniments. In the following
pages the hypothesis is intended to apply purely to physical con¬
ditions ; the mental states associated with these are necessarily
alluded to, but what we are concerned with are nerve-cells and
nerve-fibres. No amount of jugglery with these terms can ever
convey to our minds the faintest conception of the how or why
of pain and pleasure, or of any other mental states ; it must be
sufficient for us to know that certain physical conditions are
invariably associated with certain mental states. It will, there¬
fore, be understood that when such terms as melancholia, mania,
stupor, etc., are used, that in all cases we are only dealing with
the physical changes that underlie, as it were, these psychical
states.

The doctrine of evolution teaches us that the physical sub¬
strata of all consciousness, all intellectual actions, in fact all
mind, is the sensori-motor apparatus.

The only nervous elements we know of are cells and fibres.
Fibres either convey ingoing (sensory) stimuli, or outgoing
(motor) stimuli, or stimuli passing from one cell to another.

The type of all nervous systems is the simple sensori-mq)tor
apparatus consisting of an ingoing sensory fibre ending in a
central sensory cell, from which a connecting fibre passes to a
motor cell, out of which passes a fibre leading to a muscle,
gland, etc.

The simplest nervous system consists of few such mecha¬
nisms coupled together, the highest of an infinitely large
number piled one on top of another, and connected in every
conceivable way.

Digitized by VjOOQle

1900.]

BY JOHN TURNER, M.B.

SO 7

There is no need to refer to all the properties of these
sensori-motor mechanisms. I shall only mention those which
are directly concerned with our hypothesis.

The sensory cells may be likened to detonators which
explode or discharge the motor cells.

Now when a motor cell is discharged there are facts which
tend to show that its molecular constitution is broken down,
and a more stable composition of nervous substance results, so
that to re-discharge it a stronger stimulus is needed. The
converse of such a statement leads us to suppose that the
longer a motor cell has been left undischarged the more and
more unstable its constitution becomes.

On the psychical side there are many reasons which lead us
to infer that states of restlessness, cravings, feelings of restraint,
or actual pain are associated with motor cells in a state of
high tension—cells in which energy has been accumulating and
is latent, waiting for the appropriate stimulus from the sensory
cells to get themselves discharged.

On the other hand, motor cells which get rid of their ten¬
sion (molecular instability) by free discharge, those in which
no undue tension is allowed to accumulate, are psychically
associated with a sense of freedom and well-being; as witness
the excessive mobility of young children, in whom melancholic
states are rarely met with. Emotional disturbances with tears,
sobbing, etc., being quite distinct from states of depression.

There is a very important distinction to be- borne in mind
between two sets of sensory fibres, viz. those which convey
impressions from without, through the medium of the special
senses (epi-peripheral feelings of Spencer), and those which
convey impressions from the interior of the body, from the
viscera, muscles, joints, etc. (ento-peripheral).

The impressions received through this latter class of fibres
constitute the coenaesthesia ; it has been likened to the screen
or background of consciousness on which the impressions from
the special sense organs are flung. Although the impressions
received through this second source largely enter into the
totality of feelings which constitute the ego , yet in health they
either do not enter into consciousness, or at best only impinge
as it were on its fringe. They are, as Lloyd Morgan phrases it,
marginal states of consciousness.

Feelings derived from this source are voluminous and ill-
xlvi. 3 5

Digitized by VjOOQle

508 physical conditions of nervous system, [July,

defined. They probably constitute a large part of the mental
states we term emotions. Of course emotions are vividly con¬
scious states ; what I mean to infer is that: the continuous
currents which all our lifetime stream into the central nervous
system from these sensory channels do not as a rule arouse
vivid states of consciousness, although they largely influence
such states, and give, as we say, the emotional tone to them.

It is due to the nerve-currents derived from these sources that
there originates that sense of well-being or joyousness which at
times for no very obvious reason possesses us.

Emotional states probably represent the most primitive and
oldest (phylogenetically) of our nervous states. They are
associated with all parts of the individual ; they have grown in
complexity with the increase of complexity produced by the
evolution of the organism, and are therefore more or less asso¬
ciated with every part of that organism. Hence the univer¬
sality of their effects ; we feel an emotion from the top of our
heads to the tips of our fingers and toes and all over the body.
There seems to be such a relation between the states of mind
(not necessarily conscious states) aroused by impressions from
these two channels, inner and outer, that when one is in the
ascendancy the other is low, or but little attended to. As a
rule we may say that we are, strictly speaking, conscious only
of impressions received through the channels of the special
senses. The other set, though of importance in determining
conduct and the general state of mind, carry on their transac¬
tions beyond the margins of consciousness in health. Even
during painful states, when our “ attention is distracted ” the
pain, though acute, is often disregarded—falls outside the
margin of consciousness ;—hence most pains are most acutely
felt at night, when little occurs to distract our attention.

In all melancholic states the relation between impressions
from the special senses and from the ccenaesthetic channels is
altered, so that we get a rise of subject consciousness and a fall
of object-consciousness ; melancholics all being morbidly intro¬
spective and self-absorbed. This condition is brought about
by the undue prominence given to impressions from the coen-
aesthetic sources, owing to the other channel being, as I imagine,
interfered with or blocked.

Now regarding the entire nervous system as built up of an
infinitely large number of sensori-motor mechanisms, how may

Digitized by VjOOQle

1900.] BY JOHN TURNER, M.B. 509

we account for melancholic states when the system suffers a
reduction from disorder of some one or other part of it

Postulating that the sensory cells act as dischargers to the
motor, and that nervous currents are constantly streaming in to
the central nervous stations from every afferent channel,
whilst energy is likewise constantly accumulating in the motor
cells, in health the central sensory cells send currents in suffi¬
cient number and intensity to the motor cells to discharge them
and prevent undue accumulation of energy, by which means the
bodily activity is maintained. But if from any reason these
sensory cells are rendered functionless, or the impressions they
usually receive are hindered from entering them, then energy
must accumulate to excess in the motor cells. There is pent-
up activity, and the condition is accompanied by more or less
acute feelings of uneasiness, restraint, dulness, or actual pain.
Ultimately a time comes in most cases when the tension is so
high that the molecular equilibrium overturns itself, as it were,
and the result is an outburst of motor activity.

That we must rid ourselves somehow or other of superfluous
energy is exemplified well in the case of many idiots. Their
sensory inlets are in most cases largely unused. Their eyes
and ears respectively appear to absorb but few impressions, their
tactile sensibility is much blunted, taste is often nearly abolished,
although the appetite remains. The result of this cutting off
of sensory impressions is that energy accumulates, which gets
itself expended in apparently purposeless and often unceasing
movements ; they rock themselves to and fro all day long, or
scream or breathe rapidly and noisily, like an engine letting off
steam, which is practically what they are doing. They should
be melancholic, but to be so implies the possession of more in¬
tellectual faculties than they possess.

It must be supposed (to account for the distressing feelings)
that this accumulation of energy in motor cells is accompanied
by some leakage along the outgoing fibres. We are not deal¬
ing with one cell, but large groups of cells coupled together, and
it is possible that of this number some are discharged and give
rise to the feelings described, whilst the remainder are not dis¬
charged. Of course it is only when the group in its entirety
is discharged that the appropriate feeling or action associated
with it is realised. There are many observations in support of
such an assumption ; to give an example—we have all ex-

Digitized by VjOOQle

510 PHYSICAL CONDITIONS OF NERVOUS SYSTEM, [July,

perienced the uneasy feeling that arises when we cannot recall
a familiar name, although it is in common parlance “ on the tip
of the tongue.” We try various devices to alight on the proper
stimulus to set free the motor cells. At last it comes, often
when we have given up thinking about the matter, and with a
feeling of relief and satisfaction the word is uttered. In this
case the uneasy feeling is probably caused by an imperfect dis¬
charge from the particular cell-group concerned. It does not
seem at all likely that it can have its seat on the sensory side
of the mechanism, because immediately the right cue is hit upon
—which represents, surely, the needed stimulus—the word is
recalled and uttered.

Another instance is shown by the feeling which accompanies
some intense forms of grief, where the individual is said to be
stunned by his sorrow, and in which relief is experienced as
soon as he can give expression to his feelings, generally by
tears.

Some cases of melancholia never show motor outbursts ; it is
to be presumed in such that the accumulation of energy is not
greater than the cell can get rid of, which implies that in such
cases there must be a very much diminished accumulation, due
to general sluggishness of all the vital functions.

Stupor and melancholia would, on this hypothesis, both
depend on reduction along sensory lines, but probably stupor
represents a more universal or more intense reduction than
simple melancholia.

It would appear likely that a blocking or annulling of the
sensory channels anywhere between periphery and centre might
originate melancholia, and to a certain extent this is borne out
by this disorder appearing sometimes after cases of sudden
deafness due to peripheral defect.

Having indicated how dissolutions occurring in the sensory
sphere will give rise to melancholic states, it remains to describe
how states of exaltation and manias are brought about.

A few words only are necessary, as the condition is obviously
very much the reverse of the last. The other side of the reflex
mechanism—the motor sphere—is here affected. As cutting off
higher sensory centres leads to accumulation of energy in the
motor cells, and hindered activities, so cutting off higher motor
centres leads to a freer expenditure of energy in the remaining
motor cell levels.

Digitized by VjOOQle

igoo.]

BY JOHN TURNER, M.B.

511

The free intercommunications which in all probability connect
not only centres on the same level, but also those on different
levels, afford increased facilities for the remaining motor centres
to get their energy expended. We get a large influx of sensory
impressions arriving at the central nervous stations with fewer
motor cells to act on ; these sensory impulses become less
spread out, more concentrated, and more likely to exert suffi¬
cient force on the motor cells to produce action.

The stimulus pouring in through sensory channels, unable to
expend itself on its accustomed motor cells, does so on other
and less closely connected centres by roundabout routes, and
hence the incoherence of thought and action in these conditions.

In conclusion, I should like to draw attention to the fact
that the only condition of melancholia which has a pathological
basis capable at present of demonstration gives some counten¬
ance to the present theory.

There is a fairly well-defined group of melancholic cases,
usually terminating quickly in dementia, which present a
definite alteration in the majority of the giant and pyramidal
nerve-cells of the cortex.

Now these cells, especially the former, we have good reason
for regarding as higher level motor cells.

The alteration is identical with that produced experimentally
after section of the '1x0ns of motor cells.

It was first noticed, I believe by Dr. Wiglesworth, in certain
cases of melancholia atonita, and described by him in this
Journal in 1883 ; he, however, was inclined to regard the
alteration as of an inflammatory nature.

Now W. B. Warrington (Joum . Physiol ., Cambridge, vol.
xxiii, 1898, pp. 112 — 129) has shown that this change can
also be produced in certain of the anterior cornual cells by
dividing the posterior nerve-roots, and the reason he gives is the
withdrawal of the afferent impulses which normally impinge
on the cornual cells. If this is so, and for the moment grant¬
ing my assumptions, then the reason that in these melancholic
cases the motor nerve-cells of the cortex are affected is also to
be ascribed to the cutting off of the sensory impressions which
normally stream in and affect them.

It is interesting in this connection to note that certain cases
of imbecility, also, present these cells characteristic of divided
axons. Now there is notoriously in imbeciles a blunting of all

Digitized by VjOOQle

512

CLINICAL NOTES AND CASES.

[July,

or most of the senses, and a corresponding lack of sensory
impulses to the higher motor cells, which is sufficient, on

Warrington’s supposition, to account for their occurrence in

these cases.

Clinical Notes and Cases.

Case of Glioma of the Corpus Callosumf ) By C. Mabel

Blackwood, Assistant Medical Officer, Wadsley Asylum.

TUMOURS of the substance of the brain as a cause of mental
disease appear to be of comparatively infrequent occurrence,
some authorities having stated the number found on post¬
mortem examinations to be as few as 2 per 1000. The
name glioma, which has been given to the special form of
brain tumour, has been applied to different kinds, and more
usually to a variety of small round-cell sarcoma.

Virchow described and specified under this name a tumour
composed of tissue resembling ordinary neuroglia, and this type
appears to be much less common.

Payne mentions that a combination of the two may be met
with, though he gives the subject scanty consideration.

The form of tumour brought under notice to-day appears to
be of some interest, as belonging to the last class and being of
comparative rarity.

The primary site of the tumour was the posterior two thirds
of the corpus callosum. Thence it extended on either side,
vertically upwards, and laterally to within half an inch of the
cerebral cortex, and involved to some extent the gyrus fomi-
catus. It pressed on the lateral ventricles, partially occluding
them. The ependyma of their roof and also floor was affected.
The basal ganglia, however, were normal. The tumour was
not encapsuled, and seemed to merge indefinitely into the
white matter.

The greater part was situated above the roof of each lateral
ventricle, and each half was about the size of a pigeon’s egg.
It was soft in consistence, greyish or reddish grey in colour ;

Digitized by VjOOQle

1900 .]

CLINICAL NOTES AND CASES.

513

parts were gelatinous, and other parts translucent. Through¬
out were found small haemorrhages and cysts full of straw-
coloured clear fluid, a considerable amount of degeneration
having occurred. The pons was soft and disorganised, but the
spinal cord showed no marked change.

The skull cap was thin, the membranes normal, the convolu¬
tions somewhat atrophied and flattened.

As regards the other organs, the lungs showed evidence of
pneumonic consolidation. No other growth was found in any
part of the body.

On microscopic examination the cortical cells of the left
ascending frontal convolution showed granular degeneration.
They were diffusely stained and irregular in contour. The
blood-vessels had thickened coats. Portions of the tumours
were treated by the paraffin method, and stained in various
ways. Under a low power the field is seen to be studded with
nuclei, the cell-substance not being visible, and between them
is an indefinite intercellular substance. A number of blood¬
vessels are present, and the nuclei are more thickly clustered in
their neighbourhood. Under a high power the cells of which
the tumour is composed are distinctly seen. One type is
roughly ovoid, with angles where processes are given off. The
smaller cells have single nuclei, the largest as many as three
or four. The cell-substance is faintly granular, and the intra¬
nuclear network is well shown. From the cells pass off several
processes which interlace and form a network. These cells,
which are modifications of those of normal neuroglia, are more
numerous in the neighbourhood of blood-vessels. The vessels
are fairly well formed, and their endothelial plates are easily
made out. There are numerous small haemorrhages, and a
certain amount of pigmentary deposit which, occurring chiefly
in the neighbourhood of vessels, is evidently due to extravasa¬
tion of blood.

In other parts of the tumour the cells more nearly approach
the sarcomatous type, though they have not the embryonic
character of those of true sarcoma. Some of them are of the
small round variety with large nuclei, and in such parts of the
tumour as they are found there is greater vascularity and
haemorrhages are more numerous. The reticulum here is fine
in character. Elsewhere numerous spindle-shaped cells are
observed, and here the reticulum is of a denser and coarser

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

5*4

[July,

character, giving rise to the impression that the shape of the
cell is due to pressure.

The subject of the tumour was a man aged fifty-six, with a
hereditary predisposition to insanity, who had had previous
attacks, but of these no definite information could be obtained.
His last attack ran a rapid course, as he died four weeks after
his admission into Wadsley Asylum, and it was stated that his
more marked symptoms had only existed for a week previous
to his admission.

Physically, he was very feeble; his gait was lurching, and
there was distinct tremulousness of his lips and limbs. His
pupils were small, gave a limited reaction to light and accom¬
modation, and his vision was not good. His hearing was fair.
His superficial and patellar reflexes were increased. Mentally,
his intelligence was much diminished and his memory was very
poor. He had vague fears of impending evil, and was very
restless in his habits. He soon became very drowsy, and
latterly semi-comatose, and died without exhibiting any further
symptoms of importance. During his residence he had no
convulsions.

The clinical history of this patient shows the vagueness
of the symptoms in the case of a tumour of the corpus
callosum, and the consequent difficulty of diagnosis. In such
cases as have been recorded the cardinal symptoms of cerebral
tumour—convulsions proceeding in definite sequence, headache,
vomiting, etc.—appear to be very inconstant. The most
obvious symptoms seem to be advancing dementia, drowsiness,
and paresis. These are held to point to brain tumour, and the
absence of any other marked symptoms is stated to localise
the site in the corpus callosum. In the case just described
the clinical history of the patient and the vascularity of the
tumour appear to show that the latter was of fairly rapid
growth.

Description of Photo.

The photo was taken with the camera directed vertically downwards on the speci¬
men. The anterior third of the brain has been removed by a vertical incision. The
corpus callosum has been divided, and the parts turned outwards on each side.
Incisions through the basal ganglia, and also incisions through the tumour about
the level of the gyrus fornicatus have been made on each side.

The cut surface of the tumour is seen in four places. The lateral ventricles are
beneath the surfaces of the two inner portions of the tumour.

(*) Read at the Spring Meeting of the Northern Division of the Medico-
Psychological Association, 18th April, 1900.

Digitized by tjOOQle

JOURNAL OF MENTAL SCIENCE, JULY,

Digitized by

Google

To illustrate case by C. Mabel Blackwood, L.RC.P.Edin.

Digitized by VjOOQle

1900 .]

CLINICAL NOTES AND CASES.

SIS

Foreign Bodies in both Bronchi; Broncho-pneumonia;
Death . By Francis O. Simpson, L.R.C.P.Lond.,
M.R.C.S.Eng., Senior Assistant Medical Officer, Lancaster
County Asylum, Rainhill.

The following case appears to me to be unique, and there¬
fore worth placing on record :

The patient came under my care in the Govan District Lunatic
Asylum, to which he was transferred from the Govan Parochial Asylum,
on July 28th, 1898. He was suffering from epileptic dementia, which
was so profound that he could scarcely tell his name, and was totally
unable to answer any other question addressed to him. He was untidy
and dirty in his person and habits, and subject to attacks of post¬
epileptic furor, and violence to those around him. His physical con¬
dition on admission was fairly good. The pupils were equal and myotic,
the right reacting very sluggishly, the left readily to light. The patellar
reflexes were exaggerated.

The progress of this case was uneventful until May 18th, 1899, when
he was seized with violent cough and great difficulty of breathing at
5.30 a.m. There was no history of any epileptic attack having occurred
during the night, and, as he was found to be suffering from lobular
pneumonia of both lungs, he was ordered a sedative expectorant
mixture.

The case presented the usual symptoms, excepting that there was
most marked orthopnoea present throughout, though the patient
exhibited no cyanosis whatever. The respiratory rate, too, was noticed
to be very disproportionate to the elevation of temperature and of
frequency in the pulse; for, whilst the respirations varied from 30 to 41
per minute, the temperature never rose beyond ior8° F., nor the pulse
above 108 per minute.

The patient lasted rather over four days from the first onset of
symptoms, dying on May 22nd, 1899, at 11.30 a.m.

The autopsy was performed twenty-three hours later, the weather
being cold and damp. There were numerous old white scars upon the
skin covering the occiput. The skull was rather asymmetrical and the
thickness considerably increased throughout. The membranes were
normal, but the left lateral and superior longitudinal sinuses were
thrombosed. The brain weight was 1395 grammes, and the hemi¬
spheres were unequal, the right weighing 595 and the left 615 grammes.
The cortex was considerably atrophied, and the white substance con¬
gested and oedematous, the total fluid collected measuring six ounces.
The ventricles were of average size, and their ependymata were smooth.
There was no sign of any sclerosis of the cortex nor of the cornu
Ammonis. In the region of the left olfactory nerve and bulb there was
an area of yellow softening, irregularly oval in shape, surrounding these
structures in their whole extent, and involving both the cortex and
subjacent white matter. On section of the olfactory bulb, there was

Digitized by

Google

5 1 6 CLINICAL NOTES AND CASES. [July,

seen to be a small central portion only which did not appear to be
affected to the naked eye.

The heart weighed 625 grammes, and was normal in every respect.

The right lung was firmly fixed in its cavity by old pleuritic adhesions.
It weighed 980 grammes, and was in a most marked condition of lobular
pneumonia throughout, being also very cedematous at the base. A
large piece of the bowl of a clay pipe was found wedged firmly into the
right bronchus about half an inch below the bifurcation of the trachea.
The bronchial mucous membrane was congested at the seat of impaction,
but showed no sign of erosion. The left lung weighed 1080 grammes,
and was free in its cavity. It was in a precisely similar condition to its
fellow of the opposite side. A rather smaller piece of the bowl of a clay
pipe was found firmly impacted in the left bronchus in a similar position
to that already described on the right side. The lining membrane was
here, also, congested, but not eroded. The bronchial glands were much
enlarged upon both sides.

The kidneys were in an advanced stage of interstitial nephritis. The
other organs do not call for special comment.

It was only subsequently to the post-mortem examination
that I ascertained that this man had been in the habit of
chewing pieces of broken-up tobacco-pipe when he was unable
to obtain the weed itself.

Whether the foreign bodies had been inhaled into the air-
passages during the clonic stage of an epileptic seizure, or
whether the patient had gone to bed with them in his mouth,
and inspired them automatically during sleep, it is very difficult
to say, but the latter seems to be the more probable hypo¬
thesis, as it would appear impossible for such irritating sub¬
stances to be dormant for even a short period.

Nothing further could have been done to prolong this man’s
life. It was impossible to diagnose the condition with cer¬
tainty because of the distressing orthopnoea, which became
much aggravated and threatened to prove fatal whenever any
attempt was made to raise him from the bed-rest. The bodies
were jammed so firmly into the bronchi that it was impossible
to pass a small probe between them and the lining membrane
at any part of their circumference, and the jagged edges were
buried in the mucous membrane by any attempt at extraction
with dissecting forceps, so that even had the condition been
diagnosed during life and the patient inverted, it is extremely
improbable that they could have been dislodged.

Digitized by VjOOQle

1900 .]

CLINICAL NOTES AND CASES.

517

Emphysema of Subcutaneous Areolar Tissue occurring
in a case of Stuporous Melancholia. By Thomas
Philip Cowen, M.D.Lond., County Asylum, Prestwich.

I was much interested in Dr. Conolly Norman’s account of
a case of “ Emphysema of Subcutaneous Areolar Tissue occur¬
ring in a case of Acute Mania,” published in The Journal of
Mental Science , October, 1899. A somewhat similar case
occurred in the County Asylum, Prestwich, in 1892, of which
I give a short history.

G. McE—, aet. 20, single, a seaman, was admitted December 9th,

1892, suffering from stuporous melancholia. His previous history
presented nothing of special interest. His mental disturbance com¬
menced six weeks before admission with the usual symptoms of melan¬
cholia with gradually increasing stupor. He had been fed with soft
oesophageal tube on several occasions before admission.

On admission .—A short, slight, thin young man. His ribs showed
slight evidences of rickets (rosary of lower ribs). His thoracic and
abdominal viscera are quite healthy. He is in a condition of melan¬
cholic stupor with proximal rigidity. Will not speak ; collects saliva in
his mouth. He refuses food, and has to be fed with feeding-cup. Has
retention of urine, and catheter has to be used. He was not fed with
feeding-tube until after he had been in the asylum for ten days.

December 18th.—It is noted that “he remains in a state of melan¬
cholic stupor. Keeps blowing his cheeks out and holding his breath
until it seems as if he would burst; this he has done for the last three
days. To-day a subcutaneous emphysema of face and neck was noticed.
There was no injury, nor can any phthisical condition of lungs be
made out.”

The emphysema gradually spread during the next day over upper
part of chest and shoulders, and apparently equally so on both sides of
the body. He still continued the violent effort of holding his breath
and ballooning out his cheeks. A week later he ceased these violent
exercises, and the emphysema gradually subsided.

He gradually improved, and was discharged recovered May 16th,

1893, having got quite fat (increased nearly three stone in weight).

Remarks .—In this case there was no suspicion of injury to ribs or

throat by external violence. No subcutaneous injections had been
given. A soft feeding-tube had been used, it is true, before ad¬
mission, but not until ten days later in the asylum, i. e. several days
after the appearance of the emphysema.

There was not the least sign of emphysema until some six days after
admission, and I do not think that the feeding-tube used before
admission had anything to do with its causation. That it was caused
by “ straining,” and so rupturing a portion of the apex of one lung by

Digitized by VjOOQle

OCCASIONAL NOTES.

[July,

518

over-distension, I have not the least doubt, and may I suggest that,
in Dr. Norman’s case, it was not the strain caused by excessive
shouting, but the increase of intra-thoracic pressure in resisting any¬
thing being done for her by the attendants.

Such cases are, indeed, very rare, and I cannot find any other record
of a similar case in this asylum.

Occasional Notes.

Crook v. Crook and Horrocks .

Dr. CROOK sought a dissolution of marriage on the ground
of the adultery of his wife with Dr. Horrocks. Mrs. Crook
suffered from some uterine trouble, for which, under her
husband's advice, she consulted Dr. Horrocks. She visited the
latter at his consulting-rooms, and stayed for two or three days
at a nursing home near by. The attendance lasted, at intervals
which do not appear to have been absolutely frequent, and
were certainly not increasingly frequent, from November, 1896,
to October, 1898. In May, 1898, Mrs. Crook, who had been
married in 1891, had her first child. In November, 1899, she
suddenly came into the room in which Dr. Crook was sitting
and said to him, “ I have something I must tell you. I have
broken the seventh commandment” On being asked when it
happened and who was the man, she replied, " Heaps of times
with Dr. Horrocks.” Asked why she did not tell it before, she
said that she did not wish to get other people into trouble, but
it was unhappily only too true. She repeated the statement in
various forms. She also said that Dr. Horrocks had the most
extraordinary influence over her, and that she never ought to
have seen him. It is remarkable that after making her con¬
fession she asked her husband with what appeared to him to
be perfect good faith, “ What does committing adultery mean ? ”
Subsequently she made a confession in writing, and, in reply to
questions, said that the very first time she saw Dr. Horrocks
they kissed each other, and that on each subsequent occasion
of her seeing him at his consulting-rooms they committed
adultery. The witnesses agreed that she was a woman of very
ladylike and modest demeanour.

Digitized by

Google

1900.]

OCCASIONAL NOTES.

519

In July, 1899, Dr. Crook consulted a woman who professed
palmistry in Margate. He was impressed by what she told him,
and communicated this impression to his wife. In August
Mrs. Crook went to the woman, who told her that her marriage
lines were broken, but not by death ; that she had been un¬
faithful to her husband, and that there would be a dreadful
scandal.

When Dr. Crook took proceedings against his wife, the latter
naturally placed herself in the hands of her solicitors, who, it
appears, were so impressed by her demeanour, that they advised
her to consult Dr. Savage. She did so on December 13th,
1899, and, having seen her, Dr. Savage wrote to Dr. Crook
expressing the opinion that the charges that she had made
against herself were probably only hysterical fancies, and
suggested the same to the patient. She made answer, “ That
is not my case; mine is true,” but subsequently she declared
that the whole thing was a delusion on her part, due to the
powerful impression made upon her by the declaration of the
palmist. The President summed up with the most absolute
impartiality, and without giving the jury any indication of a
lead, and the jury disagreed, and were equally divided. Probate
and Divorce Division, March 2nd, 5th, 7th, and 8th, 1900,
Times , following dates.

Such is a very brief rtsumt of the facts of this case, a case
of great psychological interest. The story of Mrs. Crook’s
adultery rests entirely upon her own uncorroborated confession,
a confession which she subsequently withdrew. But it is to be
remarked that before withdrawing it she adhered to it for
several months, and that she was fully aware in making it of
the terrible consequences that it would entail, not only upon
herself but on Dr. Horrocks, and that in spite of this spon¬
taneously, and without any sort of provocation, or occasion ;
without any prospect of deriving benefit for herself or her
child, or anyone dear to her; without, in short, any discernible
motive; she did in fact make this accusation against herself and
him. The question that presents itself to every student of the
human mind is, What was her motive in making this confession,
a , supposing it was true ; b , supposing it was false ?

Supposing that her confession was true, the motive naturally
alleged by Dr. Crook’s counsel was that of remorse. “ Why
on earth, it was asked, should she suddenly have confessed her

Digitized by VjOOQle

520

OCCASIONAL NOTES.

[July,

guilt after years of silence ? Why did Constance Kent seven
years after the murder of the child confess from the seclusion
of her retreat ? From the motive that had made thousands of
persons confess since the world began—namely to unburden
her mind.” This is a very fair argument and, granting the
truth of the confession, there is nothing inconsistent with ex¬
perience in the confession being delayed for months and even
years. But the whole story told by Mrs. Crook is intrinsically
so extremely improbable, that were it not balanced by the
improbability that any sane person would make such an accu¬
sation against herself if it were not true, no one would believe
it. But of these improbabilities the second is undoubtedly the
greater. Granting that Mrs. Crook was in all respects sane at
the time of her confession, either her story is true, or in confes¬
sing falsely she was actuated by an undiscoverable sane motive.
But the circumstances of her life are so well known to her
relatives as practically to destroy this latter alternative, so that
the question that the jury had to determine was practically
whether Mrs. Crook's statement was true, or whether her state¬
ment was the outcome of disorder of mind.

Primd facie her story is improbable in the extreme. She
herself is a woman not only of irreproachable record, but of the
most marked and distinguished modesty of demeanour. On
the other hand, Dr. Horrocks’ record is equally irreproachable.
The members of every calling live, with respect to their col¬
leagues in that calling, in houses of glass. Every carriage-
builder in Long Acre knows of every other carriage-builder in
that street whether his work is honest or shoddy, how he treats
his workpeople, and all the details of his modes of managing
his business. Every solicitor in London knows enough about
every leading firm of solicitors to be confident as to whether, in
dealing with them, he may expect fair treatment or sharp
practice. And every practitioner in the neighbourhood of
Cavendish Square knows quite well the general ethics of all the
leading consultants in their dealing with their patients. If a
surgeon has ever so slight a tendency to operate too frequently;
if a specialist takes ever so little too generous a view of the
limits of his speciality; if any practitioner is the least inclined
to see his patients too frequently ; every one knows of it. All
his colleagues are quite well aware of his peculiarities, and if
such a thing should happen as that a physician should exhibit

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

521

gallantry towards his lady patients, not only would all the
Portland estate ring with it, but not a practitioner in the country
but would hear of it. That a man against whom the slightest
shadow of suspicion of such a thing could exist could have been
recently elected to the Examinership of the London University
is utterly out of the question. And yet if we are to believe
Mrs. Crook we must believe, not only that this modest, delicate-
minded woman, who did not even know the meaning of the
word adultery, kissed Dr. Horrocks the first time she ever saw
him, and committed adultery with him the second time, but that
Dr. Horrocks belied the record of his lifetime by displaying
towards a patient, and that patient the wife of a brother prac¬
titioner, conduct that would revolt a Yahoo. Nemo repente
turpissimus , says the old adage. How then shall we believe
that any man, least of all a man of acknowledged probity and
honour, could become turpissimus repentissime ? Such con¬
siderations compel us to turn to the consideration of the state
of mind of Mrs. Crook, to see whether in that we can find an
explanation of her confession.

When Mrs. Crook withdrew her confession she attributed
her delusion, as she then called it, to the influence of the
palmist. This woman was first visited by Dr. Crook, who
appears to have been deeply impressed by her, and who talked
to his wife about her. Subsequently the wife goes to her and
is told positively that she has committed adultery, and that
there will be a great scandal. Her own account is that she
was shocked and horrified at the statement, and that she
brooded over it continuously until she persuaded herself that it
was true. Whatever the palmist had told her husband was
true, and therefore whatever the palmist told her must also be
true ; and at length she was convinced that it was true. After
three months brooding over the matter she made her con¬
fession.

To the ordinary hard-headed juryman this story seems at
least as unlikely as the other ; but the question to the student
of psychology is, “ Is this story consistent with known facts ?
Is it consistent with experience that a person should falsely
accuse herself under the influence of a delusion manufactured,
as it were, by the promptings of another person ? Have we
any facts to guide us ? ” False confessions from which the con¬
fessing party does not seek to derive benefit are not very un-

Digitized by VjOOQle

522

OCCASIONAL NOTES.

[July,

common. Whenever a very notorious crime is committed and
the crime remains undiscovered, two or three sots are sure to
come forward and confess to it ; but these cases have no bear¬
ing on the present one. That insane persons very frequently
accuse themselves falsely of all kinds of crimes and wickedness
is, of course, well known ; but then such persons manifest their
insanity in other ways, and it is never in doubt, and Mrs. Crook
evidently did not belong to this class. If her mind was
unsound at all, it was unsound with reference to this particular
subject only, and cases of ordinary melancholia exhibit no exact
parallelism with hers.

No one who has witnessed the growth of an uneasy suspicion
of general unworthiness into a delusion of wickedness of a par¬
ticular kind, can doubt that, in a susceptible mind, the constant
brooding upon a specific subject may contribute to the develop¬
ment of a delusion upon that subject. The growth of definite
delusions in this manner is quite a common occurrence. It is
true that the growth is not ordinarily traceable to suggestion
from without. The suggestion usually comes from within, and
is combated by those who surround the patient; but it is easy
to recognise that if there existed any tendency to self-deprecia¬
tion, a suggestion of criminality made from without, in a very
positive manner, by a person believed to have exceptional and
supernatural knowledge, would at once carry conviction, and
give rise to a delusion. Such events are not now common,
because self-depreciatory persons are carefully guarded against
suggestions of the kind, but the time was when they were very
common. Undoubtedly many of the confessions of witchcraft
were due entirely to suggestion from without. It is undoubted
that many of these confessions were extorted by torture, and are
therefore valueless; and it is undoubted that some of them were
deliberately made for a suicidal pufpose. It is probable, also, that,
as pointed out by Hume, in some of these cases the accused had
actually employed means which they bona fide believed would
raise the devil or injure others through his means. But still
there remains a residue of cases in which the influence of sugges¬
tion alone remains to account for the confession. In the well-
known case, for instance, of Isobel Gowdie, there appears to
have been no influence operative beyond mere suggestion, and
the same may be said of that notorious witch, Bessie Dunlop.
Moreover, there is a case recorded by Sir George Mackenzie of

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

523

a woman who was willing to confess that she was a witch, but
asked first if a woman might be a witch and not know it, a
position not very different from that of confessing to adultery
without knowing the meaning of the word. Of the influence
of hypnotism, and how far an hypnotic state might be respon¬
sible for such a confession as that of Mrs. Crook, it is useless to
speak, for I do not pretend to any knowledge of hypnotism,
and the professors of that art, while they are agreed that under
its influence any susceptible person may be made to do any¬
thing, are agreed, also, that no person can by its influence be
induced to commit a crime ; and as the making of a confession
of this nature is, if the confession is false, several degrees worse
than the crime itself, it would seem that the exercise by the
palmist of an hypnotic influence is excluded.

There is, at any rate, no doubt that many persons have, under
the influence of suggestion from others, believed themselves
guilty of crimes which they had never committed, and, under
the influence of this belief, have made confessions in which the
purely imaginary crimes were described with minute particu¬
larity of detail; nor that these confessions were made in full
view of the terrible consequences that it was known they would
entail. If we balance the two alternatives, on the one hand,
whether both Mrs. Crook and Dr. Horrocks suddenly and simul¬
taneously underwent a sudden and total revolution in their
whole natures, and gave the lie to the whole of their past lives;
or, on the other hand, whether Mrs. Crook was the victim of a
delusion arising under circumstances peculiarly provocative of
delusion, and known to have produced delirium in many pre¬
vious instances, we cannot, under the ordinary canons of proba¬
bility, avoid giving our adhesion very decidedly to the latter
hypothesis. C. MERCIER.

Degeneracy and the Increase of Diseases of the Nervous System

and Insanity .

Dr. Ireland has recently attacked these problems^ 1 ) and
although “ always with us,” like the poor, they are and must
remain of perennial interest, since the factors on # which their
solution depends are ever varying, never constant.

“ Degeneracy ” has been charged against every nation, in
xlvi. 36

Digitized by VjOOQle

524

OCCASIONAL NOTES.

[July.

every age, but in most instances the charge has been refuted by
events, and in few can it be deemed to have been proven.

Nervous diseases, suicide, and insanity are usually taken as
the pathological evidences of degeneration in a community.
It might be also argued that they were evidences of evolution ;
the stress, of rising to higher standards of nervous and mental
activity, breaking down weaklings who in less progressive com¬
munities would fail from physical disease. These forms of
disease, again, may easily replace other diseases, from changed
conditions of living, without constituting evidence of general
degeneracy.

The statistics of deaths from diseases of the brain and
nervous system in Scotland, quoted by Dr. Ireland, show that
these have increased by about a third since 1855. During the
same period deaths both from heart disease and from disease of
the urinary organs have doubled ; many other diseases, on the
contrary, have greatly diminished.

The census returns show that there has been an enormous
increase since 1855 in the number of persons living aged fifty
years and upwards,—at ages, that is, when fatal nervous diseases
(apoplexy, paralysis, convulsions, etc.), kidney and heart disease,
are most likely to occur. This, if true, would certainly not
point to degeneracy as their origin, but rather to the increase of
longevity.

Statistics of suicide, again, demonstrate that (*) the increase
in England has been much greater in men than in women,
and especially in men from forty-four years of age onwards.
If the suicidal act were the outcome of national degeneracy,
the increase in the two sexes should be more equal, and pro¬
bably more evenly distributed over the age periods.

The increase of insanity has been so fully and so recently
reported on, by both English and Scotch Lunacy Commissions,
that nothing need be said on this point

The causes of disease, as well as the age periods of the com¬
munity, are, moreover, continually changing. Alcohol, for
example, is probably becoming a smaller aetiological power, but
the great increase of the number of narcotic and sedative drugs,
and their wide-spread abuse in the very accessible and portable
form of tabloids, is probably answerable for an enormous
amount of nervous disease. This may ultimately cause degene¬
racy, but is certainly not a result of it.

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

525

Physical degeneracy, as evidenced by a lowering of the
average stature of our army recruits, is surely of little worth in
a country such as England, where so many occupations demand
men of superior stature. Moreover the stature of the people
is rising in France and other countries, where nervous and
mental diseases are very numerous.

The moral degeneracy, manifested according to Nordau in
literary and artistic tendencies, can be traced for the most part
to the licence which has accompanied the emancipation of
thought from traditional bondage, and constitutes but a small
proportion to the total output of normal art and literature.

Degeneracy, again, is scarcely compatible with the statistically
proven increase in the duration of life which is taking place in
Great Britain.

The census statistics record that the number of mentally
deficient persons under the age of forty-five has not materially
increased; yet these are the age periods in which hereditary
degeneracy should be most pronounced if it were a fact.

Civilisation is, undoubtedly, attended with many evils, arising
from the new temptations to self-indulgence or self-sacrifice
which it offers. The individuals who exercise self-restraint in
the face of these temptations make a distinct step in evolution ;
while those who do not, break down and are classed as degene¬
rates ; evolution and such degeneracy are thus found side by
side, but the latter tends to extinction, the former to survival
and development.

Degeneracy, indeed, needs to be defined, and the defects of
growth, energy, self-control, life-duration, and disease, which
are evidence of it, must be distinguished from the same condi¬
tions resulting from other causes before any satisfactory con¬
clusion can be formed of its existence or of its extent.

In Notes and Queries of this issue definition is asked of the
meaning of the term degenerate. The essence of the question
is, whether degeneracy is meant to signify a failure to develop
to the existing normal standard, or whether it implies an actual
retro-evolution. If the former, how does it differ from disease;
if the latter, what are its distinguishing characteristics.

( J ) International Monthly , March, 1900, and Scottish Medical and Surgical
Journal, May, 1900.—(•) Sec Journal of Mental Science , January, 1897, p. 115.

Digitized by VjOOQle

526

OCCASIONAL NOTES.

[July,

The Strife with Alcohol.

The period of the year has come when the statistics of drink
are being presented to the public, and when the advocates of
temperance are making themselves more loudly heard than
usual. We have no desire to discuss the very puzzling statistics
which are placed before us, which seem to prove some facts
oddly at variance with common notions ; for. instance, that a
luxurious use of intoxicating drinks is increasing in some circles
in these islands, and that Englishmen are very much more
drunken than Scottish or Irish folk.

Neither do we desire to figure among those wonderful econo¬
mists who seem to think that all the world would be very rich
if most of the world were a little more sober.

Finally, we are not anxious to take a place among the “ unco*
guid,” or to gain credit with the rigidly righteous by denouncing
vices the temptations to which are probably not those which
specially beset our particular mode of life.

But there are no people in the world who see much more of
the ruinous effects of drink than do those who practise in our
specialty, and it is the duty of the alienist to bear evidence to
the truth in this, as in any other matter where his special oppor¬
tunities enable him to be of service to society, by pointing out
what he knows to be grave social dangers.

We do not hold in the infallibility of asylum statistics, but
there must, we believe, be some significance in the following
figures. In the five county asylums for London in the year
1897 intemperance in drink was more often assigned as a
cause of the insanity of those admitted than any other cause
except “ hereditary influences ” and “ previous attacks.” Omit¬
ting “ previous attacks,” which, if legitimately classed as a cause,
certainly form a factor not easily comparable with other aetiolo-
gical items, we find drink standing second only to heredity, which
it generally runs very close, while in one asylum the number of
cases attributed to drink actually outstrips the number attributed
to hereditary influence. Again, taking Table xxvi of the last
‘ Report of the Commissioners in Lunacy,* which shows by
yearly averages the assigned cause of insanity in the patients
admitted to all asylums, private and public, in England and
Wales during the five years 1893-7 inclusive, we find intem¬
perance in drink standing for the male sex absolutely at the

Digitized by VjOOQle

OCCASIONAL NOTES.

527

1900.]

head of the list, with a percentage of 21*4 for private male
cases, and a percentage of 22 # i for pauper male cases ; heredi¬
tary influences, which come next, only showing the respective
percentages of 21*3 and 20*3. Among women the Commis¬
sioners’ table shows a much smaller proportion of drink cases,
but still not an inconsiderable one—8‘6 per cent, for private, and
9*i per cent, for pauper cases. It thus seems from these
statistics, which are compiled from information supplied by
members of our Association, that in the London district drink
is answerable for almost one fifth of the cases of insanity which
occur, and in the country generally for rather more than one
fifth of the cases of insanity in the male sex. It is needless
here to say that the sum of misery and degradation resulting
from intemperance is not to be measured solely by such
statistics, which we quote with reservation.

We are not blind to the many contributing elements which
go to increase the force of the drink craving, to the wretched
housing of the poor, to the absence of provision for rational
amusement and recreation of the people, to the demoralisation
which results from the disintegration of social life among the
struggling masses in our great centres of population ; to the
dangers of a civilisation which is progressing too quickly for
the health of the weaker members of society ; but we hold
that the state of affairs shown by the figures quoted above is
one which calls for the earnest consideration of every humane
man. And these figures are in general accordance with the
experience of all of us.

The absurdities into which the wholesale advocates of a good
cause have been sometimes led, “ the intemperance of temper¬
ance enthusiasts,” have tended to make sober-minded men
somewhat shy of dealing with this subject; but these absurdities
should not cause us to hesitate to do whatever lies in our
power to rectify so great an evil. We can be useful chiefly by
helping to educate public opinion on a subject on which we can
speak with authority. Physicians have been mainly instru¬
mental in the great reform which has taken place in the habits
of the population in Sweden. Similarly in Russia, in America,
and in France. An English newspaper has recently told us
that the French are becoming as ridiculous about temperance
as the English themselves. This means that the French have
become alive to the increase of drinking which has unfortunately

Digitized by VjOOQle

528

OCCASIONAL NOTES.

[July,

taken place of late years in France, and are not afraid of
charges of absurdity or hypocrisy in combating the evil. The
pages of our excellent contemporary, the Annales Midico -
psychologiques , contain in nearly every issue some notice of “ La
Lutte contre PAlcool ” or of “ Les M^faits de rAlcool.” We
can help to educate public opinion. Little is to be hoped from
legislation, we fear, partly because legislation is not a very effi¬
cient way to alter the habits of a free people, and partly
because our legislators will not seriously attend to anything
that does not make for party gain. The “ easy patrons of their
kin ” whom we select to rule over us tell us that they know no
more about our wants than “ the man in the street.” The man
in the street is their master in wisdom as well as in voting
power. Let us go to the man in the street and persuade him.
When he is convinced, whatever legislation can do will be easily
accomplished, should legislation then be needed.

The Medical Graduated College and Polyclinic , 22, Chenies

Street , W.C.

Though this institution has no very direct connection with
our special work, we consider that its objects and claims should
be placed before our readers. It owes its origin and success to
the great personal energy of Mr. Jonathan Hutchinson, who for
long has been endeavouring to develop the advance of know¬
ledge among those who have already taken their Degrees or
have received the Licences to practise. It is quite certain that
all of us need some stimulus to follow the advances which are
being made so rapidly in our profession, and it is most import¬
ant to have some central place where the latest knowledge can
be obtained from the most advanced and skilled teachers. .

London has almost too much medical material, but a great
part runs to waste. The Polyclinic saves some of this.

There are two distinct sections of the College work—one
consisting of courses of instruction and of lectures on subjects
which are of importance to the qualified man and the advanced
student, as well as special lectures given by representative men.
The other main part of the work consists in what might be
called open consultations. General practitioners who have diffi¬
cult or rare cases can bring them to the Polyclinic, where daily

Digitized by VjOOQle

OCCASIONAL NOTES.

1900.]

529

there are, at fixed hours, consultations held on poor patients by
physicians and surgeons connected with London hospitals.

We can only say that for assistant medical officers to asylums
such opportunities are invaluable, for we all know the danger
of specialism, and the need for medical men connected with
asylums to be able to grasp the whole medical aspect of their
cases. We believe there is a great future for this College.

Recent Metropolitan Lunacy Scandals .

The St. Pancras Board of Guardians are reported to have
discovered that their pauper lunatics have been sent to Hoxton
House and Bethnal House Asylum, where they were paid for
at the rate of two guineas per week instead of igs. 3 d. t which is
the rate at other private asylums.

The Relieving Officers, it is alleged, have been in the habit
of receiving “ tips ” of from ten shillings to two pounds for each
patient taken to these institutions.

Whether this be true or not, there must be a scandalous want
of supervision of the Relieving Officers, who have thus been
enabled to put the parish to an unnecessary expense of about
£6000 a year.

The Relieving Officers are also stated to have received bribes,
varying from one to five shillings, from medical men certifying
in lunacy cases.

The procedure in both respects has been the same; the asylum
or the medical man who would not give the bribe has been
rigidly excluded. No excuse can be made for the medical men,
but the parochial authorities are certainly to be condemned for
leaving the selection of the certifying medical practitioner and
of the asylum to officials of the stamp of the ordinary relieving
officer.

We understand that the Lunacy Commissioners are probably
to hold an inquiry in regard to these allegations, which have
been referred to in the House of Commons, and have been dis¬
cussed by the St. Pancras Board of Guardians.

Digitized by VjOOQle

53 °

OCCASIONAL NOTES.

[July.

Night Supervision.

A coroner’s jury were lately summoned in reference to a
fatal accident in Colney Hatch Asylum. It appears that one
patient killed another in a dormitory visited four times each
night. This is not by any means the first time that such an
occurrence has taken place, and the questions raised are suffi¬
ciently serious to open a discussion on means of prevention in
the future. Theoretically every insane person should be under
constant observation, but the magnitude of the difficulties
raised by such a sweeping assertion can hardly be appreciated
by those who are not practically intimate with the conditions of
asylum life. First of all it is not desirable to keep our patients
too long wrapped in cotton wool. We have to strengthen
their impaired self-control, to guide them to health by a
development of their mental faculties. The number of those
enjoying liberty on parole is a real test of good administration,
and as that number increases so may the doors be left unlocked
and irksome discipline relaxed. Conditions of comparative
freedom must, however, be faithfully considered in regard to
mental variations day by day. Even then the unexpected
happens, and consequently there is an unworthy temptation to
apply the bad old rule, “ never trust a lunatic.”

Then with regard to the majority of cases for whom parole
is out of the question, there is a broad but ill-defined distinction
between those who are “ harmless ” and those who are u dan¬
gerous.” No human prescience is sufficient to foresee when
the harmless may suddenly develop into the dangerous, and
we may take it that the Colney Hatch murderer belonged to
this class, otherwise he would certainly not have been sent
to sleep in a dormitory visited at infrequent intervals, but
would have been kept apart or under special supervision. The
coroner’s jury suggest to the Asylums Committee of the
London County Council “ the desirability of providing some
means of communication between the dormitories and the
attendants, and a more frequent supervision of the inmates.”

The first suggestion is by no means new. Patients have
made it of their own accord, not only those who have slept
in dormitories, but also those who have occupied single rooms.
We are not aware of any such system in use in the asylums of

Digitized by VjOOQle

OCCASIONAL NOTES.

531

1900.]

this or other countries, and it would be desirable to ascertain if
anything has been done, anything which is not liable to
frequent abuse nor prohibitive in cost. The country has long
demanded similar protection in railway trains, and the results
are as yet far from satisfactory.

The second suggestion is engaging much attention at pre¬
sent Adequate supervision at night has long been desired
by every superintendent, and we need only refer to the
discussion on the paper by Dr. Middlemass and Dr. Elkins
at our last Annual Meeting, to show that it occupies a
foremost place in our thoughts. No doubt fatal accidents of
the kind will continue to occur by day as well as by night.
These are risks which are inseparable from asylum life, and risks
which have been duly noticed by the Parliamentary Committee
in their efforts to secure compensation for those whose duties
place them in posts of danger. Yet these are risks which should
be minimised by every possible effort. It is evident that the
question is ripe for discussion, and we hope that practical
suggestions will be forthcoming by which, without great increase
of staff, patients in dormitories may be assured of safety.

Notes and Queries.

Dr. Mercier has made a suggestion which might easily be
developed into a valuable aid to those who are concerned with
the progress of mental science. He thinks that part of this
JOURNAL should be reserved for Notes and Queries. There are
many questions demanding solution, and closer thinking might
well result in concise statements of opinion as to undecided
or undefined points. This has already been brought under
notice in the short-lived career of a French journal to which
we referred in January of last year.

LIntermidiaire des Neurologistes et des A leftistes was de¬
signed to be a medium for the exchange of ideas connected
with neurology and insanity. Unfortunately it did not prove
a success. Perhaps the comparatively small numbers of those
to whom it appealed did not suffice to maintain an extra
periodical so limited in scope. Dr. Mercier’s proposal, however,
is well calculated to stimulate and to inform. It gives promise

Digitized by VjOOQle

532

REVIEWS.

[July

of results which would render this JOURNAL more useful to our
readers. We do not ask for lengthy replies to the questions ;
but we hope that, by the middle of next quarter, brief answers
will be forthcoming to the preliminary inquiries which he
submits, and that further queries will be suggested.

Queries .

1. What becomes of the children of general paralytics, be¬
gotten in the early stages of the malady ?

2. What is the meaning of the word degenerate ?

3. How may heredity be supposed to act in the production
of insanity ?

4. How is a morbid change in the brain cell to be in¬
terpreted ? Havelock Ellis.

Part II.—Reviews.

The Elmira Reformatory . The Twenty-third Year-book (1898) of the
New York State Reformatory .

A sound if uneventful record of work. The reports of the school
director, the trades-school director, the manual training director, and
the physical director show that all these departments are carried on
with energy and considerable success. Much is claimed for manual
training, and it is believed that in enabling prisoners to do good honest
work they are enabled to become good honest men. Considerable
weight is also attached to the experiment now going on with regard to
treatment by food and diet.

It is noteworthy that in the report of the Board of Managers a
strong appeal is made for an absolutely indeterminate sentence. At
present the managers are limited by the maximum sentence imposed
by law. When that is reached, the prisoner must be released, whatever
his condition may be. The managers believe that public feeling is
now ripe for the abolition of this restriction, and they point out that no
hardship could thus be inflicted on the prisoners, for the inmates of
Elmira are liberated considerably sooner (on an average after two
years and two months, instead of four years) than if they had been sent
for the same offence to an ordinary prison. While, however, the
majority are stimulated to exertion and improvement by the hope of
earlier release, there remain a minority whose inertia requires a greater

Digitized by VjOOQle

1900.]

REVIEWS.

S3 J

stimulant, and who are unwilling to contribute to their own betterment
because they know that they are sure of liberation at the expiry of the
maximum sentence.

The physical director’s report contains an interesting summary of the
average measurements, etc., of 2000 inmates, chiefly founded on the
Bertillon system. The tattooed are 60 per cent., and some 9000 scars
are recorded. Compared with Amherst students of the same age it is
found that the Elmira inmates are inferior in every respect but length
of head and length of forearm. The average excess in head length is
one third of an inch; while the student tends to be brachycephalic, the
Elmira criminal tends to be dolichocephalic.

The physician’s report shows that among 1500 inmates there were
67 cases of tuberculosis admitted to the hospital, while 13 inmates
were sent to the lunatic asylum. He remarks that an apparent increase
in insanity is due to increasing liberality in the interpretation of insanity
by the asylum authorities. Havelock Ellis.

Del Libero Arbitrio (Concerning Free Will). By C. Biuso. Florence:

Barbera, 1900, pp. 303, small 8vo. Price 3 lire, 50.

T*he question of free will has never appealed very strongly to the
medical mind. Among the v&st number of writers who have dis¬
tinguished themselves in the discussion, it is difficult or impossible
to find one of the masters of medicine. The great English philosopher
who was most deeply imbued with the principles of a medical training—
Locke—declared, with his customary sagacity, that to inquire whether
the will is free is much the same as to ask whether sleep is rapid or
virtue square. Yet this insoluble problem has exercised some of the
keenest and subtlest minds of Europe for nearly three thousand years,
and, moreover, the lucubrations of the philosophers have in their
ultimate outcome and bearings very closely concerned, and, indeed, do
still concern, the activities of the physician, and most of all the alienist.
There may be some interest, therefore, for psychiatrical readers in this
very able critical history of the fluctuations of philosophic opinion on
this question.

The volume seems to be printed for the author, and so far as appears,
the author has no academic qualifications or position. He writes from
Catania; and Sicily, it may be noted, has always been richly productive
in men of philosophic mind. Certainly, whatever the author’s position,
his claim to deal with the subject he has undertaken cannot be disputed.
Evidently a thinker of original and independent mind, he is strictly
impartial, fairly representing all sides and views. Although clearly no
great lover of ecclesiastical philosophy, he has devoted a considerable
part of the book to the exposition of ecclesiastical doctrine ; indeed, a
special feature of the book may be said to be the full recognition shown
of the great part played in the constitution of the doctrines of free will
and responsibility by the mediaeval and earlier theologians. The
author’s erudition is remarkable; he seems to be most defective as
regards a knowledge of very recent writers, but since the recent writers

Digitized by VjOOQle

534

REVIEWS.

[July,

can scarcely be said to have revealed any new aspects of the old
problem, this is of little moment. Not less remarkable is the skill
shown in condensing the history of so long and important a chapter in
human thought into so small a volume, and the orderly manner in
which the whole discussion is marshalled.

A sufficiently clear idea of the scope of the work will probably be
obtained by outlining its scheme, and then briefly stating the author’s
own conclusions. The work is primarily divided into three books : the
first containing a classification and exposition of the various doctrines
of free will; the second, the criticism of these doctrines; and the third,
a statement of the author’s own point of view. Socratic determinism
is expounded first, with the opinions of Plato and Aristotle, and the
revival of these at the Renaissance; incidentally the author remarks
that possibly Havet was right in asserting that Hellenism played a
larger part in Christianity than Hebraism. This remark is made in
connection with the discussion of theological determinism, in which
Thomas of Aquinas is the chief figure. The next chapters deal with
sensual and ideal determinism (Locke, Condillac, Leibnitz, Kant,
Schelling, Fichte, Hegel, etc.), and indeterminism (Epicurus, Cicero,
the fathers of the Greek Church, Duns Scotus, the Jesuits, Reid, etc.);
then follows the consideration of astrological fatalism (Greeks, Romans,
Arabs, Priscillian and the theologians, mediaeval courts and modern
superstition), and physical fatalism (especially among the Stoics). A
chapter on theological fatalism follows (the Manicheans, Predestina-
tionists, Wiclif, Huss, Luther, Calvin, Jansenists, etc.), and finally a
chapter on physiological determinism or autodeterminism (the philo¬
sophers of the Renaissance, Bruno, Bacon, Hobbes, Spinoza, Hel-
vetius, the Positivists, and many other modern philosophers).

The second book is really a fresh historical discussion of the same
ground, introducing references to many other philosophers who were
passed over in the first book, and though somewhat freer and more
critical, its object is still mainly intended to elucidate the history of
the doctrine of free will.

In the third part of the work, though even still to some extent
making reference to the views of others, the author sets forth his own
point of view, and deals with the social and practical bearings of the
doctrines of free will as they are especially expressed in penal law. He
thinks that the best justification of the penal law is that—suggested by
Romagnosi, and developed by Ferri—by which it is regarded as the
right of social defence. It is thus a social reaction independent of any
criticism of moral liberty or moral guilt. It has no ethical value or
retributive justice, but is imposed purely and simply by the necessity
of social conservation, such necessity being equally imperative what¬
ever may be the psychic state of the individual who has injured
society. Of the various justifications of penal law which have been
proposed this seems to Biuso the best, but at the same time he points
out that any modern justification whatever for a prehistoric practice
which arose under altogether different conditions of life and belief can
be at most but “a pious interpretation or an elegant lie.” The real
direct natural cause which determines and justifies punishment is
force. Society instinctively exercises force against its weak members,

Digitized by VjOOQle

REVIEWS.

535

1900 .]

and criminals are always among its weak members. “The right of
punishing is equal to the force of punishing. Social dynamism is not
different from physical dynamism. To explain so simple a fact we
require neither the moral responsibility of the criminal, nor the hope of
his amendment, nor the example of his punishment, nor distributive
justice, nor the lex talionis , nor the necessity of social defence.”

So that if it is said that we are thus brought no nearer to any funda¬
mental principles on which we may rest securely when asserting that
one man is “ responsible ” and must go to prison, while another is not
and must go to the asylum, the author would reply that that is
inevitable, since no such fundamental principles can be found. His
concluding chapters are an eloquent tribute to the mission of psychiatry.
The freedom of the will he finds to be an inevitable social illusion, just
as the immobility of the earth is an inevitable physical illusion, and it
must be our chief concern to develop the scientific principles of
psychic hygiene. Such hygiene, which it is the future task of
psychiatry to control, is necessary for all. “It cannot be too often
repeated that no line of division can be drawn with mathematical
precision between sanity and pathological states.” That fact is alone
sufficient to demonstrate the impossibility of any rigid distinction be¬
tween the prison and the asylum. It is also sufficient to show the
great part to be played by “psychic hygiene, which may be called
social hygiene par excellence .” The healthy and happy man is, on the
whole, more disposed to fine actions than the diseased or melancholy
man, and “ morality in its true sense is nothing else but sanity raised
to the highest power.”

These are the main ideas of a book in which a powerful and sincere
thinker seeks to make clear that part of metaphysics with which an
alienist, whether he will or not, cannot avoid entangling himself. It is
thirty years since the brilliant author of Ereivhon satirised the popular
notions of responsibility by setting forth a state of society in which the
subjects of disease were brought before the courts, condemned and
sent to prison, while crimes were treated privately by medicine; yet
these same notions still rule among us. The alienist is compelled by
tradition, as well as by motives of philanthropy, to flounder more or
less helplessly among ideas of “ responsibility,” or, even worse, “partial
responsibility,” which are altogether outside the sphere of medicine.
These ideas arose in prehistoric days, were formulated by mediaeval
schoolmen and ecclesiastics, and handed down to the present by the
science of law, the least progressive of all the sciences.

Such a book as this of Biuso’s may help the alienist to realise into
what a quagmire he is adventuring himself when he endeavours to ,
translate the ideas of medicine into the terms of an antiquated meta¬
physics. It may not enable him to avoid that swamp, but may usefully
suggest caution when approaching a region in which, if he quite knew
where he was, he might rather wish not to be.

Havelock Ellis.

Digitized by VjOOQle

536

REVIEWS.

[July,

Sensation et Mouvement: Etudes experimentales de Psycho-mecanique.
Par Ch. F£r£. Second edition, revised. Paris: Alcan, 1900,
pp. 170. Price 2 fr. 50 c.

It is now thirteen years since this extremely interesting little volume
was first published, and, while its reputation has long since been made,
it is only now that a new edition has been called for. Although the
book has been entirely reprinted, the revisions are very trifling. We
have carefully compared the two editions, and have only found a few
slight verbal alterations and the addition of half a dozen foot-notes,
chiefly references to later literature. The author seems to have felt,
and no doubt justly, that any attempt to rehandle the questions dealt
with would mean an entire change and enormous enlargement of the
volume, and that it was wise to leave the original record of his pioneer¬
ing experiments practically untouched. It is unnecessary, therefore,
for anyone who possesses the original edition to acquire the second.

At the same time we may take this opportunity of recommending the
book to those who do not already possess the earlier edition. That it
is of any immediate practical value can scarcely be claimed; at the
most it is helpful in making clear the rules of moral and physical
hygiene. But for all those who are interested in the more subtle
relationships of mind and body these “ experimental studies in psycho¬
mechanics ” are in the highest degree suggestive and valuable. So far
as there is any central thought underlying the various subjects dis¬
cussed, it may be said to lie in the proposition: “ When we say that
the brain thinks, it is the whole being that becomes active.” Some of
the experiments here recorded (and illustrated by 44 curves) have
been criticised, and, as the author himself states, some of his subjects
were hysterical, but on the whole the experiments remain very in¬
structive, and even the hysterical subject often presents us merely
with an exaggerated degree of a normal reaction. The experiments
illustrate the delicate manner in which mental representation influences
movement, how a strong excitation of sight, hearing, smell, or taste
reinforces muscular power; they indicate that the various colours
(especially red) possess dynamogenic power; they show the influence
of tobacco. The effect of such influences on the blood-vessels is also
shown by F 6 r 6 by means of plethysmographic tracings. He attempts
to explain “maternal impressions” by the muscular response of the
uterine walls to emotional and other shocks. As also throughout his
later work, F£r£ insists on the large part played by conditions of ex¬
haustion and anaemia in the production of morbid nervous and psychic
states. The volume is throughout an argument for the study of psycho¬
logy by the methods of general biology. There can be few workers
in either psychology or psychiatry for whom this little book contains
no new and suggestive ideas, and it is to be hoped that the second
edition will find a wide circle of readers among those who neglected to
procure the first.

Digitized by VjOOQle

1900 .]

REVIEWS.

537

Les Criminels. Par le Dr. Charles Perrier. Paris: Masson, 1900,
pp. 380, large 8vo. Price 10 fr.

This work is written by the chief medical officer of the Central
Prison at Nimes, already known as the author of a very elaborate study
of tattooing among criminals, published in the Archives d > Anthropologie
criminelle.

The present work is also issued under the auspices of Professor
Lacassagne, since it appears in the Bibliothkque de Criminologie. It is
a work of great value, but one that appeals entirely to the expert. To
the ordinary reader, even the medical reader, it will be almost entirely
unreadable, for it is largely made up of detailed facts and measure¬
ments concerning 879 criminals, which the author never summarises of
uses for the purpose of deducing general conclusions. The only
generally attractive portions of the book are some passages near the
beginning dealing with the characteristics of various groups of criminals.
It is noteworthy that real anarchists are rare in French prisons, in spite
of the prevalence of so-called anarchist outrages; six out of eight
so-called anarchists, remarks Dr. Perrier, are not really anarchists at
all, and the real anarchists belong to the most genuinely estimable
part of the prison community. It is somewhat amusing to find that
the English criminals in French prisons do their best to maintain the
character of their country. “Cold and correct,” writes the author,
“ these gentlemen have only one aim—to obtain comforts. They are
careful about their property, and they perform their toilet before the
common pump with as much gravity as if they were operating in front
of a luxurious washstand, nor do they neglect the care of the teeth and
hands. They are looked after, assistance reaching them daily. Their
chief ambition is to have ‘clean* work and to live in peace. A detail
to be noted is that the mother country still watches over them, and
that they have only to express the wish and the Embassy sends them
books.”

Not the least valuable part of the work is constituted by its seventy
illustrations; of these thirty-nine are portraits of inmates, drawn by
one of the inmates of the prison, a Spaniard, from photographs; they
form a marvellous gallery of criminal types. The remaining illustrations
are mainly reproductions of criminal art, tattoo designs, etc., nearly all
of a highly expressive character.

It does not seem impossible that Dr. Perrier might have put his
work into a more effective and readable form without sacrifice of its
scientific quality, but it remains a worthy monument of his energy and
his intimate knowledge of the prisoners in his care. We might be
well content if our English prisons yielded scientific work half as
thorough. Havelock Ellis.

The Psychological Index . Compiled by H. C. Warren. New York :
Macmillan, 1900, pp. 174, large 8vo.

The issue of this bibliography for 1899 (published in connection with
the Psychological Review , and sold separately, price not mentioned)

Digitized by VjOOQle

REVIEWS.

53«

[July.

reaches us this year before the Annee Psychologique , in which it is also
regularly included. In one form or the other it is almost indispensable
to every serious worker in psychology or psychiatry. There are 2584
entries in the present issue, which must represent a considerable
amount of labour on the part of Dr. Warren and his coadjutors in New
York, Paris, Berlin, and Lausanne. The entries are divided into eight
main groups with numerous subdivisions; the last group, with nine
subdivisions and some 550 entries, is devoted to the “ abnormal and
pathological” literature for 1899. Every other group will, however, be
found to contain numberless references that are £t least on the border¬
land of psychiatry. The question of classification is, indeed, beset
with many difficulties, and it can by no means be said that the com¬
pilers of the index have solved these difficulties; we find, for example,
to take two instances out of many, that two papers of a similar
character on the same subject (Modesty) have to enter different
subdivisions, while the author of a little note on voluntary move¬
ment of the cremaster may smile to see his observations worthy of
entry between two massive ethical treatises on the doctrine of virtue
among the ancient Greeks, and on the foundation of morals. The
literature of the senses is, again, awkwardly treated, “ Physiology of the
Nervous System,” including the sense-organs, being given in a different
group from “ Sensation.” We note that the date of Hampa , the latest
work of Salillas, is given as “(1899?),” although the date, 1898, is
clearly printed three times over on the distinguished Spaniard’s work.
As a section is devoted to anthropology, it is unfortunate that no
mention is made of DenikePs monograph on the cephalic index in
Europe, containing the most important contribution to anthropology
issued in Europe during the year. There are numerous little misprints,
but, so far as we have observed, always of a trifling character. Minor
defects of this kind are inevitable in a bibliography which would lose
much of its value if not issued speedily. Havelock Ellis.

V Ideazione Geniale . Un esempio: Augusto Comte . Prefazione di

C. Lombroso . (The Ideation of Genius . An example: Auguste
Comtek) Antonio Renda. Turin, 1900, 8vo, pp. 205.

This book is a fresh attempt to illustrate the old theory of Morel,
advocated and amplified by Professor Lombroso. The main facts
about the derangement of Auguste Comte and the eccentricities of his
later years are dwelt upon in a somewhat disquisitional fashion.
Though Mr. Renda sometimes loses sight of the French philosopher,
he never loses sight of his theory about the relation of insanity to
genius. We should wish those who discourse after a somewhat myste¬
rious fashion about genius would give a clear definition of it. Nothing
is more erroneous, Renda tells us, than to believe that genius consists in
a potential increase of the logical faculty, or to confound it with a capa*>
city for doing things with greater ease and perfection than most people
can. Genius is a faculty sui generis; it works unconsciously, though it
can revise and improve upon its own efforts. Men of genius are either
insane or on the verge of insanity. They are degenerates, have always

Digitized by VjOOQle

1900.]

REVIEWS.

S39

something pathological about them; and this, instead of hindering their
mental manifestations, seems absolutely necessary to them. In fact, a
good many men of genius who figure in Lombroso’s gallery seem to
have nothing which would make them rank as men of exceptional
ability, save some nervous derangements, often of a trifling cha¬
racter. In a long preface to this work, Lombroso dwells upon a few
instances which he thinks confirm his theory. Amongst others we
have Goethe, who had an unsymmetrical head, and could not be got
to return objects of art or curios which his friends lent him. We learn
it is necessary to genius that there should be a morbid stimulus to the
brain. This stimulus may be chemical—wine, ether, or opium, as with
Poe or Hoffmann. In others the stimulus is pathological, as is proved
by the platycephaly of Paracelsus, Meckel, and Humboldt. The early
synostosis in the skull of Dante, the cranial asymmetry of Schiller and
of Kant, gave us the Divina Commedia , the historical dramas, and the
Critique of Pure Reason. The cause of Helmholtz’s genius seems to
have been hydrocephaly, which exercised acertain pressure upon the
brain so as to produce epileptiform attacks. Alexander the Great, we
are told, was afflicted with moral insanity and “gamomania,” which he
showed by making ten thousand of his soldiers marry Persian women.
The professor’s theories have been subjected to some searching criti¬
cisms in the Annales Medico-Psychologiques and the Revue Philosophique,
but he returns to the charge as undaunted as ever. He has had an
opportunity of examining the brain of the celebrated anatomist, Gia-
comini. Lombroso finds in his old colleague a striking narrowness of
the temples, great development of the jaw, a large brain, finally struck
by epilepsy, like that of Helmholtz, something wrong about the
fissures of Rolando (sdoppiamento), which is owing to pressure in the
embryonic condition. Thus he triumphantly records great cerebral
anomalies in a man of genius, who in spite of the anomalies, or in
despite of the genius, combated Lombroso’s theories. It is impossible
to deny that some men of very great mental powers have been afflicted
with insanity and nervous disorder; but this, so far from helping the
exercise of their genius, generally acted to its detriment, and sometimes
extinguished it altogether. It cannot be said that the nervous troubles
of Comte helped the evolution of his ideas, or assisted him in his study
and classification of the sciences; quite the contrary, they checked
the correct working of his intellect, and led him in the end to folly
and extravagance. It does not seem at all wonderful that men recog¬
nised to have great mental power, who are led by the pressure of events
to exert them to the utmost, should feel the strain where the tension is
hardest. If many brain-workers die of apoplexy, surely this is but
what might be expected. We are suspicious of Lombroso’s uncritical
array of anecdotes and gossip about celebrated men. The difficulty of
coming to a conclusion whether nervous disorders are more common
amongst them than amongst ordinary people consists in the want of
a comparative scale. After all, nervous disorders and insanity are
common enough amongst some quite mediocre people. I have counted
how many such derangements occurred amongst several families whose
life-histories are well known to me, and it seems as if such disorders
are quite as frequent as with families well known for their great mental
XLVi. 37

Digitized by VjOOQle

540

REVIEWS.

[July,

power. What we should call genius implies the highest functional
vigour of several mental faculties, and this we cannot think to be the
result of unhealthy nutrition or of degeneration. Wm. W. Ireland.

Anatomie clinique des Centres nerveux. Par le Dr. Grasset, avec 2
figures dans le texte. Paris, 1900, i6mo. Prix 1 fr. 50 c.

In this little manual Dr. Grasset takes for granted an acquaintance
with ordinary descriptive anatomy. He treats the structure of the
nervous system in relation to its functions: thus the optic nerve appears
as one trunk, whereas it is known to consist functionally of two hemi-
optic bundles of nerve-fibres answering to homonymous segments of the
two retinas. The author begins by describing the histological structure
of the nervous centres, and gives the most recent views about the
neurons and their connections with one another. According to Bethe
and Cajal, the passage through the body of the nerve-cell is not indis¬
pensable for the conduction of the nervous influx from a protoplasmic
prolongation to a cylindraxile. The neuron, to exercise its function,
must be complete in its parts and prolongations; some hold that the
cell has only a trophic function. After describing the anatomical
elements which make up the nervous system, Dr. Grasset goes on to
give the special anatomy of the nervous centres, and the distribution
and development of the nerve-cells and fibres and the different sym¬
ptoms which result from their lesions. It is curious to observe how
much we have advanced beyond the rough topographical anatomy of
forty years ago. We remember asking Professor Goodsir, then thought,
at least by his pupils, the first anatomist of his day, about Solly’s tracing
the fibres in the medulla oblongata and brain; to which Goodsir
sententiously replied, “ The fact is that a good dissector can trace the
nerve-fibres any way he wants.” This would certainly be thought a
strange answer for a teacher of anatomy nowadays. It is wonderful
what an amount of information the distinguished professor of Mont¬
pellier manages to give in less than a hundred pages, and the subtle
questions of nerve function which he manages to treat. The physician
who deals with brain and nervous diseases will find such a book highly
useful. The descriptions have all that clearness of definition character¬
istic of French scientific writers, which is aided by the admirable
precision of the French language. Nothing of importance is left
out, and on every difficult or debatable point the learned Professor has
taken occasion to study all the separate treatises of those who have
made special researches. For example, we wanted light on the question
whether the fibres of the optic nerve and of the nervus cochlearis ran
right in an uninterrupted course to the visual and auditory spheres in
the brain cortex. We looked up some bulky works without finding the
point clearly stated; on consulting Grasset?s little book we learn that
some of the fibres do not pass through the basal ganglia on their way to
gain the cortical auditory centres, and that this also holds good with the
optic fibres passing to the occipital lobe. Wm. W. Ireland.

Digitized by VjOOQle

1900.]

REVIEWS.

541

The Nervous System of the Child> its Growth and Health in Education .
By Francis Warner, M.D. New York: The Macmillan Com¬
pany. London: Macmillan and Co., Ltd., 1900, crown 8vo,
pp. 2 33* Price 4 s. 6 d.

This book is intended for the use both of medical men and of
teachers, and of all who take an intelligent interest in the training and
education of children. Dr. Warner remarks that during the past
century much has been accomplished in the study of mind connected
with the evolution of brain-action, as observed in the child through close
observation and inference.

Though child-life was always an object of interest and attention, it
has within the last twenty years been studied in a more systematised
manner. In this field the author is well known as a close and accurate
observer. He may be said to have extended our knowledge of the
physiognomy both of healthy and of diseased action. The whole book
is evidently written upon the object, not taken from other men’s sayings
and studies. The author not only gives the result of his own accurate
observations, but he stimulates others to observe, and shows them what
to look for. As the title indicates, he deals principally with the child
undergoing education. He shows the phenomena which accompany
the mental evolution of children, and gives the interpretation of these
phenomena. He explains the method by which the senses, muscular
system, and mind may be cultivated up to adolescence. Altogether the
book is useful and instructive and full of original ideas. The style is
graphic, and successfully conveys the meaning, though it needs polish
here and there.

We have been much struck by Dr. Warner’s observations upon
spontaneity in the child, which lessens at seven or eight years of age as
co-ordinated action gradually increases. While the faculty of self-
contained or spontaneous thinking lasts later in the life of the brain
than the spontaneous vivacity of movement in the body, inhibition of
movement may be noticed in the infant of four or five months when
spontaneous action is momentarily arrested under the stimulus of sight
or sound. “ You ask the pupil a question : he pauses a moment, and is
still: if he answers in reply to your direction, you know that some brain
process of thinking occurred during the period of inhibition.

“ The pause period does not, then, mean absence of brain activity—
as in sleep—but a new kind of action among the brain-centres. The
faculty of inhibition of movement becomes rapidly manifested under
good training.”

Dr. Warner’s idea of training and education is much more compre¬
hensive than the reading, writing, and arithmetic which form the staple
of the ordinary pedagogue. He observes that, while much attention is
given in early school days to training through the eye and ear, too little
care is bestowed upon exercising the brain by impressions received
through the muscular sense. He would also have children exercised in
judging of distance by sight. This is especially required for town
children, who do not get the same chances as those in the country for
looking at distant objects. We think he should have said something
about the recognition and treatment of short-sightedness in children.

Digitized by VjOOQle

542

REVIEWS.

[July,

This deficiency, which is common with town children, is not readily
noticed by the schoolmasters. This is often the cause of loss and con¬
fusion to the child. We do not notice that Dr. Warner gives his views
on the proper age to send children to school; we think that five years
is too early to force their attendance. Few of the countries on the
Continent make compulsory attendance at school begin till the age of
six years.

To the chapter on hygiene and feeding we can offer no objection,
save that we have much misgivings about the prominence given to
animal food in the dietary for children. Dr. Warner reproduces some
tables from Dr. Clement Dukes, in which figure such articles for break¬
fast as sausages, broiled ham, dried fish, pressed beef, cold ham, and
brawn; and for dinner the most stress is laid upon butcher’s meat—
mutton, beef, roast or salted pork, and pies. Dr. Warner recommends
that sugar or salt should be supplied at choice with the porridge, and
does not mention milk. He observes that sugar taken with food is a
useful heat-former, and aids brain nutrition. He thinks that delicate
and ill-developed girls are more apt to suffer in health from adverse
circumstances in education than boys. He observes that there is
apparently more difficulty in recovering from injured health among
women than among men, and that “ anaemia with neurosis is liable to
follow neglect of the health, and to become confirmed as a form of
nervous dyspepsia. This has incapacitated many women otherwise
intellectually fitted for a business or professional life.” Dr. Warner
observes that “it would be interesting if intelligent persons could
describe their own early difficulties and analyse them, so as to see what
was lacking; whether their teacher tried to connect ideas that did not
exist"in their heads, or used words that had no meaning to them at the
time.” We are afraid this is still done to some extent; but there has
been a great improvement in educational methods during the last thirty
years. Children not only get a better and more varied training; the
instruction is conveyed in a less harsh and mechanical manner, and the
teachers take more trouble to explain what is taught. The improve¬
ment in school furniture, diagrams, and illustrative pictures is very great.
We are pleased to see that Dr. Warner lays stress upon the cultivation
of the faculties of observation. He shows how this may be done by
making the children observe the germination of seed and the growth of
plants.

Eft rorigitie de la Pensee et de la Parole . Par M. Moncalm. Paris:
Ancienne Librairie, Germer Bailliere et Cie. F 6 \ix Alcan, Editeur,
1900, pp. 316. Price 5 fr.

This is a study of the evolution of speech and thought through the
various ages of humanity; and as it may be said that we know nothing
absolutely concerning any question if we ignore its beginning, it is
especially with the origin of thought that the author is concerned.

Although so much has been written on this subject, a point which he
insists upon is that our real knowledge is but slight, owing in a large
measure to the arbitrary manner in which words are used and their

Digitized by VjOOQle

igoo.]

REVIEWS.

543

meaning perverted. Speech is undoubtedly responsible for the origin
and spread of error. In studying history carefully it is possible to identify
the periods in which errors, more or less generally recognised as such,
first appeared in the world; but one may look in vain for the times
when truths were first uttered. Does not this silence in history show
that the truths of which one seeks the origin were revealed to man before
the dawn of history ?

Hence the various chapters in the book deal with the results of his
researches into early history of humanity, that history which was told
from one generation to the other—not written, for speech came before
writing—and his researches into the oldest literatures of peoples. It is
there that is to be found the truest information concerning the manner
in which our distant ancestors represented to themselves a divinity in
its relations to mortals; for instance, there are the Old Testament of
the Hebrews, the sacred books of the Hindus, the mythologies of the
Aryan family, etc.

Comparative philology, so much enriched by the work of Max Muller,
to whom the author repeatedly acknowledges his indebtedness, has been
an instrument of the greatest utility to Moncalm in his studies,—“ a
powerful telescope enabling him to define outlines and figures where
unaided he could detect nothing but clouds and fogs.”

In the chapter on the philosophy of language he dwells on the
fundamental law of reason—the unity of speech and thought; and while
criticising the abundance of terms in philosophical language, which leads
to confusion of ideas, regrets the absence of a word corresponding to
the Greek “ logos.”

Comparative philology confirms the view that word-roots were
originally used in a purely material sense, although they may now help
to form words for the most abstract concepts; and when by the com¬
bination of predicative roots and demonstrative elements words were
used to distinguish between the subject acting and the object produced,
the passage from perception to conception was accomplished. Some of
the most interesting pages of this work are those which show how
conscious perception, which does not exist outside words, advances step
by step with the progress of language.

The Vedaic hymns, which are full of information concerning the
thoughts of the human mind thousands of years back, and from which
we judge that human feelings have scarcely varied, are frequently
referred to in the course of Moncalm’s inquiries, and, as he justly
observes, deserve at least as much attention as the most profound
speculations of the best modern philosophers.

This work may be pronounced patchy, but must prove very interesting
to any student of the evolution of the human race. H. J. Macevoy.

Judicial Statistics , England and Wales , 1898. Part I: Criminal
Statistics. London: Eyre and Spottiswoode, 1900, 4to, pp. 204.
Price 2 s. Sd.

The Criminal Statistics for England and Wales for the year 1898
have been prepared under the direction of Mr. C. E. Troup, who so

Digitized by VjOOQle

544

REVIEWS.

[July,

successfully inaugurated the improved series of these returns in 1893.
The lapse of a period of five years since that date has suggested to the
editor a somewhat fuller review of criminal problems than has been
attempted in the immediately preceding volumes, and on that accoun
the present issue is of peculiar interest.

Before referring to the larger questions dealt with by Mr. Troup in
his Introduction, we may note briefly a few of the salient points in the
statistics for 1898.

Owing to the possibility of fortuitous oscillations in the amount of
crime, the returns for any particular year do not, per se , possess much
significance. Therefore, though in all the categories of indictable crime
the figures for 1898 are higher than those for the two preceding years,
it cannot be assumed that this indicates a definite tendency to increase,
except in those offences, such as sexual crimes and attempts to commit
suicide, where the upward movement is traceable over a considerable
period.

With regard to criminal proceedings it is noted that the proportion
of convictions to the total number of prosecutions was unusually high
during 1898; this was not, however, an effect of the Criminal Evidence
Act, as it was more marked in the earlier part of the year in question,
before the Act came into operation. Both in the superior courts and
in the courts of summary jurisdiction the recent tendency to lenient
sentences continues. This is particularly evident in the increase of
the number of persons ordered to enter into recognisances.

Nonindictable offences show their usual increase, largely due to the
multiplication of cases of a quasi-criminal character—offences against
the Education Acts, against bye-laws, etc. Prosecutions for drunken¬
ness were in 1898, absolutely and relatively to population, very much
more numerous than they have been for some years past.

The number of criminal lunatics received during the year was 209,
of whom 160 had committed indictable crimes. Amongst these latter
the existence of insanity was established before sentence in 717 per.
cent, of persons accused of homicidal crimes, in only 30 per cent, of
those tried for other offences. This result, which is observable every
year in the returns of criminal lunatics, suggests the need of fuller
medical examination in non-homicidal cases.

During the year there were 2849 suicides, and 2084 attempts to
commit suicide, as compared with 2769 suicides and 2004 attempts in
i8 97-

We now turn to the larger questions discussed in the Introduction to
the statistics. Of these the first is the present tendency of crime. To
determine this point Mr. Troup has been at pains to trace through a
period of forty years, from 1858 to 1898, the movement of crime in this
country, including in his review not only all indictable offences, but
also as many as possible of those nonindictable offences which are in
substance of a criminal character. His conclusions, which are more
exactly set out in tabular and in diagrammatic form, are—“ That the
actual number of crimes brought into the courts has diminished
appreciably during the last thirty years; that if the increase of population
is taken into account, the decrease in crime becomes very marked ;
that if we also take into account the increase of the police forces and

Digitized by VjOOQle

1900.] REVIEWS. 545

the greater efficiency in the means of investigating and punishing crime,
we may conclude that the decrease in crime is even greater than the
figures show; and finally, if we take into account the fact that habitual
criminals are now for the most part imprisoned only for short periods,
and have more frequent opportunities than formerly of committing
offences, we must hold that the number of criminals has diminished
in an even greater ratio than the number of crimes.” On the other
hand, all these conclusions must be qualified by regard to the fact that
now-a-days there is much greater reluctance than formerly to prosecute.

With regard to the question of juvenile crime it is shown by a series
of tables based on the figures for the last six years that the number
of juvenile offenders has diminished with the general diminution of
crime, but that they still bear the same ratio as before to the total of
criminals.

The geographical distribution of crime during the past five years
is also dealt with, and illustrated by maps and tables corresponding
to those published in 1893, based on the figures for the preceding
quinquennial period. There appears to be in England, as in the rest
of the United Kingdom and in France, a marked predominance of
crimes of every sort, but especially of crimes of violence in the great
seaports; crimes of acquisitiveness generally prevail most in urban
districts; crimes against morals, which in France are most rife in cities,
predominate in rural districts in England; prosecutions for drunkenness
are most numerous in the northern counties.

The maps and diagrams illustrating the volume are excellently lucid.
Regret may be again expressed that it is not possible to give in the
English tables that detailed information regarding the criminal in¬
dividuality which is so useful a feature of the Continental statistics.

Diagnostic des Maladies de la Moelle—Silge des lesions . Par le Dr.
Grasset. Paris: Librairie J. B. Baillifere et fils, 1899, 1 vol. in
i6mo, pp. 96 and fig. Price 1 fr. 50 c.

Within the compass of a small volume Prof. Grasset, of Montpellier,
here contributes a most useful guide to the diagnosis of the seat of the
lesion in diseases of the spinal cord—the physiological diagnosis. It is
divided into two chapters, the first dealing with the symptoms and
signs connected with affections of the various systems of the cord
(anterior cornua, posterior cornua, posterior columns, etc.), and the
second with the diagnosis of the extent of the cord involved. He has
included the latest views on localisation, metamerism, etc., and for
those in search of fuller information concerning these, numerous
references are given to various works which contain it.

In dealing with the systematic affections of the cord, after a descrip¬
tion of the signs and symptoms of the diseases in which the various
systems are affected, exclusively or in combination with one another, an
attempt is made in each case to give the synthesis and pathological
physiology of the syndroma characteristic of the affection. Thus, in
considering affections of the posterior columns, the sign of Romberg is

Digitized by VjOOQle

REVIEWS.

546

[July,

discussed. This. Gtasset

or loss of the muscular sense. Stimul ^ Qthers ascend to the

spinal cord ; some go to provoke s^n efle^ ^ ^ muscular sense.

higher centres and produce P ta betic lesion, causing inco-

The former alone my he amsted by the > may rea * h the

ordination and the sign of ’ ^ s ; sts So a i s0 , in discussing

brain, and hence the muscular *® ns , eP nldes that n0 satisfactory
affections of the lateral columns h ' ““n them and contracture,
theory accounts for Ae^or centre in th e bulb

Grasset suggests the existenc /inhibiting it), the suppression of

which regulates the muscular tonu ( ^ explains the difference

Scilie”‘‘«’riu8*4“l°e' is *cll Mroterf under the he.d.ng of
Affections of the Centro-Postenor Grey ’ j n addition to the

In the second chapter the inal cord corre-

symptoms arising from a limite syndroma of affection

sponding .0 the level netves (second to

of dorsal cord corresponding to the ongm a corresp0 nding to

twelfth), etc., the metamenc or segmenmy y d haracter ‘ se d by its
affection of a defined section o ^ '“VeTnS.hed. “eugigot,”
definite segmentary distnbution 1 -S- . . h ^ thrown by the

sssa«3 SSfiSf a **— ° f ,he

anaesthesia of syringomyelia, etc.

The Care ami Treatment ' ^ State^Boid of
SL LL N« To^r and London : SV P»«m and Son,

Ab R om ten'yearsagole reviewed^c^orth’^book THcJnsa* *

ment of Epileptics, a subject wh ch ^TeSorth s0

in our islands. We are indebted to Dr ^wortn^ ^ most * un _

much information about what is enter ® nto pathology and thera-
fortunate class. 1 hough it oe ex tends is very comprehensive,

peutics, the book, so far as its scoreaffile «5. of information
The author has evidently The writing is

both in North America and l the E P u which in som e passages
clear and pervaded by a kindly to g deS cription of the

rises to eloquence. Where cou . one find a tt«» « Bow £ g? _.. The
miseries that beset the victim ofTim> m >J\ As a child he i s an

epileptic holds an anomalous po uar ^j ans ^ The street to him is

object of solicitude to h.s t0 seizures on the way

full of danger, and if sent to£hoohe *******™ classmates and

crVa n te h c:n C Sn 00m He cannot^tend church and public entertainments,

Digitized by

Google

1900.]

REVIEWS.

547

nor participate in social gatherings with those of his own age and station.
In consequence of his infirmity, the epileptic grows up in idleness and
ignorance, bereft of companionship outside of the family, and, friendless,
he silently broods over his isolated and helpless condition.

“ If the epileptic succeeds in learning a trade, business men are
reluctant to employ him, and artisans will not work with him, especially
if sharp-edged tools are used. I shall never forget the shock ex¬
perienced, when I was a lad, in seeing a journeyman workman, a tall,
manly, but sad-faced young man, fall at his bench with keen-edged
tools within his reach, his dazed fellow-workmen moving in awe about
him as he struggled in convulsions, with open eyes, set teeth, and
foaming mouth. He was an ambitious young man, of good character,
and a skilful workman; but he was obliged to leave his position on
account of his infirmity and seek a new situation, where, undoubtedly,
he had to go through the same experience. In such cases there is but
one result—the breaking down of hope and energy.”

After a general description of the character of epilepsy and its causes,
and suggestions for its prevention, the author gives us an account of
what is being done in the United States within the last few years, which
is most praiseworthy, the Ohio Hospital for Epileptics, the Craig Colony
in New York State, and the Hospitals for Epileptics in Massachusetts,
New Jersey, and Texas, Pennsylvania. He then gives us a shorter
account of what is being done in the same field of charity in Maryland,
Missouri, California, Michigan, Minnesota, Wisconsin, West Virginia,
Ohio, Illinois, Connecticut, and Virginia.

Coming to England, Dr. Letchworth has less to say, but this is not
his fault. We have, however, a friendly account of the Home for
Epileptics at Maghull and the colony at Chalfont, the outcome of the
efforts of the National Society for the Employment of Epileptics, and
the Meath and St. Luke’s Homes. Nothing whatever has been done in
Scotland for the relief of this unfortunate class, though epileptics are
not uncommon, and the people of the Lowlands are quite as rich as the
English.

Perhaps the most interesting chapter in the book is the concluding
one, in which the author gives an account of the different institutions
for the special care of these unfortunates in Germany and Switzerland,
of which there are now as many as twenty-eight. The first successful
effort on a large scale to better the lot of epileptics, and to render them
helpful to one another, was made by Pastor von Bodelschwingh. The
Colony of Bethel was begun near Bielefeld in 1867 upon a small farm
with four patients.

On the 1 st of July, 1898, the epileptics in this colony numbered 1516
including children. Most of these patients came from Northern
Germany. The establishment is supported by gifts from the charitable
and by the boards paid by the provincial councils, for though a good
deal of work is done by the inmates, the colony is not self-supporting.
It is necessary that the health and well-being of the boarders should be
the first consideration, but much is done to give the epileptic children
a fitting education, and to utilise the working capacity of the adults.
“ Labourers without employment have here been able to return to the
calling that was dear to them, and to enjoy a sense of independence

Digitized by

Google

548

REVIEWS.

[July,

which comes from self-support, although in many instances they over¬
estimate the pecuniary value of their services.” In the asylums in
Great Britain the epileptic lunatics are generally the strongest, and often
do a good deal of work. Though epileptics suffering from only temporary
mental derangement are still retained, more severe cases are sent to the
lunatic asylums. In 1898, at Bielefeld, 25 per cent, of the patients were
without any perceptible signs of disease, 33 per cent, had only slight
mental defects, 17 per cent, were classed as mentally disturbed, and
2 5 per cent, as imbecile. One useful feature of the book is the know¬
ledge derived from the experience of such institutions as the Zurich
asylum about the diet, regimen, gymnastics, and scholastic treatment
which have been found most serviceable in the treatment of the
patients. The work is well printed, on good paper, and is illustrated by
a large number of engravings, which add much to the interest about the
places described in the text. Altogether, Dr. Letchworth’s book is one
which does much credit both to the head and heart of the philanthropic
author. William W. Ireland.

Der Alkoholismus, nach Wesen , Wirkung, und Verbreitung ( Alcoholism ,,
its Nature, Influence, and Distribution ). Von Alfred

Grotjahn. Leipzig: Wigand, 1898, pp. 412, 8vo. Price 6
marks.

The Bibliothek fur Sociatwissenschaft, edited by Dr. Hans Kurella, has
already given us several volumes of the highest merit, dealing with
questions of contemporary interest, and informed with a rigidly scien¬
tific spirit.

In Dr. Grotjahn’s work on Alcoholism the reputation of the series is
fully maintained. The book combines in a high degree the exactitude
and omniscience of the German with that lucidity of thought and
neatness of expression which are rather attributes of the Gallic mind.
These qualities are never very common ; to the English reader, at least,
they will appear doubly remarkable in their present connection. For
in this country the subject of inebriety has exercised such a potent
attraction on amateur moralists of the emphatic sort, that its discussion
has been more usually associated in our minds with excess of zeal than
with accuracy or reason. Other countries have not suffered from these
disabilities; and in Germany, notably, the scientific literature of
alcoholism is extensive and valuable. It is in accord with these better
traditions that Dr. Grotjahn has written this admirable summary of our
present knowledge on the question.

The work is prefaced by an historical sketch of alcoholism in ancient
and modem times. In this connection the author lays stress on the
fact that different drinking customs differ in the degree in which they
further the development of alcoholism. The earlier forms of drinking
—drinking at meals and at social gatherings—did not tend to manu¬
facture inebriety on a large scale; on the other hand, in modern times
alcoholism has acquired an enormous development, and has become a
grave social question through the prevalence amongst the labouring

Digitized by VjOOQle

REVIEWS.

549

1900.]

classes of the practice of drinking concentrated alcoholic liquors with
the object of supplying deficiencies in diet, or counteracting the effects
of a depressing physical and social environment.

The action of alcohol on the organism forms the subject of the first
part of the book. The influence of moderate doses of the drug on the
different functions is discussed. In regard of psychic effects, concur¬
rence is expressed with Kraepelin’s view that alcohol, even in small
doses, retards sensory and intellectual functions, but induces a real
though temporary acceleration of psycho-motor processes. In all cases
it increases the feeling of well-being.

The symptoms of drunkenness are subsequently discussed; their
predominantly paralytic nature is insisted on; it is pointed out that the
phase of psycho-motor acceleration in drunkenness is very brief.

The chapters dealing with chronic alcoholism in its clinical and
pathological aspects, and with the position of alcohol as a medicinal
agent and as an article of diet, are carefully written, and give an
adequate rtsumS of present views on these points.

The second section of the work treats of the causes of alcoholism.
The author is inclined to assign an important part to neuropathic
organisation in the genesis of inebriety; and he believes that it is in a
large measure through dependence in common on conditions of nervous
degeneracy that crime and suicide are found in such frequent associa¬
tion with alcoholism. He admits, however, that chronic intoxication
is capable per se of producing these phenomena. In the same connec¬
tion the author discusses the influence of alcoholism on racial
degeneracy ; he holds that chronic alcoholism in the parents may cause
somatic and psychic inferiority in the offspring, and may so be an agent
in racial deterioration; but he considers that on the whole inebriety is
more often a symptom than a cause of this degeneracy.

After a brief review of such bio-social influences as race, climate,
character of national beverages, etc., the author devotes a long and
important chapter to what he regards as the chief factor in inebriety—
the influence of industrial conditions. By reference to personal obser¬
vations and to the extensive German literature dealing with the hygiene
of occupations, it is shown that alcoholism stands in close relation to
the form of labour, thfc rate of wages, length of working hours, home
conditions, quantity and quality of food, etc. This thesis is maintained
with much ingenuity, though the author’s interpretation of the facts is
perhaps a little coloured by his partiality for the economic doctrines of
Karl Marx.

The third and last section of the book deals with remedial measures.
For confirmed inebriates, restraint in special asylums under exclusively
medical control is indicated as the SQle treatment. From the various
prophylactic measures—legal punishments for drunkenness, taxation of
alcohol, licensing restrictions—the author does not anticipate much
result, as they leave the main causes of the evil untouched. He con¬
siders, however, that the Gothenburg system has had some real
influence in replacing spirit-drinking by less objectionable alcoholic
beverages.

A review of the present distribution of alcoholism in the different
countries of Europe and in the United States brings the work to a close.

Digitized by VjOOQle

55°

REVIEWS.

[July

Considering the extent of the matters dealt with, there are singularly
few errors. We have noted only one or two of any importance. In
the chapter treating of the chronic intoxication, epilepsy is mentioned
as one of the frequent effects of that condition ; except in cases of
absinthe poisoning this is hardly in accord with the more recent obser¬
vations. Again, in reference to crime and alcoholism in the State of
Maine (p. 160) the author has overlooked the fact that, as the U.S.
Commission on the question has reported, “ Prohibition in Maine has
had no effect on the consumption of alcohol.”

A commendable feature of the work is the summary of the main
conclusions appended to each chapter. W. C. Sullivan.

NOTES ON BOOKS RECEIVED.

The Mental Affections of Children — Idiocy , Imbecility , and Insanity .

2nd edition. By William W. Ireland, M.D. London: J. and

A. Churchill, 1900. 8vo, pp. 442. Price 14 s.

Dr. Ireland’s classical treatise may now be said to be in the third
edition, and we have to congratulate him on the ready sale which it
commanded when presented to the public as an enlarged work two
years ago. By the removal of less important passages and shortening
others the latest results of recent research are introduced without
increasing the size of the volume. For instance, Hirsch’s observations
on the pathology of amaurotic genetous idiocy have not been over¬
looked, and the advance in developmental studies in regard to the
brains of infants has been utilised to clear up the position.

Dr. Ireland is, as ever, keenly alive to the adoption of every practical
hint in reference to the prevention of idiocy. He quotes Kocher’s
recommendation as to the utilising of rain water, or the boiling of
suspicious water which is to be drunk, in districts where cretinism is
endemic, and Kocher’s statement that this practice has been successful
in preventing goitre. We also find a summary of the case of Helen
Keller, an idiot by deprivation, who made a remarkable appearance at
an examination including English, Latin, and German, having been
successful in every subject, with honours in English and German. She
is now at Cambridge (U.S.A.), studying with a tutor. The literature of
juvenile general paralysis is brought up to date, and an adequate index
completes the work. It is late in the day to commend Dr. Ireland’s
book to those who are concerned with the problems with which he
deals. We are rather desirous of noting a few of the improvements
which this new edition permits, emendations which show that Dr.
Ireland’s natural force has happily not abated. We trust that yet
another edition will soon be called for, and that he will be as active in
capturing for his great purpose whatever is of value to the physician
who is charged with the care of the unfortunate class to which Dr.
Ireland has devoted the best years of his useful life.

Digitized by VjOOQle

1900.]

REVIEWS.

SSI

Asylum Retrospects .

We have of late received several publications of definite interest,
presenting historical surveys of the care and treatment of the insane in
various localities. These cannot fail to be useful as documents of
achievement in medico-psychological practice; they are valuable and
suggestive records, which will be referred to when scattered facts are
collected and arranged by the historians of the future.

The History of the Pennsylvania Hospital for the Insane from 1751
till 1895 is set forth in a sumptuous illustrated volume of 575 royal 8vo
pages, by Dr. Thomas G. Morton and Dr. Frank Woodbury. The
authors entered on their work with an enthusiasm which has carried
them through with great credit. References to the labours of Dr.
Rush, and many others famous in the annals of Pennsylvania, are to
be found set forth in detail, for the early records of the institution
were fortunately found in an abandoned closet some fifteen years
ago, and these invaluable documents formed the basis of this publi¬
cation. The contributors to the Pennsylvania Hospital determined
that a fund should be raised for the preservation and perpetuation of
the records of an institution which was the first of its kind in America,
and which was so intimately connected with the medical progress of the
State. Letters from Lieutenant-Governor Hamilton to the Penns, from
Dr. Fothergill, of London, and from Benjamin Franklin, are given for the
first time; the managers and physicians are well represented in admir¬
able portraits; and the work abounds in illustrations of deep and
abiding interest. We are tempted to make large extracts from this
noble record of philanthropic work, but space forbids, and we can do no
more than commend it to those who are in any way interested in the
care of the insane.

The Crichton Royal Institution, Dumfries, is one of the charitable
foundations of which Scotland is justly proud. Mr. James Carmont,
who acts as Treasurer and Secretary to the Crichton Institution, has
presented us with an interesting and handsome volume giving an
account of its history. The book is uncommonly well illustrated with
portraits and views of the various buildings. Although the general
outlines of the history of this well-known asylum are already familiar,
we gladly receive a detailed account of its progress from 1839 onwards.
The book should have a wide circulation in order to arouse the interests
of wealthy philanthropists who may be stimulated to go and do likewise,
and in order to show how much can be accomplished in the develop¬
ment of a modem asylum by the application of the principles of self-
help. The ratepayers of the south-western district of Scotland have
very largely benefited by the operations of the Crichton Institution,
and the private patients under treatment have been attracted from a
very wide radius. We congratulate Mr. Carmont on having brought into
moderate compass the long and honourable history of the asylum he
serves, and we trust that his book will reach many readers. To those
of us whose work is concerned with the insane it cannot but be an instruc¬
tive and encouraging volume.

A Sketch of the Care and Treatment of the Insane in the Parish of
Paisley. By Donald Fraser, M.D.—This brochure deals with an

Digitized by VjOOQle

552

REVIEWS.

[July,

interesting period, and shows the changes which have occurred in
parochial methods since 1749. Dr. Fraser divides that period as
follows: the early days of the town’s hospital, from 1749 till 1818 ; the
later years of the town’s hospital, from 1818 till 1845 > from tiie passing
of the Poor Law Act, from 1845 till 1867 i from then till the erection
of Riccartsbar Asylum, upon a report of the committee in 1871. This
historical survey is supplemented by statistics of medical interest and
references to cases and causes of insanity. The question of parochial
versus district asylums was at no distant date, and even still is a thorny
one to handle, but Dr. Fraser presents the case for Paisley in moderate
terms. His work is not of merely local interest; it opens an attractive
field for consideration and discussion, and we hope that it will be as
widely read as it undoubtedly deserves.

A Short Account of the Origin and History of the Glasgow City
Parochial Asylum , with a note on the System of Boarding-out the Insane .
—Dr. Alexander Robertson, on retiring from active service in this
institution, which is now replaced by the new asylum at Gartloch,
presented the public with this brief resume of his experience in the old
place. We cannot but regret that he did not treat his interesting
subject at greater length, but he has given a good account of his
personal opinion and methods, which we gladly welcome. Dr. Robert¬
son claims a recovery rate of 47 per cent, upon the admissions of the
ten years ending with 1888, and a freedom from serious accidents
which is worthy of all praise. Our readers are already familiar with the
methods adopted by him, and we need only add that his note on
boarding-out seems to approve the aggregation of these cases in certain
rural localities.

Die Heil- und Pflege-Anstalten filr Psychisch-Kranke des deutschen
Sprachgebietes am 1 January 1898.—We have received the new
edition of this useful book by Dr. Heinrich Laehr and Dr. Max Lewald.
The first edition was published in 1852, and the last in 1891. Succes¬
sive editions have shown the distinct value of such a work, as we
indicated in this Journal for October, 1898. With the increase of
asylums this record keeps pace, and we can only regret that no one has
yet attempted to write a similar account of the asylums of English-
speaking countries. We strongly recommend those of our readers who
intend to travel in Germany to obtain a copy of this book before
setting out It is published by Mr. Georg Reimer in Berlin, and costs
only a few shillings. A map inserted at the end shows the geographical
situation of each asylum.

The Attendant’s Companion . By Charles Mercier, M.B.—Dr.
Mercier’s useful companion reached a second edition in 1898. He
retains the form which it at first took from his hands, and desires it to
be understood that its scope is essentially practical. It was intended
to supplement rather than to displace more ambitious treatises, and to
put before attendants in a homely way subjects of importance. We-
need not revert to Dr. Mercier’s little book further than to say that his
emphatic and well-considered advice should find attentive readers in
every asylum. The modest price of 2 s. brings it easily within reach,
and we congratulate Dr. Mercier on having found it necessary to
re-issue it within a few years.

Digitized by VjOOQle

1900.]

RETROSPECTS.

553

Part III.—Retrospects.

ASYLUM REPORTS FOR 1898.

Some County and Borough Asylums , England.

Carmarthen. —Dr. Goodall reports two cases of insanity following
cranial injury, both of which made a good recovery. In another con¬
nection he writes:

Syphilis was traced as the cause of the brain lesion in only one case, but this
has no bearing upon the influence of syphilis in producing brain disorder. In
examining the bodies of persons dying in asylums one observes the comparative
frequency of degeneration of the blood-vessels (arteries), especially of the
brain, and I quite subscribe to the view expressed by eminent authorities, that
syphilis is the most frequent cause of organic brain disease in persons not much
past middle life. In an asylum drawing largely from a rural population, such as
this, one does not expect to find much evidence of the after-effects of syphilis,
but any towns in the asylum district are sure to supply their quota of general
paralysis and organic brain disease ; and it is precisely in this class that a careful
inquiry into the personal history of these cases often discloses the existence of
hereditary or acquired syphilis in a surprising degree.

Derby County. —Dr. Legge mentions a case in his report which
illustrates the risks, not always personal merely, attaching to asylum
service:

An inquest was held in February upon the body of J. W. M—. This case was
remarkable from the fact that another patient (C. P. M—) made a strongly
expressed and elaborate statement before the coroner, in which he accused an
attendant of having murdered the deceased. The coroner’s jury, however,
accepted the Medical Officers’ opinion that death was due to natural causes. The
matter was also investigated by the committee.

Devon County .—This is the last report to come from the pen of
Dr. Sanders. The committee in their report mention that he has
retired after thirty-eight years of able and faithful service on a pension
of ^742 10s. The present average residence is practically double what
it was when he first took charge, while both recovery and death ratios
have decreased considerably. We note six out of sixteen admitted and
eight out of twenty-six remaining general paralytics are females. This
proportion is remarkable in view of the fact that Plymouth has its own
asylum.

Gloucester .—Dr. Cradock adverts to the “uselessness, not to say
absurdity, of most of the vaunted nostrums for checking the spread
of insanity or for curing the insane,” and derives some pleasure from
noting at last an effort in what he considers the right direction. This
is refusing to people with strong hereditary taint permission to marry.
The practical application of this principle is said to have come from
America, but we think that we have heard before of the principle itself.
In fact, we have always thought that while it is absolutely correct from
an Utopian point of view, in practice it is only another vaunted nostrum.
Prohibition of marriage will not, except, perhaps, in the case of a few
exalted cases, stop marriage, especially in those to whom heredity brings
strong impulses with weak control. Compulsion, unless it is backed up

Digitized by

Google

554

RETROSPECTS.

[July,

by the bistoury, is hopeless ; and the bistoury is rightly tabu . Moral
suasion and education are the only possible weapons wherewith to fight
the genesis of insanity, and these under the circumstances are of little
account.

Hants .—We are glad to note the award of the full pension of ^250
to the Clerk, who retires from continued ill-health. The following bit
of economy is worth notice :

In last year’s report I mentioned the completion of the Water Softening
process, erected by Messrs. Maignen, of Regent Street, London, and said it was a
great success. I am now able to state that, in addition to the economy in soap
and soda in the laundry, and the labour and expense expended in replacing pipes
that were choked, a very considerably less amount of water is used, and that
therefore the engines run daily for twelve hours instead of fourteen, as they did
when the water was hard, and in this way a large amount of coal is saved.

Hereford, —Dr. Morrison brings before his committee the proposal to
combine with other asylums for the purpose of joint pathological
investigation. He is quite right in protesting as follows :

I desire to draw the attention of Boards of Guardians to the lax, unreliable,
and absolutely worthless manner in which many relieving officers fill in the
statement of particulars accompanying the order of admission. If this information
is inaccurate, it may easily prejudice the nature of the treatment and care that
has to be adopted on the admission of the patient, besides prejudicing a portion
of the future history of the case as recorded in these statistics.

Lancashire—Prestwick .—The following extract comes from the
report of the committee :

At the same time the committee must not be taken to agree in the theories
held by the Commissioners as to the size of asylums, as practical experience
appears to be altogether in favour of large asylums, as securing a better classifica¬
tion of patients and a more complete subordination of officers and attendants,
besides affording greater scope for the study of insanity in all its phases, with
a view to its treatment or amelioration.

Now-a-days there can be no division of opinion as to the benefits to
be obtained from the Association’s system of training attendants.
Nevertheless, as coming from a superintendent with such unrivalled
experience as Mr. I^ey has, the subjoined reference to it by him
deserves recording.

I wish to record my appreciation of the interest taken by the medical officers in
this important work. There can be no doubt that the successful care and treat¬
ment of the insane largely depends upon the experience and character of those
who are in immediate charge of them. Our aim has been to perfect a staff of
experienced attendants, imbued with an intelligent appreciation of their responsi¬
bilities and duties, for without such a trained and experienced staff no system,
however good, can be successfully carried on.

Middlesborough .—This is the first report of a new asylum, and we are
very glad to note that Dr. Pope has, like Dr. Kidd of Chichester,
worked in a full and detailed account of the design, building, fitting,
and furnishing. The particulars given cannot fail to be of use to
committees and medical superintendents advising them, who have to
undertake similar work hereafter.

For particulars we must refer our readers to this valuable report
itself, and plans attached thereto. That things have been well and

Digitized by VjOOQle

RETROSPECTS.

555

1900.]

efficiently done is evidenced by the fact, communicated to us by Dr.
Pope, that no hitch whatever has occurred during the two years in
which the asylum has been at work.

We are glad to see that the Association tables are adopted in their
entirety.

Newcastle .—The ratios of general paralytics for the year, always high
in this asylum, are remarkable.

Admitted.

Died.

Remaining.

M. F. T.

M. F.

T. M. F. T.

G.P. .

28 8 36

*5 7

22 32 14 46

Total .

77 * 3 8

35 32

67 242 274 516

Alcohol in 61, and venereal disease in

5 out of 138 admissions are

assigned as causes.

We regret to notice from the report the death of the former medical
superintendent, Dr. Wickham, who for many years was a member of
the Association.

Suffolk .—We note that this county has followed the example of
Lancashire in availing itself of Section 26 of the Lunacy Act. It sends
patients under that section to Mildenhall Workhouse. It is possible
that the capacity of workhouses throughout the country has been
seriously let down since the 4 s. stampede commencing twenty-five
years ago, but it is impossible to believe that a determined effort
could not bring into use for lunacy purposes some of the accommoda¬
tion which is being vacated by the decrease in indoor pauperism. I )r.
Whitwell urges that the word “ asylum ” should be dropped in favour of
the term “ hospital ” in connection with public institutions for the insane.
He has extended the principle of demonstrating facts by charts by in¬
troducing new ones, showing the admissions and residua year by year
in respect of each of the unions in his area. Beyond the possibility of
some one working out valuable scientific deductions from them, we
cannot but think that there is a special value attaching to them, from
the probability that the various unions and their officers will be led to
take a more intelligent interest in their own lunacy production.

Sussex , West .—It is somewhat alarming to read in a second report
of a new asylum that accommodation so recently provided is actually
being increased by 66 per cent., but so it is in Sussex. When this is
finished, and East Sussex has its asylum for 1100 patients or more,
and Brighton is in sole possession of the 900 beds at Hayward’s Heath,
nearly 3000 beds will be provided where 400 was considered ample
forty years ago.

Dr. Kidd has gone one better than Dr. Whitwell in inducing the
committee to call their institution Graylingswell Hospital for unofficial
purposes. The report shows that thus soon Dr. Kidd has got every¬
thing into perfect working order, a fact which was clearly substantiated
by the inspection of those members who attended the meeting there
in February last. The impression left then was that Graylingswell was
a cheerful, efficient, and orderly place, in which it will be good for a
pauper lunatic to live.

Wilts .—In view of the serious block arising from many workhouse
cases being sent to the asylum unnecessarily, the committee took the
XLVI. 38

Digitized by VjOOQle

556

RETROSPECTS.

[July

step of addressing through their chairman a letter of strong protest to
the authorities of each union. It is very satisfactory to read that it
has had an excellent effect.

Dr. Bowes records the fact that the number of relapsed cases is
twice what it was ten years ago. He offers no explanatory theories.

West Riding. —The statistics in relation to the admission of general
paralysis into the three county asylums present a contrast that is worth

reproducing.

Asylum .

General Paralytics. All Admissions.

Percentages.

M. F.

Menston

29 17

255 3*7

572

11*2

5*3

Wadsley .

14 5

227 232

459

2*1

4 * 1

Wakefield .

28 9

191 151

342

14*6

10*8

The following are some of the assigned physical causes :

Sexual

Venereal

Asylum.

Alcoholism.

Intemperance .

Disease.

Self-abuse.

M. F. T.

M. F.

Menston

54 21 75

527

x 7 3

3 0

Wadsley .

49 a 7 7<5

202

1 0

0 0

Wakefield .

57 »9 7 <S

7 1 8

11 4

x 5

13 0

It will be seen that drink pressed heavier on the Wadsley and Wakefield
cases, and that sexual troubles were much lighter at Wadsley than at
the other two places. A comparison of urban and rural sources of
the admissions and a comparison of “ previous occupations,” while they
might be of use in comparing the West Riding with all other counties
and boroughs, do not seem to throw any light on the differences
between the three asylums in regard to this particular disease. Some of
the large towns, such as Leeds and Halifax, share their new patients
between Menston and Wakefield, but Wadsley has Sheffield and Hudders¬
field to itself. The senile and congenital admissions were ratably rather
more frequent at Wakefield, as was the case with dementia. There was,
therefore, a smaller proportion of active insanity admitted.

Scottish District Asylums .

Argyll and Bute. —Dr. Cameron notes the curious fact that the
number of patients chargeable to the latter county exceed those chargeable
in 1882 by one only. Those from Argyll seem to increase a good deal
faster, but both counties together do not show the increase found else¬
where.

Fife and Kinross. —Dr. Turnbull strongly advocates the discharge
to private care or boarding out of those who have improved but have
not recovered. Of the seventy-two discharged no less than thirty-four
are returned as relieved only. He finds that in many such cases after a
time the patients cease to be chargeable on the rates. We note that out
of four general paralytics admitted three were females.

Glasgow District — Garloch. —The “ Hospital ” here is reported to fulfil
the expectations entertained in regard to its usefulness. Dr. Oswald
has not found treatment with animal extracts as successful as it has been
with others, but in a few cases it had led to recovery. The amalgamation
of the two parishes of Glasgow has brought this and the Woodilee

Digitized by VjOOQle

RETROSPECTS.

1900.]

557

asylum together. New cases are admitted into each in alternate
weeks.

Govan District. —Here, too, the “ Hospital ” is well spoken of. The
Sutton bacterial form of sewage disposal has been adopted and found to
work economically and efficiently.

Lanark District — Hartwood .—The extension has been completed,
and there is now accommodation for 950 patients, which Dr. Clark
thinks may suffice for eight or nine years.

Referring to treatment by spleen extracts he gives the following
results:

Physical

Recovery . Improvement. Improvement.

Females . 19 per cent. 12 per cent. 36 per cent.

Males . 33 ” 25

The treatment was applied to forty-two female and thirty-six male
cases. He thinks it fair to point out that it was used when other means
failed. The most striking results are found in young, especially male,
persons. Only 7 cases in 133 males and none in 123 females of general
paralysis were admitted. No less than ^£5344 of work in making roads
and laying out the estate has been done by the patients in a little over
three years.

Royal Asylums.

Crichton .—Of 176 cases admitted (98 male and 78 female) there were
8 male cases of general paralysis. A careful examination of facts showed
that with the exception of two it was impossible to eliminate syphilis
as a factor. The two exceptions were both traumatic, from injury to the
head. One of these cases is particularly interesting. The injury was
caused ten years before death, and was at once followed by change of
manner, headaches, dyspepsia, etc. The patient managed to do his
work, and kept his appointment till four weeks before admission. On
admission he had the usual motor signs, with aural hallucinations and
itiarked mental weakness. He died within a year, and on post-mortem
examination it was found that no injury had occurred at the seat of the
blow, but the results had been produced by contre-coup and in the
line thereof.

In consequence of fresh arrangements being made for the Glasgow
District patients, the admissions fell from 423 in 1892 to 176 in 1898.
The recovery rate was 50*6 on all admissions, including 15 transfers.

Dundee. —The following extract from Dr. Rorie’s Report shows
that his experience proves what common sense and knowledge of
asylum life suggest; and it is impossible to believe that quiet homeli¬
ness is to succeed only in private cases. This element of quiet homeli¬
ness is likely to be missed in the grand “ villas ” which are, thanks to
official requirements, now becoming the most advanced form of decen¬
tralisation in pauper asylums.

Gray House, which has so frequently been referred to in high terms of com¬
mendation by Her Majesty’s Commissioners in Lunacy, continues to prove a
valuable adjunct in the treatment of the private patients, and to afford a quiet
and homelike place of residence for such as do not require the rigid supervision
of an institution. Several ladies have recently left it recovered, who, I feel sure,
would not have done so had they been placed in less favourable surroundings.

Digitized by VjOOQle

558

RETROSPECTS.

[July,

Dr. Rorie gives some valuable additional tables, which we lately
published. In them are given some statistics of the 6000 patients
admitted since the opening of the asylum in 1820. One can here see
how the proportion of mania cases has dwindled down from 51 per
cent, for the first twenty-eight years, to 31 in the last seventeen, melan¬
cholia from 22 to 18, while dementia has risen from 10 to 21, mono¬
mania from 11 to 23, and general paralysis from 2 to 3*39. Other
interesting facts are given as to the ages on admission, which will repay
perusal.

James Murray's , Perth .—Dr. Urquhart, in stating that the present
report is his twentieth, shows that the total number of patients has
risen from 66 in 1879 to 131 in 1899, in these numbers there being
included 1 and 7 voluntary boarders respectively. This great increase
has been accompanied by a satisfactory recovery rate and a reasonable
death rate. More satisfactory still is the financial aspect, which shows
a moderate balance on the right side for the year’s working, with a
substantial and progressive reduction in the capital indebtedness
incurred by reason of the extra accommodation and furniture provided.

The Tables of the Medico-Psycho logical Association.

Having finished now our perusal of many asylum reports for 1898, we
feel constrained to say that we find more and greater departures in the
handling of these tables in Scotland than in England. Those who
rigidly adhere to them are in the great majority everywhere, while not a
few give additional yearly tables of value and interest. We venture to
plead for catholicity, especially in new asylums. It may be probable
that an individual superintendent has good reasons of his own for
scepticism as to the value of any or all of the tables; possibly it may be
that these reasons are better than those of the able gentlemen who drew
the tables up, but in any case figures extending over the whole of our
area are better than those falling short. As a concrete example, we find
that in a few reports there is no table of forms of disease on admission
(No. XI). Those—and there must be several—who are closely following
the fell march of general paralysis are thereby baulked from a full
inquiry into facts. Beyond this is the fact that the greater and the
more complete the bulk of opinions expressed by figures, the more are
the extremes of variation in personal opinion eliminated. One has only
to glance at the elaborate statistics of the English Commissioners as to
the causation of insanity to establish this. New men with strong ideas
come in and report, but the averages of the mass of opinion vary but
little from year to year, and in consequence are of more established
value.

1. Anthropology.

The Cephalic Index in Europe \L'index cephalique\ (Les Races de
FEurope — Assoc . Pranf. pour I’Avanc. des Sc ., 1897, appearing in
1899.) Deniker.

Dr. Deniker, of the Paris Museum of Natural History, has for some
time been engaged in preparing a monograph of great importance on the
races of Europe. The eminent French anthropologist has expended a

Digitized by VjOOQle

RETROSPECTS.

559

1900.]

very large amount of labour and learning over his task, and the coloured
map, which is the chief feature of the present part (the letterpress being
mainly an elucidation of the map), reveals in the clearest manner the
distribution of the cephalic index in Europe. The broad-headed or
brachycephalic populations are shown in various shades of red, and the
long-headed or dolichocephalic populations in various shades of blue.
It is at once apparent that the populations of Europe lie in three layers—
southern, central, and northern ; the first and the last being long-headed,
and the central broad-headed The broad-headed portion is wedge-
shaped, with the basis lying along the Asiatic frontier of Russia, the
apex (broken into by the Bay of Biscay) being in Brittany, and to a trifling
extent on the northern coast of Spain. Thus Central France, Switzer¬
land, Northern Italy, Austria, much of Germany, and nearly the whole
of Russia are more or less broad-headed, while the rest of Europe is
mainly long-headed. Dr. Deniker refrains from drawing any general
conclusions, but his map shows how easy it is to conceive that the
broad heads all come from Asia, while the long heads all come from
Africa, according to the theory now tending to prevail. It is clearly
visible in any case that there are three main races, the northern race
being distinguished from the southern by greater blondness and stature,
necessarily not apparent in a map of the cephalic index. The greatest
range of variations exist in Italy and France; but while, however, in the
former country the transition from extreme broad-headedness in the
north to extreme long-headedness in the south is gradual, in France
regions strongly contrasting in index may be found side by side. Great
Britain is fairly uniform throughout, with an index usually between
seventy-seven and seventy-nine. Spain is also very uniformly long¬
headed, while Russia on the whole shows a moderate broad-headedness.

Havelock. Ellis.

The Brain of Hermann von Helmholtz [ Ueber das Gehirn von Helmholtz\

( Ophth . Klin., Stuttg., 1899,///, 43—45. Zeits. f Psych., 1899.)

Hansemann .

The examination of the brain of Hermann von Helmholtz, who died
at the age of seventy-three in September, 1894, was made by Prof.
David Hansemann and three other physicians. The head was de¬
cidedly brachycephalic. The circumference with the skin was 59,
without 55 cm. The greatest breadth of the skull was 155 mm., the
greatest length 183 mm.

The weight of the encephalon, including the blood coagulum, was
1700 grammes. This being removed the brain weighed 1540 ; but so
much blood remained that it was estimated that 100 to 120 grammes
should be deducted. This would reduce the brain weight to 1420—
1440 grammes. There was sclerotic degeneration of the vessels of the
base of the brain, which was more marked on the right side. Helm¬
holtz’s height was 169*5 cm * (5 ^ eet 6 inches). Prof. Hansemann
observes that the relation of the form of the brain to the mental
capacity has been a subject of investigation since the days of Erasis-
tratos, and it is clear little knowledge has as yet been gained. He
mentions a number of brain weights of celebrated men, the lowest
given being that of Ignatz von Dollinger, the celebrated Catholic

Digitized by VjOOQle

RETROSPECTS.

560

U*iy.

theologian, which weighed 1207 grammes. Helmholtz’s brain was not
much above the average weight, which Bischoff has stated to be 1358
for men, and 1220 for women.

There are two plates given of the brain, from which it appears that
it was not finely convoluted; in fact, we notice nothing to explain the
great mental superiority of Helmholtz, whose wonderful researches in
optics entitle him to be placed in the first rank as a scientific investi¬
gator. The only thing remarkable, in the outcome of this investi¬
gation, is that it confirms what Helmholtz himself believed, that he
suffered, when young, from a slight hydrocephalus. We are told that
Peris believed hydrocephalus, when arrested in childhood, to act favour¬
ably for the growth of the brain, by widening the skull and allowing
more room for the increase of its contents. This notion Hansemann
declines to adopt, but he is disposed to believe that there may be some
connection between an arrested hydrocephalus and a powerful and active
brain,—on what grounds he does not state. He thinks that the hydro¬
cephalus in Helmholtz’s case may have helped the development of the
association spheres, as described by Flechsig. At any rate, the only
unusual development of Helmholtz’s brain lay in the central region,
which Flechsig has styled terminal areas, and designated with the
numbers 33—40. These spheres in the frontal, parietal, and temporal
lobes, and in the praecuneus, especially the regions 33, 39, 36, 37, 40,
and 34, were much fuller than in the brains of ordinary men, the sensory
spheres of which are most developed, while the association spheres fall
behind. “Sometimes, however,” remarks the Professor, “we see one
or another of these large spheres especially well formed in the brains of
ordinary persons. Flechsig has already stated that he had seen the
gyri between the first temporal and the subangular as well developed in
a clever woman of humble condition as in Helmholtz, and during the
last few weeks I have found this development in four brains of men
who showed no uncommon mental capacity. I have repeatedly
observed in the brains of ordinary men a considerable development of
the association centres, but it is rare to see the praecuneus so divided as
in Helmholtz’s brain.” W. W. Ireland.

Craniometric Observations in the Post-mortem Room . (Journ. Anat.

Physiol ., vol, xxxiv.) Waters ton, D.

A method is described of taking the measurements of the unmace¬
rated skull by means of a modification of Hepburn’s calliper, the
lower limb of the instrument being so constructed as to enable it to
reach the basion through the nasal cavity.

Pathogenesis of the Delusional State in General Paralysis [Pathogknie
du delire de la paralysie genkrale\ (Ann. Med.-Psych., January ,
1900.) Lalande .

To the four characteristics which Falret notes as belonging to the
delusional ideas of general paralysis (multiplicity, variability, absence of
ground, contradictoriness), Lalande proposes to add three more—a
tendency to the unlimited, a loss of the elementary notions of space
and time, and finally, what he proposes to call auto-psychism. He
labours to show that the general paralytic reduces everything to an

Digitized by VjOOQle

1900.]

RETROSPECTS.

561

absolute here, an absolute now, an absolute I. The egotist thinks of
his own advantage, and of what can aggrandise himself. Not so the
general paralytic, who, far from wishing to secure his own advantage,
is conscious of nothing but self, and is his own object as well as subject;
hence the name auto-psychism. The location of objects or events in
space or time depends upon the function of comparison. Relativity
lies at the bottom of our notions of time and space. When comparison
is in abeyance, sensations, ccenaesthetic and other, are translated into
absolute ideas. Hence the unlimited nature of the general paralytics*
notions, who is god, everything, unborn, nothing, and so forth; who is
Caesar and Napoleon; who is in London and at the Cape in the same
breath.

Lalande argues that our knowledge of the morbid anatomy of general
paralysis shows that the most distinctive lesion therein resides in the
most superficial portion of the cortex occupied by the small cells of the
molecular layer and by the tangential fibres of Exner. He argues from
anatomical reasons that this layer may plainly be supposed to be the
seat of the faculty of comparison, and concludes that, hallucination
being excepted, the delusional state in general paralysis is entirely
explicable by the gradual loss of the faculty of comparison, localised
in the molecular layer and carried out by the small cells which occupy
that region. C. N.

[This Retrospect should appear under Section 5.]

2. Neurology.

The Progress of Neuropathology \Le progrh de la tieuropathologie\
{Rev. Scient ., Nov., 1899.) Vires.

The author passes in review the principal landmarks in the history of
neuropathology from the beginning of the nineteenth century down to
the time of Charcot. Then follows an epitome of the more recently
acquired data of the anatomy and physiology of the nervous system,
especially of the ectodermic elements, which are classified into—

(a) The supporting tissue.

(£) The specific nervous tissue.

(<i) The supporting tissue is considered under the headings of (1)
the ependymal cells, and (2) the neuroglial cells and fibres.

(h) The specific nervous tissue consists of innumerable distinct ele¬
ments known as neurons. Each neuron consists of a cell body, an axon,
and several dendrons.

The cell body contains the nucleus, and in the perinuclear mass two
elements may be distinguished, viz.—

(1) The achromatic fibrillar trophoplasm.

(2) The chromatic granular kinetoplasm.

The axon is always single, fibrillar in structure, and becomes enclosed
in a myelin sheath shortly after leaving the cell body; it is cellulifugal,
and gives off a small number of collaterals.

The dendrons are numerous, and situated at the opposite pole of the
cell body to the axon. They are protoplasmic granular cellulipetal
ramifications with a large number of collaterals.

Digitized by VjOOQle

562 RETROSPECTS. [July,

In a scheme of the central nervous system we have to recognise
physiologically two classes of neurons, viz. projection neurons and asso¬
ciation neurons.

Projection neurons serve for the transmission of nervous impulses
from the skin, etc., to the cortex cerebri (sensory neurons), and from the
cortex cerebri to the muscles, etc. (motor neurons). In each of these
classes we have to distinguish between the peripheral or proto-neuron,
and the central or deuto-neuron.

The cell body of the sensory proto-neuron is in the posterior root
ganglion ; its dendritic prolongation is the sensory nerve from the skin;
its axon passes up the posterior root to the posterior cornu, the medulla,
or the optic thalamus. This last connection is probably indirect.
Here it ramifies among the dendrons of the sensory deuto-neuron,
whose axis-cylinder reaches the cortex cerebri. This is the direct path.

There is also an indirect path by way of the cerebellum. Here the
proto-neuron passes up to Clark's column, and the deuto-neuron
sends its axon to the cerebellar cortex or dentate nucleus, there to
ramify among the dendrons of deuto-neurons whose axons reach the
cortex cerebri.

The cell bodies of the motor deuto-neurons are in the Rolandic areas
of the cortex cerebri; their axons form the pyramidal tracts. The cell
bodies of the motor proto-neurons are in the anterior cornua, and their
axons form the anterior spinal roots whose component fibres are distri¬
buted to the muscles.

Here, again, there is also said to be an indirect path, the motor deuto-
neurons extending from the cortex cerebri to the cortex cerebelli, and
again from the cortex cerebelli to the anterior cornual cells. [If this
latter statement be true, this descending cerebello-spinal tract must be
still further broken up, probably at Deiter’s nucleus, since we now
know that destruction of the cerebellum alone causes no descending
degeneration in the spinal cord.]

The association neurons connect projection neurons with one
another. Association is in the spinal cord mainly subserved by col¬
laterals. In the cerebrum, however, there are special systems of asso¬
ciation neurons. These have connection with three chief centres in
each cerebrum (association centres of Flechsig), an anterior one in the
frontal lobe, a middle one in the island of Reil, and a posterior one in
the temporo-parietal region. From these centres association fibres pass
to all parts of the brain. W. H. B. Stoddart.

On the Structure of Brain Cells and their Degeneration in General
Diseases . (Lancet, May 27 th, 1899.) Campbell Thomson , H.

Dr. Thomson gives a resume of the neuron theory of the structure of the
nervous system, and also of the fine anatomy of the nerve-cell. He then
looks at Marinesco’s work on the influence of artificially produced high
temperatures on the structure of the nerve-cell protoplasm in animals,
and quotes Marinesco's opinion that a temperature of at least 41 0 C. is
necessary in man to produce the appearances of artificial hyperpyrexia
got in animals.

Dr. Thomson gives illustrations of three cases of meningitis with
hydrocephalus. The nuclei of the cells are lost together with the

Digitized by VjOOQle

RETROSPECTS.

563

1900.]

chromatophile differentiation, and patchy staining of the cells is shown.
In one ceil the nucleolus is displaced, while in another a dark band is
shown in the cell body similar to that which occurs occasionally in
artificial hyperpyrexia. In two of the cases moderate pyrexia was present
during life, in one case it was never present at all.

An illustration is given from a case of acute septicaemia with a
temperature of 106° F.; in this there was swelling and deformity of the
cell, diffuse staining of the cell body and nucleus, and disappearance of
nucleoli. Cells from a case of tetanus are shown. In these there was
extensive chromatolysis, and the body of the cell appeared spongy ; this
occurred mainly in the motor cells of the brain and cord, and probably
corresponds to the network described by Ramon y Cajal and Marinesco,
on the meshes of which the chromatic blocks of the cell are built.

W. F. Pen fold.

Notes on the Arrangement and Function of the Cell Groups in the
Sacral Region of the Spinal Cord. ( Journ . Nerv. Me fit . Dis.,
August , 1899.) Onuf B.

Onuf confirms Waldeyer’s observations with regard to the gross
structure of the grey matter of the sacral region—the changes in con¬
figuration at the second sacral segment, etc., considering that structu¬
rally the first sacral segment belongs more properly to the lumbar than
to the sacral portion of the spinal cord.

He describes the arrangement of the cell groups in the various seg¬
ments of the sacral portion of the cord, which he believes is character¬
istic, so that a study of a number of consecutive transverse sections will
reveal fairly exactly the level or segment from which they are taken.

The conclusions to which he has arrived regarding the functions of
the various cell groups in the sacral region of the spinal cord are
enumerated. H. J. Macevov.

On the Development of the Axial Fibres of the Brain [ Ueber Markscheiden
Entwickelunz des Gehims und ihre Bedeutung fur die Localisation ].
( Allgem . Zeits.f Psychiat ., B. lv f H 6.) Siemerling.

Dr. Siemerling gives here a report on the development of the myelin
of the brain, and its significance for localisation. He quotes Vogt’s
* remark that all men who have studied the structure of the brain fibres
are from their observations opponents of Flechsig’s views, and only those
who have not this advantage subscribe to them.

He cites the observations of Righetti: in the new-born child fibres
provided with medullary sheaths are found in the cortex of the median
convolutions and in the paracentral lobules. At the beginning of the
second month they are also to be found at the foot of the frontal gyri,
in the orbital part of the first and third frontal, in the cuneus, the lobu-
lus lingualis fusiformis, in the second and third parietal and the first
and second temporal, the gyrus hippocampi, the cornu Ammonis, and
the insula. In the third month the fibres are mature in the other parts
of the frontal and parieto-temporal lobe. The radiating fibres become
mature in all the convolutions excepting the insula, where the super¬
ficial fibres appear at the same time. The tangential fibres of the deeper
layers of the cortex are already completely formed at birth in the upper

Digitized by VjOOQle

564

RETROSPECTS.

[July,

third of the median gyri. In the second month of life they appear in
the insula and in the cornu Ammonis, and in the third month round
about the calcarine fissure. The superficial tangential fibres, at first ~
formed in the second month of life, appear in the insula and the cornu
Ammonis, and in the third month round the calcarine fissure. The
middle tangential fibres are more early developed in the cornu Ammonis
than in the other part of the cortex,—that is to say, at the beginning of
the third month.

From the observations of Monakow upon the brains of new-born
children, it appears that other nerve-fibres besides the projection ones
are mature at birth.

Dr. Siemerling has examined twelve brains of infants at different ages.
As the result of his researches he has come to the conclusion that although
the completion of the development of the nerve-fibres takes place in
certain parts, it does not remain long circumscribed, but goes on in quite
distinct regions. He, however, admits that, as a general rule, in certain
regions of the brain the development of the nerve-fibres is fuller and
earlier. He agrees with Righetti that it is the radiating fibres which
first take on the medullary sheaths. At the end of the third month of
infant life there is scarcely any part of the brain in which mature fibres
are not found. He considers it too bold to assume that all these axis-
cylinders surrounding themselves with myelin are purely projection
fibres. The only way to reproduce some of the statements and con¬
siderations advanced by Siemerling would be to translate entire the
passages in his report. Microscopists are far from agreeing in their descrip¬
tions of the brain structure. Siemerling grants that differences may be
made out in the distribution of the anatomical elements, and it is
reasonable to suppose that these differences in structure imply differences
in function. The principal objections to Flechsig’s views lie in the
limited extent which he allows to the fibres of the corona radiata,
against which both Siemerling and Sachs bring their observations and
arguments. W. W. Ireland.

The Function of the Cerebellum [Zur Lehre von den Functionen des

Kleinhims\ (fahrb . f Psychiat . u. Neurol^ B. /, H. 2, 1899.)

Pineles , F.

We have read many such papers as the above without learning much. *
Assuredly this great mass of nervous tissue must have something to do,
and yet what is assigned to it amounts to little. After wading through
forty weary pages we find the following passage:—“The cerebellum, with
its three powerful connecting crura, belongs to the subcortical portions
of the brain, and plays an important part in the innervation of move¬
ments, especially those which are automatic. Through what part the
connecting fibres of the cerebellum join with the grey matter of the
spinal cord cannot at present be decided. What is noticed after loss of
the cerebellum is an impairment of the regulation of voluntary move¬
ments which affects the hemisphere of the cerebrum on the opposite
side.” The regulating power of the cortex is much greater in man than
in the lower animals. Dr. Pineles thinks that the quicker recovery in
hemiplegia from paralysis of the leg over the arm is owing to the leg
receiving more innervation from subcortical parts of the encephalon.

Digitized by VjOOQle

1900.]

RETROSPECTS. '

565

It has been noted that diseases of the cerebellum in man do not always
lead to disturbances of movement. The observations of the last
twenty years, in which clinical observation has been closer, have shown
that injuries of movement are much more frequent. Observations
upon cases of softening of the cerebellum or circumscribed haemorrhage
are too few to give a decided inference. On the other hand, in a
number of observations in cases of deficiency of the cerebellum and
scleroses, there is no doubt that even the most trifling clinical symptoms
were wanting. This holds good especially of defects acquired in early
life, in which we may assume that the want of the cerebellum is made
up for by the compensating action of other parts of the encephalon.
In those cases of complete deficiency of this organ which have been
published within the last ten years, the symptoms almost without
exception consisted in a reeling, trembling, and wabbling of the whole
body. W. W. Ireland.

The Functional Cells in the Cerebral Cortex. (Jbum . Comp . Neur. y
June , 1899.) Thompson , Helen .

This is a valuable paper, being the result of an investigation as to the
total number of functional cells in the cerebral cortex of man, and the
percentage of the total volume of the latter composed of nerve-cell
bodies calculated from Karl Hammarberg’s data, together with a
comparison of the number of giant-cells with the number of pyramidal
fibres. The most elaborate and reliable work upon the cells in the
cortex of the human cerebrum, as is well known, is Hammarberg’s
Studien iiber Klinik und Pathologic der Idiotie. The conclusions reached
by Miss Thompson are that—(1) the total number of functional nerve-
cells in the cerebral cortex of the adult man is, in round numbers,
9,200,000; (2) the proportion of the total volume of the cerebral
cortex of the adult man composed of functional nerve-cell bodies is only
1*37 P er cent.; (3) the number of giant-cells in the cerebral cortex of
man is almost the same as the number of pyramidal fibres passing to
the spinal cord. These results are in some respects so startling that Miss
Thompson enters into a detailed critical investigation of the methods
by which they are reached, as well as of the results of other workers, and
finds that there cannot be very large room for error. Prof. Donaldson
appends a note on the significance of some of the results, especially as
to the small volume of the nerve-cell bodies in the cortex. His
conclusions may thus be stated:—(1) The weight of all the nerve-cell
bodies in the human encephalon is less than 27 grammes. (2) When
comparison is made of human encephala grouped according to race,
sex, mental power, stature, and age, the differences in weight within
each group are always more than twice that of the nerve-cell bodies,
and hence these differences depend mainly on variations in the medul¬
lary substances. (3) Small variations in the mass of the nerve-cell
bodies (though physiologically highly important) escape detection by
the method of weighing, or may be masked by the greater growth of the
medullary substance. Havelock Ellis.

Digitized by VjOOQle

566 retrospects. [July,

Rigidity of the Spinal Column . ( Joum . Nerv. Merit. Dis ., 1899.)

Zenner.

A review of published cases and additional cases are giveh. The
various theories of spinal root affection, arthritic nature, etc., are
propounded, but the author inclines to the view that, in his own cases
at least, the trouble was primarily of muscular origin.

A Case of Internal Hamorrhagic Pachymeningitis in a Child of Nine
Years, with Changes in the Nerve-cells . ( Joum . Nerv. Ment. Dis.,
Nov., 1899.) Spiller, IV. J., and McCarthy, D. J.

The central nervous system is studied microscopically, and changes
in the cortical and spinal cells and of the blood-vessels are described
and figured. The authors give a resume of the literature of this con¬
dition in childhood, and enter into a full discussion of the aetiology of
pachymeningitis, the views of a large number of writers being adduced.
The conclusion is drawn, partly from experimental evidence, that the
new membrane is formed by cellular changes in a subdural blood-clot
originating from the under surface of the dura. The degeneration in
the nerve-cells may result either from the pressure of effused blood
or disturbance in the nutrition produced by intense proliferation of
new tissue.

Alveolar Sarcoma of the Right Middle Fossa of the Skull. ( Joum.

Nerv. Ment. Dis., Nov., 1899.) Lewis, M. J.

The tumour arising from the dura caused a large depression in the
temporo-sphenoidal lobe and involved certain cranial nerves. Right¬
sided anaesthesia of the face and tongue was produced. Diagrams
and photographs are given.

Multiple Cavernous Angioma, Fibro-endothelioma, Osteoma , and Hcema-
tomyelia of the Central Nervous System in a Case of Secondary
Epilepsy. {Joum. Nerv. Ment. Dis., July, 1899.) Ohlmacher, A. P.

A single case presenting this remarkable combination of lesions is
admirably summed up by the author as follows: —“ Adult male—
Secondary (Jacksonian?) epilepsy of comparatively recent origin—
Spinal paraplegia, rapidly progressing—Terminal pneumonia. Ana¬
tomical Diagnosis:—Right lobar pneumonia—Acute splenic tumour—
Fibro-endothelioma (psammoma) of cranial dura, pressing into Rolandic
sulcus—Cavernous angioma of callosal gyrus, of optic thalamus, and
of cervical spinal cord—Haematomyelia—Osteoma of spinal arachnoid.”
The paper is illustrated by macro- and micro-photographs, and the
nature and origin of the neoplasms are discussed.

3. Physiological Psychology.

The Rdle of the Blood-supply in Mental Pleasure and Pain. (Dubl.
Journ. Med. Sc., Feb., 1900.) Dawson, IV. R.

The researches of Flechsig, in particular, indicate that some two
thirds of the cortex cerebri are employed neither in receiving sensory

Digitized by VjOOQle

RETROSPECTS.

567

1900.]

impressions nor in sending motor impulses, but in “ weaving into the
complex tissue of thought 99 the infinite variety of sensations received—
the brain is thus rehabilitated in the eyes of the world. The
structure of the neuron has been shown by recent investigation to
admit of vastly complex associations, and the inner structure of the
cell body of the neuron, as revealed by NissTs method, multiplies still
further the potential powers of nerve structures and the marvel of the
cortex cerebri. The rich blood-supply of the cortex, and the intimate
relations between the capillaries and the nerve-cells, suggest an im¬
portant functional role as belonging to the cerebral circulation. Dr.
Dawson labours to establish a definite connection between the blood-
flow and certain emotional states—of pain and of pleasure. He brings
forward evidence to show that states of malnutrition associated with
general anaemia are attended by mental distress, melancholia being the
prevailing mental attitude. On the other hand, the blood-pressure
in mental depression rules high. Anaemias rapidly produced and con¬
siderable in degree are often attended by states of mental exaltation,
and in these states the blood-pressure rules low. To what actual rate
of flow through the cortex do these physical conditions correspond?
Here comes the great difficulty, for there is no trustworthy evidence
at disposal, the physics of the question being exceedingly complicated.
It is obvious that, other things being equal, a high blood-pressure must
mean an increased rate of flow through the capillaries, but other things
do not remain equal, for Raised blood-pressure is attended by arteriole
contraction and this may become so great that a given area is actually
starved in its capillaries. The paper is well worth reading, but the
subject needs more elaboration and is in too speculative a region
at present. Meanwhile, as practical physicians, we should take note
of the raised blood-pressure in melancholic states, of the low blood-
pressure in exalted states, and in our treatment attack these attendant
phenomena. Harrington Sainsbury.

4. /Etiology of Insanity.

Biological Conditions of Families of General Paralytics [Conditions
biologiques des families desparalytiquesgen'eraux\ {Arch, de Neur.,
Feb., 1900.) Bechet , G.

Ball and Regis, in an article on this subject {Encephale, 1883),
came to the conclusion that general paralysis should be classed among
the cerebral diseases and not among the insanities. Dr. Bechet, as a
result of his stjudy of forty families of general paralytics, comes to an
opposite conclusion. These families were studied from four aspects:
—(1) Longevity; (2) Natality; (3) Vitality; (4) Morbidity. The his¬
tory of four generations (grandparents—children) was traced. He finds
that:—(1) The duration of life is superior in the ancestors of general
paralytics to that found in normal families. (2) The average of births
is higher in the families of general paralytics than in normal families.
In the second generation the natality is a little inferior. There is
a tendency more pronounced among general paralytics to sterility than

Digitized by VjOOQle

568

RETROSPECTS.

[July.

in normal individuals. (3) Vitality is much inferior in the families
of general paralytics to that observed in normal families; this is espe¬
cially noticeable in childhood. (4) Morbidity, that is the frequency of
various diseases in the families of general paralytics, presents notable
differences from that observed in normal families. While the first
place must be given to congestive (cerebral) heredity in the aetiology
of general paralysis, insane heredity comes close upon it. General
paralysis, therefore, takes place with the other insanities, and no special
heredity is concerned in its production. Alcoholic heredity is also
an important aetiological factor. H. J. Macevoy.

Heredity in General Paralysis , with regard especially to the Hereditary
Transmission of this Disease itself [De Pheredite, et en particular de
Pheredite similaire dans la paralysie generate ]. (Ann. Med.-Psych.,
May and June y 1900.) Ameline.

The writer’s remarks are based upon the statistics of the admissions
to the Parisian Asylum Sainte Anne from the beginning of 1895 to
the middle of 1889—forty-two months. These supplied him with 238
cases, in whom heredity was absent in 104, doubtful in 14, and
present in 120. In the latter total are included 97 cases in which
heredity was said to be partial, 1. e. in which mental disease existed
in one relative, or in which alcoholism or nervous disease (epilepsy,
hysteria, hypochondriasis, etc.), or grave nervous accidents (infantile
paralysis, apoplexy, or hemiplegia, when not concomitants of very old
age, etc.), occurred in the antecedents. In 23 cases, on the other
hand, in which heredity was heavy or double, there was insane taint
on both sides, or collaterals were engaged as well as ancestors. Only
34 cases of the partial class showed actual insane heredity. The word
heredity is used by M. Ameline in a wider sense than that which is
general in these countries.

In 7 of the grand total (238) there was like heredity, i.e. general
paralysis (ollowed general paralysis. In 4 of these father and son
were attacked, in 2 mother and daughter, and in 1 maternal uncle and
nephew. The author observes that in none of these cases was heredity
of general paralysis the sole aetiological factor which could be assigned.
In 5 alcoholism existed on the patient’s part, and in one of these a
paternal aunt was insane, while the father was a general paralytic.
In another case of paternal general paralysis two uncles and an aunt
died paralysed. In yet another such case the mother suffered from
ordinary insanity. In one case there was a distinct personal history
of syphilis. In others it was probable but unproved. None presented
the form of juvenile general paralysis, the youngest of the second
generation attacked being about thirty years old. In one case it is
noted that general paralysis in the father appeared at tliirty-seven (the
son being then 13) and in the drunken son at 35.

M. Ameline details two other interesting cases. In one, two brothers
at the respective ages of forty-one and forty-five became affected with
what at first appeared to be chronic alcoholism, and turned out to be
general paralysis. In another a drunken brother suffered from general
paralysis, a sister from tabes on which supervened mental enfeeblement
with absurd delusions of grandeur. C. N.

Digitized by

Google

1900.]

RETROSPECTS.

569

5. Clinical Neurology and Psychiatry.

A Contribution to the Statistics of General Paralysis [Beitrag zur
Staiistik der allgemeinen progressiven Paralyse ]. (Psychiat. IVoch -
ens ., No. 18, 1899.) Svenson , F.

Mr. Svenson, in a series of general paralytics, found 12 per cent,
suffering from melancholia, 28-5 per cent, from simple mania, 18 per
cent from acute mania, and 41*5 per cent, from dementia.

Compared with Kraepelin’s results, they show the same number of
the demented type but a large excess of the agitated and expansive
forms, and a correspondingly small number of the melancholic type.
Mr. Svenson thinks this may be due to a personal error. This explana¬
tion is surely not required, since the type of general paralytic is well
known to differ clinically and pathologically in different districts. In
134 who died 97 males and 28 females were examined post mortem.
The signs of general paralysis found differ in no way from the ordinary.
The pia was not adherent in 20 of the cases. Pachymeningitis was
present in 17 of the cases. In some English asylums this is practically
never found, while in others it is exceedingly frequent. In only 4
of the pachymeningitis cases was there an alcoholic history. Gross
softenings were found in 4 cases, while in 8 the cerebral vessels were
atheromatous.

The average weight of the brain was found to be 1273*3 grms. for
men and 1129 grms. for women; the weight was taken after dissection.
This weight is compared with the normal weight and the weight in
general paralysis as given by other authors.

Lung troubles were frequent, mostly hypostatic pneumonia, phthisis,
and pleurisy. Mr. Svenson draws special attention to the frequency
of chronic aortitis. W. J. Pen fold.

General Paralysis in the Later Years of Childhood [Fall von Dementia
paralytica im spdteren Kindesalter ]. (Arch, f Psych., B. xxxiii,
H 1.) Gaumpertz.

A lad of fifteen presented the symptoms of general paralysis together
with infantilism (a combination noted by Fournier, Mott, and others).
He had been an odd child, but had got through school work fairly
and only broke down when put to learn a trade (apparently between
fourteen and fifteen). At fifteen years he presented no signs of
puberty and his build was childish. Owing to this fact the author
holds that the case can be fairly called infantile. No history of
syphilis could be obtained, and Gaumpertz seems to think it can
be excluded ; but the mother's only other pregnancy ended in abortion.
Mother's father was a drunkard, and patient’s father committed suicide.
Patient had always been dull and odd, and perhaps considerable mental
weakness had existed and been unnoticed. Gaumpertz inclines to the
belief that a severe attack of influenza two years before the definite
beginning of paralytic symptoms, together with the altered mode of
life consequent on his apprenticeship, may have been considerable
factors in the production of the illness, and he reminds us that Althaus
has described dementia paralytica after influenza (Arch. f. Psych.,
xxv). [It must be said that Althaus's two cases are not wholly con-

Digitized by VjOOQle

570

RETROSPECTS.

[July,

vincing. One case that author only seems to have seen when in
articulo mortis , and there is no record of an autopsy; the other pre¬
sented some conditions certainly very rare in general paralysis, for
example, a degree of convulsibility so extreme that the production of
the knee-jerk was followed by alarming consequences; and this latter
case is recorded as incipient general paralysis which recovered.]

C. N.

Two Cases of Juvenile Organic Psychosis depending on Hereditary
Syphilis [Zwei Falle jugendlieber organischer Psychosen auf Grund-
lage von hereditdrer Lues]. ( Zeits . /. Psych ., B. Ivii , H. i.)
Kaplan and Meyer.

In the case first described the patient broke down mentally at
eleven years, and suddenly became worse after trifling injury to the
head. Symptoms resembled general paralysis. The anatomical finds
were endarteritis, with foci of softening, periencephalo-meningitis,
interstitialis diffusa chronica anterior, and that rare condition called
by Koppen periencephalitis angiomatosa (Arch. f. Psych ., B. xxvi,
H. 99). [Koppen’s patient was a man of thirty-eight, showing some
physical signs of syphilis (denied), who suffered from symptoms re¬
sembling general paralysis. Koppen notes that the changes found
in the brain were, on the whole, similar to those found in dementia
paralytica, and that distinct syphilitic lesions were wanting.]

Kaplan and Meyer’s second case became ill at fifteen years and
died at almost nineteen. The symptoms seem to have been quite
characteristically those of general paralysis. Post-mortem appearances
were found, both macroscopic and microscopic, perfectly typical of
general paralysis, but besides, the authors note the existence in the pia
of bodies having the structure (finely granular with evident indications
of breaking up of nuclei) characteristic of infective granulation tissue,
and these they believe to have been truly gummatous. C. N.

A Case of Juvenile Tabes [.Demonstration eines 1 yjahrigen Mddchens mit
den Symptomen einer incipienten Tabes], (Zeits. f Psych. % B. lx:tv,
H. 2 u . 3.) Kutner.

In this case the sufferer was a girl of thirteen years, whose illness
had commenced at the age of ten. Her mother suffers from advanced
tabes dorsalis; her father has died of progressive paralysis in an
asylum; he contracted syphilis two years before marriage. The girl’s
illness began with lancinating pains in the legs, difficulty of micturi¬
tion, and inequality of pupils with active light-reflex. At the time of
demonstration she showed paralysis of light-reflex, girdle zones of
hypaesthesia and hypalgesia round the thorax, slight ataxy of the
lower extremities, with bladder troubles and lively knee-jerks.

C. N.

A Case of Juvenile General Paralysis [Un cas de paralysie generate
juvenile ]. (Ann. Med.-Psyche May and June , 1900.) Marchand.

In this case there was no hereditary or personal history of syphilis.
The patient was nineteen years old. He had been a boy of strong
memory and unusual success at school up to the age of fifteen, when

Digitized by VjOOQle

1900.]

RETROSPECTS.

571

his memory began to fail. He made great efforts, but fell behind his
coevals, and at seventeen broke down at his (Baccelaureat) examination.
He then met with a railway accident in which he received a tolerably
severe scalp wound, but apparently no further injury to the head.
After this bis gait became much engaged, his speech much em¬
barrassed, he became generally tremulous, he grew incoherent and
began to entertain delusions of grandeur and of persecution. He
took to accumulating rubbish and he became unclean. When ex¬
hibited he appears to have been in a happy demented state, and to
have shown physically indications of general paralysis with an unusual
accentuation of ataxy. C. N.

Suicide in General Paralysis [Contribution a P etude du Suicide dans la

Paralysie generale\ {Ann. Med.-Psych., March and April, 1900.)

Monestier.

The writer gives details of three original observations. In the first,
the patient before admission threw himself across a railway line, and
after admission threw himself out of a window; but on each occasion
it was doubtful how far he was animated by any real suicidal intent
This patient was generally exalted, though he had from time to time
delusions of negation. In the second true delusions of culpability
existed, and caused the patient to attempt suicide by drowning. In
the third the patient showed no tendency to suicide. He had been
arrested for shop-lifting. He showed the usual signs of general para¬
lysis and had grandiose delusions of a silly character (was very rich,
a great singer, had three voices—a baritone, tenor, and bass, etc.).
He was very violent, and ceaseless in his clamour for discharge. Quite
unexpectedly he hanged himself in his cell one night. Post-mortem
appearances verified the diagnosis of general paralysis. Dr. Monestier
further refers to* the case reported by Dr. Sizaret (‘Ann. Med.-Psych.,’
1892). [This is probably the most remarkable case of suicide in
general paralysis on record. Consecutively to what was diagnosticated
as tabes the patient developed general paralysis, with at first exaltation,
and then hypochondriac terrors and delusions of culpability. The
latter persisted, and ideas of persecution, conspiracy, and mystic in¬
fluence also appeared. During a short sojourn at home he attempted
suicide by shooting himself with a revolver. In the asylum, he
wounded himself in the chest with a table knife which he had secreted,
and eventually destroyed himself by thrusting a piece of green wood
into the pericardial sac.] C. N.

Senile Dementia and Marriage. (Alien, and Neur., Oct., 1899.)

Kieman,J. G.

He gives firstly the symptoms of senile dementia, as loss of memory
for recent events, irritability, garrulity, restlessness, and a tendency to
wander, and occasionally erotic manifestations which may lead to
unsuitable marriages and to perverted sexuality. He further states
that acute insanities coming on in old age must be carefully distin¬
guished from senile dementia, and in doing so the physical signs of
senility must be taken into account. This may be of medico-legal
importance.

XLVI. 39

Digitized by CjOOQle

572

RETROSPECTS.

Duly,

Dr. Kieman quotes an interesting case in which he gave evidence.
An old man who had made a fortune during a life of hard work began
to decline mentally and physically. He gave up business, and became
slovenly and childish, and would appear semi-nude in public. His
literary tastes, religious habits, and family affection all changed. He
became restless and wandering, and determined to go to Europe.
During his tour in Europe he spent his money lavishly on useless
trash. Soon after his return his wife died, on which occasion he sent
for a fiddler to play merry tunes. He then proposed to an old servant,
who pronounced him mad. He showed physical signs of senility. No
conservator was appointed, because publicity was feared. He then
married again. His second wife, previous to her first marriage, had
had an illegitimate child and had been immoral for gain, which facts
were unknown to the old man. The marriage was partly brought
about by undue influence used over the groom by the uncle of the
bride, and by his misrepresentation of the character of the bride. On
finding that the bride was of bad character the old man left her, and
she entered suit for maintenance and to set aside certain trust deeds.
A decree of nullity of the marriage was, however, obtained for the
following reasons:—(i) One of the contracting parties was insane.
(2) Undue influence had been used to effect the contract. (3) Fraud
was also used, in as far as the uncle of the bride represented her as
being a suitable wife.

Judge Fully was of opinion that what applied to contracts in general
applied also to the marriage contract, and that consequently the above
marriage was no contract at all. W. J. Pen fold.

Mental Dissolution. (Lancet, Feb . 10 th, 1900.) Savage , G. H.

Dr. Savage points out that dissolution is not exactly the reversal of
evolution—that it simply means separation into constituent parts. In
speaking of the duration of mental dissolutions, he states that a perma¬
nent mental dissolution, following on repeated transient mental disturb¬
ance, will have as its characteristics those of the transient states. The
signs of dissolution enumerated in the paper are simply the commoner
mental symptoms. The dissolution of mind occurs in different cases
on different lines; single faculties may be picked out and may decay—
e. g. memory or the inhibitory faculties,—and the nature of the dissolu¬
tion is determined by the inherited and acquired peculiarities of the
whole nervous system.

Individual symptoms are discussed, but the subject is dealt with in
exceedingly general terms. W. J. Penfold.

Pellagrous Insanity . (Arch, di Psichiat ., vol. xx, fasc. 4.)

This number contains a report of the deliberations of the National
Congress of the Provincial Commission on Pellagra, held in April,
1899. Since this formidable disease is known to be owing to intoxica¬
tion from a fungus, it would seem to be easy to prevent it. Nevertheless
it is still common in Northern Italy. Professor Seppilli calculates that
there are about 2320 persons affected with pellagra, of whom about 5 per
cent, become insane. The difficulty evidently is to get the poor people
to give up the use of damaged maize. Some members of the Congress

Digitized by

Google

1900.]

RETROSPECTS.

573

think that the only way to put an end to the disease is to abolish the
cultivation of Indian corn altogether. This seems an extreme measure,
especially as the prevalence of pellagra is diminishing. Maize is a very
productive grain; and though the taste is seldom agreeable to those not
brought up to it, it is much relished in North America and in India, and
forms a very nourishing food. We do not hear of pellagra in these
countries, but a form of this disease appears in Egypt. It is proposed
to abolish the sale of diseased grain, and to try to induce the peasants
to cook the preparations of maize more thoroughly. In Egypt it has
been noted that of those affected with pellagra, about 39 per cent, were
unaffected in mind, 24 per cent, were stupid and apathetic, 31 per cent
were melancholic, and 3 per cent, were affected with secondary de¬
mentia, loss of memory, ideas of persecution, poisoning, or suicide.

W. W. Ireland.

Pellagrous Insanity with Criminality [Pellagroso criminale\ (Arch, di
Psichiat ., vol. xx,fasc. 4.) Bresadola and Cobelli.

Drs. Bresadola and Cobelli describe a patient suffering from this dis¬
order, who had been put into prison. He was a man aet. 52 years,
whose mother and uncle had suffered from pellagra. He presented
the symptoms of discrete erythema on the back of the hand, the
tongue red at the margin, capillary injection upon the point of the nose,
stupidity, and an air of distress. He suffered from mental confusion and
headache. A depression was found in the cranium and the left tem-
poro-parietal region, with a cicatrix, the result of a fall. There was a
slight inequality of the pupillary reaction to light. The man was trans¬
ferred to the hospital, where he was found to be in a depressed and
fatuous condition. The movements were uncertain and tremulous; he
frequently required to be fed by force, was restless and would not stay
in bed during the night, and wandered about the room.

The author describes the leading characteristic symptoms of pellagrous
insanity as obtuseness of the moral sense and a greater irritability of
temper, so that a trifling insult or threat makes him lose all measure of
temper. A pellagrous lunatic believes himself damned because he has
missed going to a mass, or is in despair because a companion has made
game of him. This answers to the general law that a weak organ
is more easily irritated and hurt. Perversion of the affective faculties is
rare with the pellagrous. W. W. Ireland.

Self-accusations [Beitrag zur forensischen Wiirdigung der Selbstanklagen
von Geisterkranken], (Allgem. Zeits . f. Psychiat , B. vi, H. 4.)
Kreuser.

In no quarter is the skill of the physician more clearly tested than
in dealing with criminals who may or may not be of unsound mind;
and perhaps the most perplexing of all are the self-accusers. It is rare
that any crime is committed, which strikes the popular mind, without
some persons giving themselves up to the police, stating that they are
the guilty parties. It is probable that some of those who suffered for
witchcraft in the old times were insane persons addicted to self-accusa¬
tion. In the above paper Dr. Kreuser has described in detail a case in

Digitized by VjOOQle

RETROSPECTS.

574

[July,

which the habit of self-accusation was the principal feature in the mental
derangement.

E. M—, aet. 33 years, had two full brothers and sisters and three half-
brothers and sisters who presented nothing abnormal, but his father’s
brother was insane. When three years old he suffered from inflamma¬
tion of the brain. He was said to have been an ill-behaved boy, but
got on pretty well at school. He learned the trade of a butcher, and
took early to drinking, which induced him to steal from his father.
During the time of his military service he twice deserted, for which he
was punished. After a weak attempt at suicide there was an inquiry
made as to his mental state, but the military surgeons did not make him
out insane. At the end of his military service he was sent to America,
but soon came back, saying that he had been put into an asylum at
Cincinnati after heavy drinking. He returned twice more to America.
On coming back to Germany the third time he was, in 1893, impri¬
soned for stealing. From 1893 to 1898 he appeared before the courts
seven times for larceny, he himself being the accuser. The authorities
began to be doubtful of these accusations, and on one occasion he
accused himself of arson, but was set free, as his confession did not
agree with the facts of the case. In 1895 he 8 ave detailed confessions
of three fires of which he was the originator. These were found not to
agree with the known circumstances. He then gave himself up on a
confession of a murder, saying that he had robbed a man, stunned him,
and thrown him into a river. The authorities were doubtful whether
such a crime had ever been committed, when he got angry because he
was not sentenced to death. A physician employed by the court to
examine him declared the man deeply insane, on which he was com¬
mitted to the asylum at Schussenried. He was found to be of good
stature, but very much emaciated. No anomalies were noticed in
the shape of the head. He complained of shortness of breath and
violent headaches. He was troubled with persistent sleeplessness,
which he attributed to the pangs of conscience and to being persecuted
by spectres all night, whom he described both in words and writing. As
soon as he lay down at night to sleep five figures came from behind.
The first was the man he had murdered, who spoke in a whimpering
tone, as he had done when he struck him down. The second w*as a
person who had been, though innocent, seized for arson which E. M—
had committed. Then there were the executioner and his two assistants.
The last three wore red garments, and carried everywhere with them a
chest with their tools. At first the only figure that haunted him was the
murdered man, who followed him even to America, and hunted him
from place to place ; the second figure appeared later, and the three
others about the end of 1896. After he had returned from the Criminal
Court under the impression that one of his dreadful crimes had come to
light, he said that it was his conscience that drove him to those repeated
accusations. He got angry and abusive when the truth of his confes¬
sions was questioned. His stories were plausible and circumstantial, and
he could not be involved in contradictions. He thought that if he
were punished he would be free from the pangs of conscience. These
were the principal features of his insanity; otherwise his intellect was

Digitized by VjOOQle

RETROSPECTS

1900.]

575

logical enough, and he was generally quiet and orderly. He was angry
at being thought insane. This was a clear case of paranoia.

W. W. Ireland.

A Case of Family Periodic Paralysis. (Amer. Jourti. Med. Sc., Feb.,
1900.) Putman,J. J.

The author makes the case, which has come under his own observa¬
tion, the subject-matter of a discussion of the condition as a whole.
The case is very fully described, and portrays the principal points of the
clinical position, e.g. in a severe attack the completeness of the paraly¬
sis—“ if the head slips off the pillow, or the arm off the bed, it must
remain until some one comes to replace it.” In the history there is one
point of great interest, i. e. that, before the condition became developed,
a weakness was noticed in the group of muscles which are now first
affected in the paralytic seizure.

The second part of the paper contains an interesting exposition of an
original causal theory. The ideas are full of ingenuity and not without
much proof in their favour. There is still, however, a beyond ; if the
disturbance of the normal balance between inhibition and its opponent
influence be the actual change, what morbid influence is at work to pro¬
duce this ? The author suggests that it is to be found in some chemical
alteration, either in the nervous system or the parenchymatous muscular
tissue. The paper contains many instructive points bearing on the
question of the altered relationship between these two great forces which
are the outcome of nervous action. G. A. Welsh.

Contribution to the Study of the Relationship of Mental Confusion to In¬
fectious Disease [Contribution d Petude des relations de la confusion
mentale avecles maladies infectieuses]. (Pro. Med., Sept. 23 rd, 1899.)
Stanceleanu et Baup.

A young man aet. 27, with a strong neurotic taint derived from his
maternal ancestors, has been addicted to drink sufficiently to have pro¬
duced headaches, hallucinations of vision (animals), and the sensation
of falling down precipices. He gets an attack of scarlet fever and
becomes delirious. Otitis media supervenes, and the patient becomes
stuporose. Concomitantly with the recovery from the otitis the stupor
passes off, and the patient ultimately recovers completely.

W. H. B. Stoddart.

, Idiocy resulting from Hypertrophic Nodular Scleroses [Idiotie symptoma-
tique de Sclerose tubereuse ou hypertrophique\. (Prog. Mid., Oct.,
1899.) Boumeville.

Boumeville here records one of these cases—the seventh of his own
series. With some history of neurosis in the family, the patient was ap¬
parently normal till six months of age. In the following year the
patient had epileptic fits almost daily. The fits gave place at the age
of seventeen months to attacks of crying out—like some animal, accord¬
ing to the mother's account. These cries disturbed the patient's sleep.
Grinding of the teeth developed later, and there was apparently some
blunting of the senses of taste and smell.

The child was never able to stand properly; at its best attempts it

Digitized by VjOOQle

576

RETROSPECTS.

[July,

swayed to and fro. The power of grasping objects properly never
developed. She was dirty in her habits; her attention could never be
fixed; there was never any sign of intelligence, and facial expression was
absent. The patient died at the age of two and a half years from
bronchitis.

Post mortem there were found numerous nodules of sclerosis on the
surface of both cerebral hemispheres and in the lateral ventricles. Histo¬
logically, it is found that the nodules always start in the neighbourhood
of a blood-vessel as a number of much-enlarged spider-cells. A hyper¬
plasia follows, which leads to the formation of the nodule.

There is a table of ten other cases of the disease, and there are
accurate measurements of the head during life at different ages, and
after death. W. H. B. Stoddart.

Nervous Symptoms in the Early Stages of Chronic Bright's Disease [De
quelqucs accidents nerveux observes au cours de petit Brightisme].
{Prog. Med., Dec., 1899.) Fleury.

This is a record of two cases occurring in the author’s practice. The
first is the case of an active man of sixty-six, who came under observa¬
tion for mental confusion, loss of memory, difficulty of articulation, and
a trivial amount of right hemiplegia. Albumen was found in the urine,
and the patient was treated dietetically for chronic Bright’s. All his
nervous symptoms rapidly cleared up under this treatment.

The second case is that of a married woman aet. 45, who suffered from
pruritus and anaesthesia vulvae. As a result she developed the delusion
that her husband had formed an attachment to another woman, and that
he had given the patient poison to produce these symptoms. Albumen
was found in the urine, and she, also, was treated dietetically and
subsequently with pilocarpine, with the result that she rapidly recovered
her normal mental condition. W. H. B. Stoddart.

Mental Excitement and Mental Depression in Relation to Epileptic
Attacks [De quelques p he nomines d'excitation et de depression mentales
en relation avec Pattaque (Tepilepsie\ {Prog. Med., March 10 th,
1900.) De Fleury.

Dr. de Fleury gives notes of cases illustrating the marked modifica¬
tions which take place in the affective and intellectual states of epileptic
patients before and after the attacks. In one case, that of a barrister,
during the period preceding an epileptic attack the patient was excited,
insolent, exalted, pointing to some irritation of the grey matter ; while
after the attack he betrayed marked asthenia, being depressed, self-
accusing, fearful, etc. Such cases, although one frequently sees the
opposite conditions, are often noted, and are of much interest concern¬
ing the question of the genesis of affective phenomena. Soury, Janet,
etc., favour the view that the emotional state depends upon some intel¬
lectual state, some idea ; Large, James, Dumas, etc., believe that the
emotional state is primary. De Fleury is not prepared to reject either
hypothesis as false, but he gives numerous instances in which, under the
influence of an elevation or a lowering of vital activity, emotions of joy
or anger, fear or depression appear, giving rise to a related or corre¬
sponding intellectual state, to “ideas of justification” (Malebranche).

Digitized by VjOOQle

1900.]

RETROSPECTS.

577

While Janet and others who have especially studied hysterics cannot
fail to adopt the view that a fixed idea is the precursor of the affective
state, those who observe neurasthenics, melancholics, and epileptics
inevitably must tend to admit the priority of the affective state.

H. J. Macevoy.

Psychical Disorders in Malaria [Sur les troubles psychiques (Torigine
paludique], ( Gaz . des Hop ., Dec., 1899.) Tikanadse .

Three cases with notes are given, and the author refers to the work of
other writers (Pasmanik, etc.). Melancholia is more frequently referred
to as the form of insanity associated with malaria; the onset usually
occurs after feverish attacks.

Psychical disorders of malarial origin are rare, but of 444 soldiers
under treatment with malaria Tikanads^ had one case, and out of 1416
patients treated in the district of Osourghethy, two cases of insanity.
These three cases are—

(1) Woman aet. 26, hereditarily predisposed to nervous disorder, who
developed mania with delusions of suspicion.

(2) Woman aet. 23, affected with mania (excitement, delusions of
identity, hallucinations, etc.).

(3) A soldier who after a short period of excitement became depressed,
and then more or less stuporous.

All these cases had fever at the onset; they suffered unmistakably
from malaria, and recovered from their insanity fairly quickly.

The prognosis is generally good in these cases, and the best form of
treatment is by hot baths and the administration of quinine (large
doses). H. J. Macevoy.

Classification of Mental Diseases [Classification des maladies men tales],
(Rev. de Psychiat ., Feb., 1900, No. 2.) Toulouse, E.

Dr. Toulouse shows that the various classifications suggested by
alienists are not logical, being based on a variety of factors, and that
with our present knowledge symptoms can be our only guide in classi¬
fication, /. e. psychical symptoms. Physical signs in their relations with
various insane conditions are not sufficiently defined to help us in
differentiating fundamental groups, but may help in establishing
secondary divisions. If we accept symptoms as characters of our
classification, we must accept them alone. Moreover in establishing
the first division the most important character must be utilised, and for
the first subdivision the character next in importance to that, etc.

The new classification which Dr. Toulouse proposes is, therefore, sym¬
ptomatic. Mental diseases (mania, melancholia, etc.) may also be
grafted with more or less different characters on various intellectual
bases. Psychias is the name he gives to the fundamental mental states,
and psychoses to the morbid forms.

In the intellectual basis, all faculties, and especially judgment, must be
considered. Accepting the definition of insanity as a disorder of the
intellectual faculties which prevents the individual from living in society,
it follows that this intellectual basis is never intact in insanity. Obses¬
sions and impulsions depend upon morbid emotionalising; hallucinations
to which patients give credence presuppose a disorder of the mechanism

Digitized by VjOOQle

S7»

RETROSPECTS.

[July,

of sensation and judgment; and in melancholia without delusions there
is disorder of judgment and feelings. So that psychia means disorder
of the basis, just as psychoses signifies morbid forms.

As we cannot conceive the possibility of increase or exaggeration of
judgment in insanity, and as in the case of the memory, emotions, and
the will, exaggeration is accompanied with perversion, we need only
consider as disorders of the fundamental faculties—diminution and per¬
version ; that is, the psychia may present itself as intellectual weakness
(menipsychia ) or simple disorder (< dyspsychia ). This determination must
be made in moments of calm or semi-lucidity.

The morbid forms may be divided by two principal characters,
according to the emotional tone prevailing (expansion or depression), or
according to the degree of cohesion of ideas (coherence and inco¬
herence). The more important, or more fixed of these characters—
the emotional state—is selected for the first division of psychoses; the
second character (coherence) is used in the subdivision.

Although the fundamental morbid species of this classification in
some instances do not correspond to well-defined clinical types, they
constitute provisional symptomatic groupings, useful for purposes of
study, and they offer this advantage that they do not prejudge the real
nature of the diseases, which will some day be more clearly understood.
The classification is also simple and logical. H. J. Macevoy.

Transitory Mental Disorder in Hemicrania. (Alien, and Net/r., Jan.,
1900.) V. Krafft Ebing (translated by Me Corn).

The author gives a detailed account of the cases, previously re¬
corded, which bear on this subject, and in addition a description
of cases he has personally observed. His aim is to determine the
actual relationship between the psychical disorders which accompany
hemicrania and the hemicrania itself; whether it can be said that these
manifestations are the outcome or allied to the hemicrania ; or whether
the whole condition is an epileptic manifestation. There is no case
quoted where an inference could be drawn that would give actual
proof that the mental disorder and the hemicrania were the outcome
of the same condition. On the other hand, there is abundant proof,
in the minority of cases not so clear, in the majority of the cases quite
decided, that the ophthalmic migraine and the various psychical states
are manifestations of epilepsy, or hysteria and epilepsy combined. In
some of the recorded cases the actual diagnosis was not made for
some years, the condition originally looked like an attack of migraine
with ophthalmic accompaniments, but as it developed stigmata of
epilepsy showed themselves. These were distinct loss of conscious¬
ness, and the classic attacks of petit or haul mal with pre- or post¬
epileptic excitement.

Viewing the clinical evidence as a whole, most of it is unmistakably
against the existence of such a condition as the title of the paper;
only 3 cases are quoted out of 21 where there is any real connection
between the mental symptoms and migraine, particularly ophthalmic.
In these cases there are phenomena closely associated with an epi¬
leptic state, and in the author’s opinion they are psychico-epileptic

Digitized by CjOOQle

RETROSPECTS.

579

1900.]

types. He is inclined to agree with Fer6 that ophthalmic migraine
is an epileptic manifestation. G. A. Welsh.

Narcolepsy: a Contribution to the Pathology of Sleep. (Amer. Journ.

Med. Sc. } Feb.y 1900.) Me Car they, D.J.

This is a critical examination of the term “ Narcolepsy ” to deter¬
mine how far it can be called a distinctive neurosis, and how far it
ranks only as a symptom of an existing pathological state. The
author, while stating that the published work of Dana points to its
existing as a distinct neurosis, from his own experience negatives
such a theory, and states that if a careful examination of each case
be made, the clinician always finds proof of an already existing definite
lesion. He says that the chief causes are hysteria, epilepsy, and
toxaemic states, and to exemplify these he quotes several cases of
great interest. They give abundant proof that a diagnosis cannot be
made till the fullest inquiry and examination has been made into the
history and morbid phenomena of the case. Altogether he brings
forward strong negative evidence to support his views. The first case
mentioned seemed, on primary examination, to be an example of
the idiopathic state, till subsequent examination revealed hysterical
hypaesthesia.

In his differential diagnosis no new points are brought forward,
his one aim being to teach that an exhaustive examination of every
suspected case is necessary. He quotes no case where, in his ex¬
perience, one of the above causes was not made out, but mentions
that Dr. Weir Mitchell had such a case w r here post mortem, no change
w r as found. G. A. Welsh.

Diseases of the Optic Nerve in the Early Stage of Multiple Sclerosis
[ Ueber Erkrankungen der Schnerven im Fiiihstadium der multiplen
Sklerose]. (Monats. f. Psych, u. Neur ., Feb., 1900.) Bruns and
Stolting.

The writers look first at the history of the eye symptoms of the
above disease. Their diagnostic value was partly recognised in the
sixties. Oppenheim, in 1887, emphasised the fact that optic neuritis,
accompanying a spastic spinal paralysis, w f as frequently a sign of mul¬
tiple sclerosis. He pointed out, in 1894, that optic neuritis was
occasionally the first sign of multiple sclerosis. A series of cases are
given to illustrate this point. In the first case, headache, giddiness,
vomiting, and fainting occurred, but no certain signs of multiple
sclerosis, then a double optic neuritis and papillitis arose with marked
amblyopia; this disappeared and the visual acuity returned to normal
in one eye and to four sixths in the other; the neuritis was followed
by definite signs of the essential disease. The second case showed
as a first sign a unilateral papillitis with almost total blindness, followed
by normal visual acuity and normal appearance of the fundus; other
symptoms did not arise for two years. This case showed later Brown-
S6quard’s symptoms. The third case was a retro-bulbar neuritis with¬
out papillitis; the dimness of vision came on gradually and was
attended with dyschromatopsia. The visual acuity subsequently
returned to normal almost. Years intervened before other symptoms

Digitized by CjOOQle

RETROSPECTS.

580

[July,

arose. Then follow nine cases in which the neuritis was not observed
by the writers of this paper, but simply taken from the history. In
the first of these a papillitis preceded the other symptoms by five years.
In the next case two attacks of amblyopia occurred, one affecting each
eye; the amblyopia improved only slightly. The first attack of
amblyopia took place four years before the other symptoms of the
disease developed. In the next case a left-sided optic neuritis pre¬
ceded the first weakness of the leg by eight years. Other cases are
given in which the interval between the eye symptoms and other
definite signs of multiple sclerosis varied greatly and was as long as
eleven and twelve years. It is considered that, even in these cases
with such long intervals, the neuritis was an early symptom and not
a separate disease. W. J. Penfold.

On Sensori-motor Palsies of the Musculature of the Face , with Remarks
on the Ocular Palsies of the Early Stages of Tabes . (Joum . Nerv.
and Ment. Dis., Oct., 1899.) Fraenkel\J.

As long ago as the times of Bell and Majendie an interdependence
between motor and sensory nerves was recognised. Bell even sup¬
posed the fifth nerve to be a motor nerve of the face in some respects.
Attention has been more recently drawn to this interdependence by
some experiments by Mott and Sherrington in this country, and by
Komiloff on the Continent, which went to show that an animal was
unable to move a limb from which the posterior spinal roots had been
severed.

In the above paper, Fraenkel discusses the question whether some of
the ocular palsies of tabes may not be due to disease of the fifth nerve.
The discussion was primarily suggested by two cases of tabes with
ataxic overaction of one side of the face. Twenty-two other cases
of tabes are tabulated, and the author concludes that disease of the
fifth nerve may interfere with motility of the face. In the cases
under consideration the kinaesthetic sensibility of the face was usually
found to be at fault. The effect of disease of the fifth nerve upon the
motility of the eyes appears to be similar to that upon the motility
of the face, and some of the ocular palsies of tabes are probably
sensori-motor palsies. W. H. B. Stoddart.

Contribution to the Study of BabinskVs Sign—Extensor Response to the
Plantar Reflex [Contribution a ietude du “ phenomlne des ortcils” de
Babinski\ ( Gaz . des Hop., Nov . 2377/, 1899.) Cestran , R., and
Le Sourd.

While a number of observers have supported the view that
Babinski’s sign is pathological and reveals some disorder of the pyra¬
midal tract, Schuler, Cohn and others deny this, and hold that it may
be met with in hysteria and normal individuals. Cestran and Le Sourd
have studied the plantar reflex in several hundred subjects, some
healthy, others suffering from various diseases (not nervous), and
others from nervous affections. Their conclusions are given in this
article.

They have never met with an extensor response in a normal adult.
(In children under a year it is perhaps the rule.) In organic hemi-

Digitized by VjOOQle

1900.]

RETROSPECTS.

58l

plegia there is nearly always an extensor response; in hysterical hemi¬
plegia the plantar reflex is normal. The presence of hemianaesthesia
may interfere with the phenomenon in the former.

Babinski’s sign is more faithful, more delicate than ankle-clonus,
in revealing an alteration of the pyramidal tract in cases of chronic
paraplegia. It is found in disseminated sclerosis, syringomyelia with
involvement of lateral columns, cases of cerebral diplegia, etc. When
polyneuritis of the lower limbs is present the plantar reflex is absent,
so that no extensor response may be found in cases of degeneration
of the pyramidal tracts if polyneuritis be superadded.

The presence of Babinski’s sign may be the only one to indicate
an affection of the pyramidal tract associated with locomotor ataxy
or general paralysis, for the knee-jerks are absent on account of
posterior sclerosis. Hence also we find it in Friedreich’s disease.

These results fully confirm the original views of Babinski.

H. J. Macevoy.

Sensory Disturbances in Epilepsy and Hysteria. (Joum. Nerv. Ment.

DisNov. 1 8 th, 1899.) Fisher , E . D.

The author found bilateral anaesthesia in both conditions, which was
of a permanent character and probably of cerebral origin.

Interesting Hysterical Phenomena—a Transfer of Tactile to Visual

Sensations . ( Joum. Nerv. Ment. Dis., Aug., 1899.) & &

Dr. Fry details a reproduction of Kineb’s experiments in a hysterical
girl aet. fourteen years, who had been the subject of undoubted hys¬
terical manifestations. He seems to have been at pains to exclude
all sources of fallacy in his investigations.

The girl being directed to look at the wall (a plain white surface)
on the left side of her bed and name the objects she would see there,
was able to recognise various figures traced on her anaesthetic (right)
arm (triangles, squares, letters, numerals, etc.), and various simple
objects placed in the right hand (match-box, silver dollar, etc.). So
that while the subject could not recognise in the ordinary way certain
sensory impressions (tactile), she could interpret them by the aid of
another sensory function (visual). H. J. Macevoy.

On Loss of the Knee-jerks in Gross Lesions of the Prcefrontal Region of

the Brain. (Glas. Med. Joum., Nov., 1899.) Williamson, R. T.

In three out of five cases of praefrontal lesion both the knee-jerks
were lost; one of these was from bilateral praefrontal sarcoma, the
other two were due to right praefrontal disease. He looks at the litera¬
ture of the subject shortly, and shows that this sign occurs in about
20 per cent, of the cases. W. J. Penfold.

Retardation of Pain-sense in Locomotor Ataxy. (Journ. Nerv. Ment.

Dis., July, 1899.) Mus kens. L.J. I.

A zone of retardation of pain-sense on the border of the analgesic
areas is stated to be always present and an early symptom of the
disease. This important statement is based upon an examination of
thirty-one cases.

Digitized by CjOOQle

RETROSPECTS.

582

Duly,

Meralgia Paresthetica {Roth), with the Report of Ten Cases . ( Journ .

Nerv. Ment. I)is., Jan., 1900.) Miisser and Sailer.

Meralgia paresthetica is “ a disturbance of sensation on the external
surface of the thigh, characterised by various forms of paraesthesia,
associated with dissociation and more or less diminution of sensa¬
tion.” Ninety-nine cases have now been reported, which are all tabu¬
lated in the present paper, and there is a complete bibliography.

It occurs more frequently in men than in women and between the
ages of thirty and sixty. It is sometimes hereditary, there is a fre¬
quent history of neurosis in the family, and in a few cases the father
and even the grandfather have suffered from the same condition.

The symptoms are these:—In the region of the femoral external
cutaneous nerve, the patient suffers from various paraesthesiae—tingling
increasing to actual pain, a feeling of numbness, cold, or wet, or of
aching. Sometimes there is tenderness of the part; and there is always
some loss of sensation, especially to pain and to electric stimulation.
The pain is increased by pressure in the region of the anterior superior
iliac spine, and in women it is increased during menstruation. Patients
usually complain of one thigh only, but careful examination, as a rule,
reveals also some disturbance of sensation upon the opposite side.

Differential diagnosis must be made from akinesia algera and
apraxia algera , in which there are hysterical stigmata and more ir¬
regular distribution of the sensory disturbance which is purely sub¬
jective.

Intermittent claudication occurs later in life or (according to Charcot)
in diabetics. Here there is rapid fatigue of the limb, increasing to
paraesthesia and pain in the leg at first, and later, in the thigh. It is
associated with arterial sclerosis.

Meralgia paresthetica may get well in a few months, but, as a rule,
it must be looked upon as a chronic disease with remissions, ameliora¬
tions, or exacerbations. It can, however, never seriously affect the
general health of the patient.

The treatment is unsatisfactory. Most success has been attained
by the application of the faradic wire-brush. Should this and other
means of counter-irritation fail, the patient being in good general
health, recourse should be had to resection or stretching of the
external cutaneous nerve.

The attributed causes of the disease are so various that it is diffi¬
cult to fix upon the right one. The favourite view is that it arises
from some traumatism to the external cutaneous nerve, which runs a
very superficial course, and is, therefore, liable to injury.

A somewhat large proportion of the patients have been soldiers
or volunteers, and one suggestion is that the disease is caused by
pressure of a heavy army belt on the nerve, or by its being struck by
a dangling sword.

In the one case which came to autopsy, there was a fusiform
swelling of each nerve where it crossed the crest of the ilium.

W. H. B. Stoddart.

Digitized by CjOOQle

RETROSPECTS.

583

1900.]

Hysterical Breast with Melanodermia of the Nipple [&/ 7 f hysterique avec
melanodermie du mamelon\ (Extrait des comptes rendus des
Seances de la Societe de Biologic, Oct., 1899.) Fere, Ch.

This unusual case concerns a woman thirty years of age, subject to
hysterical manifestations since the age of puberty, predominating on the
left side (neuralgia, hemianaesthesia, tender spots about the articulations
of the limbs). Married at twenty-two, she has had three abortions,
and was subject to painful swellings of the breasts at the menstrual
periods. Four years ago she had a fall, followed by insomnia, and
on the fifth day by pain in the left breast with tenderness. This pain
was accompanied a few days later with a brownish tint of the skin
of the breast; the periodical swelling became almost confined to the
left breast, which was now the seat of severe paroxysmal pain occurring
several times daily. Becoming deeper with each menstruation, the
skin of the nipple and areola assumed a deep brown colour like that
of a negro’s skin.

Under hydro-therapy the pains disappeared, but the pigmentation
remained three years later. H. J. Macevoy.

Note on the Mechanical Excitability of Nerves in the Insane [Note sur
Pexcitabilite mecanique des nerfs chez les alienes\. (Extrait des
comptes rendus des Seances de la Societe de Biologic , Oct., 1899.)
Fere, Lutier, and Dauzats.

Biernacki’s sign, analgesia of the ulnar nerve, although found in tabes
dorsalis and general paralysis, is found in many cases of insanity, and
is not in any way characteristic. Lutier and Dauzats find that the
same is true with regard to the mechanical excitability of nerves in
various forms of insanity. Anaesthesia may be found in some half of
the cases taken at random and excluding general paralysis, but motor
reaction is never absent. This holds with regard to their experiments
with both the ulnar and external popliteal nerves. It therefore affords
little or no help in diagnosis. H. J. Macevoy.

Two Cases of Nerve Deafness. (Polyclinic, Jan., 1900.) Grant, D.

Both these cases seem to have been hysterical, and became more or
less spontaneously well.

(1) Woman, 18 years of age, had bilateral deafness, coming on
gradually for three years, but suddenly worse after tooth-extraction.
Rinn^’s test was positive. In air-conduction maximum loss was for deep
tones. Bone-conduction was diminished (mastoid). Under treatment
there was little or no improvement, but she rapidly got well two years
later when laid up in bed for a fortnight with a complication of ail¬
ments.

(2) Woman, aged 40, who for years had suffered with chronic sup¬
purative otitis of the left ear, had become suddenly deaf with the
right ear. She had signs of nerve-deafness, but the hearing for the
highest-pitched tones was comparatively well preserved (bone-conduc¬
tion diminished, Rinne’s test positive). In testing with tuning-forks with
air-conduction, deafness was most marked for middle tones. She had
in addition comparative right hemianaesthesia, diminished pharyngeal

Digitized by VjOOQle

584

RETROSPECTS.

[July.

reflex, and highly exaggerated knee-jerks. She was ordered valerian
internally, and very rapidly improved. H. J. Macevoy.

Psychical Disorders in Huntingdon's Chorea (Hereditary Chorea) \Des
troubles psychiques dans la Choree degenerative ]. (Arch, de Neur .,
Feb ., 1900). Ladarne , P.

Dr. Ladame excludes from consideration all cases of chorea (e.g. chronic
chorea) which do not conform to the type described by Hunting¬
don in 1872; the three leading characters of hereditary chorea being:
(1) The disease is hereditary. (2) The onset of chorea begins in the
usual way; the disease becomes aggravated, and ends fatally. (3) The
affection does not begin in youth, but generally between the ages of
thirty and forty. He gives the notes of a typical case with marked
heredity, general choreic movements, affection of speech, etc.

The leading psychical symptoms were:—Irritability, outbreaks of
violence, threats of suicide, gradual intellectual enfeeblement, childish¬
ness.

Reviewing the work of other observers of this affection, he concludes
that irritability of character is the essential and fundamental feature of
the psychical condition, and often accompanies the onset of the dis¬
ease. It is commonly associated with progressive enfeeblement of the
mental faculties. Although these patients are often said to attempt
suicide, a careful examination of the notes of recorded cases corro¬
borates his own view that threats of suicide are common, but attempts
rare. Melancholia is not so very common at the onset. The mental
enfeeblement is accompanied with progressive loss of memory, and
frequently ends in complete dementia. Attempts have been made to
relate this dementia with general paralysis, but there is a fundamental
difference in the two conditions from an aetiological point of view, and
the pathology is different. Of the pathological anatomy of hereditary
chorea, Ladame intends to treat at some future date.

H. J. Macevoy.

Association of Verbal Images and Aphasia in Children [les associations
<T images verbales et Pap has ie chez les enfanfs]. ( Gaz . des Hdp. y
Jan. 13M, 20 th } 1900.) Bernheim , F.

While motor, visual, and auditory images are of the first importance
in the study of normal and pathological language, not enough stress
has been laid upon the associations which become established between
these various images, and which are indispensable to the functioning of
each. Bernheim shows that in the development of these images as
they appear, they become closely related to each other, and the various
memories of images are united to one another by close chains. In
childhood verbal associations are especially of the highest importance,
and the pathology of aphasia shows the important part the association
of images takes in speech.

Although the subject of aphasia is not dwelt upon by some writers
on the diseases of children, Bernheim cites a large number of cases
drawn from various sources. In the case of idiots and deaf-mutes, the
clinical examples to which he refers show that disorders of speech are
due to arrest of development in the paths for verbal associations, to the

Digitized by VjOOQle

RETROSPECTS.

585

1 9 OO.]

want of the necessary incitations for bringing these paths into play if
they exist, or to lesions interfering with the transmission of verbal
images.

As regards the acute infections causing infantile aphasia, typhoid
fever is especially important; the condition arises at the end of the ill¬
ness or during convalescence. In curable cases the aphasia lasts from
a few days to a few weeks; when unaccompanied by paralysis it is
ephemeral, but it is more or less prolonged when there is paralysis.
Its incidence with the exanthemata, embolism, endocarditis, trau¬
matism to the skull, meningitis, abscess of the brain, and other less
common causes, is next referred to.

The clinical picture in these cases is very varied and polymorphous,
and in view of the limited number of complete autopsies recorded, we
must at present be contented with a psycho-physiological interpretation.
The history of cases of infantile aphasia shows that speech totally lost
for a more or less prolonged interval of time not unfrequently returns
suddenly, so that a slight modification in one of the paths of associa¬
tion affects others readily, no doubt because the associations of verbal
images are recent and constantly called into play. That a cure takes
place shows that the associations of verbal images persist, their function
being merely temporarily inhibited (by microbial infection, etc.).

Bemheim’s conclusion is that the associations of verbal images are
of fundamental importance in the acquirement, development, and per¬
fecting of normal speech in children, and that by their disorders is
brought about infantile aphasia. H. J. Macevoy.

A Case of Echinococcus of Brain , Liver, Diaphragm, with a Comment
on Late Epilepsy \Ein Fall von Echinococcus des Gehims , der Leber
und des Bauchfells , nebst einer Bemerkung zur sogenannten Spate -
epilepsie ]. ( Psychiat ’. Woe hens.. No, 42, 1900.) Kruger,

The clinical history of this case showed that a woman, healthy
previously, became disinclined for conversation, and wandered about
aimlessly. Epileptiform attacks followed, which ceased for a time,
and then returned She became demented, and her speech was
considerably affected. Giddiness was very persistent. Later, the
speech defects disappeared, but she spoke little. Post mortem : Under
the left rib arch a tumour the size of one’s fist was present in the
peritoneum, also one the size of a plum at the apex of the left lobe of
the liver. In relation to the uterus there was another the size of a
child’s head. The pia mater was thickened, and adherent to the left
angular gyrus, and also around the origin of the Sylvian fissure, and
here fluctuation was present owing to a cyst the size of a plum. In
this region some convolutions were cartilaginous and calcareous.
Kruger was of the opinion that the invasion took place with the first
mental change, since the liver cyst and the brain cyst were both
calcareous, and evidently of about the same age. and were the first
formed. Kruger then draws attention by means of three different
cases to the value of epilepsy starting in advanced life in the diagnosis
of brain tumour. VV. J. Pen fold.

Digitized by VjOOQle

586 retrospects. [July,

The Causation of Abortive Epileptic Attacks [Zur Casuistik der abortiven
epileptischen Anfdlle\ (. Monats. f. Psych . u. Neur., February ,
1900.) Strohmayer , IV.

Dr. Strohmayer divides these into two classes:—First, attacks with
unconsciousness without motor disturbance ; secondly, attacks with
motor disturbance without unconsciousness. The first type being
frequently and fully described, he confines his remarks to the second
variety.

His first case showed three varieties of attack:— (a) Temporary
aphasia and speech difficulty, with perfectly retained consciousness;
(1 b ) vaso-motor disturbances, such as local sweating, pallor of face,
palpitation, dilatation of the pupil, and the like; in these also conscious¬
ness was retained; (c) these attacks were typical ordinary fits, and
developed out of variety b , which they retained as a vaso-motor aura.

The second case described showed:— (a) Typical fully developed
fits; (b) motor disturbances, with slight clouding of consciousness.

(c) Fully developed but atypical attacks, e.g. a tonic spasm arises and
then clonic twitching, and after these consciousness is fully lost;

(d) Motor disturbance of various characters, with completely unaffected
consciousness.

The third case showed (a) typical fits ; (b) abortive fits of different
type, e. g. the angles of the mouth would be drawn, and a spasm of the
glottis would occur, with sensation of strangulation, or sensations of
heat and anxiety occurred, and tonic extension of the arms, or clonic
spasms would affect the arms, legs, face, or the whole body. A
similar fourth case is given.

Different opinions and explanations relative to the production and
nature of the above fits are shortly dealt with. Dr. Strohmayer is
of opinion that they are of infra-cortical origin. W. J. Penfold.

Contribution to the Symptomatology of Intra-cranial Disease . (Journ .

Nerv. and Ment . Dis.,July, 1899.) Fraenkel,J.

This is a report of two cases. In the first the diagnosis was made
of tumour of the optic thalamus, with great probability of being correct,
but there was no autopsy. In the second case the post-mortem
findings appear to have been too trivial to account for the nervous
symptoms. W. H. B. Stoddart.

The Clinical Features of Beriberi. (Dubl. Jourti. Med . Sc., January ,
1900.) Conolly Norman .

This paper is the result of Dr Conolly Norman’s experience of Beri-
Beri at the Richmond District Asylum, Dublin. His experience differs
but little, if at all, from that of observers of this disease in the East,
but it is extremely interesting and satisfactory to have a complete
account of the disease as it occurs in Great Britain. It is none the
less important that this paper forms the record of the personal
experience of only one observer. W. H. B. Stoddart.

Digitized by VjOOQle

1 900.] RETROSPECTS. 587

Asthenic Bulbar Paralysis. (Joum. Nero. am/ Ment. Dis., .&//.,
1899.) Sinkler , Jf 7 .

About forty cases of this peculiar disease have been recorded, all of
which are referred to in the present paper.

The disease occurs in the third decade of life, and although fifteen of
the cases have come to autopsy and many have been microscopically
examined by pathologists of experience, there is yet no morbid anatomy.

The principal feature of the disease is that the muscles generally
become very rapidly fatigued, especially those muscles supplied by the
motor cranial nerves. In later stages there is a certain amount of
permanent paresis of the affected muscles, especially of those muscles
which are continually in a state of tonic contraction and have little
rest, such as the levatores palpebrarum, the masseters, and the muscles
at the back of the neck. This rapid fatigue of muscles also occurs
when they are stimulated faradically, and the knee-jerk tires on repeated
stimulation. The fatigue is not entirely limited to the motor side, since
prolonged stimulation of the special senses rapidly exhausts them.

The current view as to the pathology of the disease is that it is due
to the deleterious influence of some unknown toxic agency upon the
peripheral neurons.

[The condition is otherwise known as myasthenia gravis.]

W. H. B. Stoddart.

Isolated Finger Paralysis. (Joum. Nerv. and Ment. Dis., Sept., 1899.)

Browning, W.

This is a careful report of the history and post-mortem examination
of the case of an old gentleman who, three years before his death,
ruptured some of the extensor tendons on the back of his right hand.
There was insufficient * exciting cause for such an accident—he was
swinging a fishing-rod at the time. There are reprints of micro-photo¬
graphs taken from the tissues on the back of the hand. The accident
appears to have been due to some senile degenerative change in the
affected tendons. W. H. B. Stoddart.

On a Case of Traumatism of Part of the Cauda Equina complicated by
Alcoholic Neuritis. (Scot. Med. Surg. Journ., Feb., 1900.) Bruce, A.

This is the report of a clinical lecture delivered to the class of
clinical medicine in the University of Edinburgh. Full details of the
case are not given, the lecturer having chiefly confined his remarks to
the question of differential diagnosis. No reference, for instance, is
made to the condition of the superficial and tendon reflexes. The
diagnosis at which the lecturer arrived is given in the title of the paper.

W. H. B. Stoddart.

Paraplegia from Acute Spinal Caries without Change in the Spinal
Cord \Paralysie pottique aigue sans alteration de la moelle tpinihre].
(Prog. Med., Jan., 1900.) Verger and Laubie.

Pott’s disease may cause paraplegia in two ways : (a) By compression
of the spinal cord by the chronic abscess or by the thickened ^dura
mater, this in turn giving rise to compression-myelitis; (b) by com¬
pression of the spinal roots resulting from tubercular pachymeningitis.

XLVI. 40

Digitized by VjOOQle

588

RETROSPECTS.

[July,

The authors here publish a case illustrative of the second of these two
causes: The patient, a man fifty-six years of age, began in March, 1898,
to complain of pain in the region of the sciatic nerve and later in the iliac
fossa. Nothing further developed until the end of the following
November, when he had retention of urine. By December 10th he
had complete flaccid paraplegia with loss of sensation in both legs.
Bedsores developed, and the patient died comatose four days later.

Post mortem there were found two chronic abscesses of the seventh
to eleventh dorsal vertebrae. The spinal roots in this region were
nipped by the thickening of the dura mater, but the cord was in no way
compressed. Microscopical examination confirmed this observation.

The paper refers to some other cases of the same nature.

[Of course, the differential diagnosis between a paraplegia due to
compression of the spinal cord and a paraplegia dependent on nipping
of the spinal roots will depend on the question of flaccidity or spasticity
of the lower limbs.] W. H. B. Stoddart.

Syringomyelia. ( Nouv. Icon. de la Salpt., Nov., Dec., 1899.)

Sabrazes.

This is the report of a case of syringomyelia, which came under
observation in November, 1898. The patient was then aged sixty-six
years, and his disease first began to show itself at the age of eighteen.
There was at first wasting of the muscles of the left arm, then of the
right, and there was the usual history of chilblains and of painless
whitlows.

When the patient was seen in 1898 there was complete paralysis of
the muscles of the upper limbs and of the shoulder girdle, and some
fibrous ankylosis of the elbow and shoulder. There was complete
anaesthesia in the left ring and little fingers, loss of sensibility to
temperature and pain in the left arm, and loss to temperature only in
the right arm and hand—ulnar nerves anaesthetic. There was slight
weakness and inco-ordination of the lower limbs. There was trophic
change in the skin of both upper and lower limbs, and the hands were
blue, cold, and tumid. The bones of the hands were also enlarged.
There was also the usual cervico-dorsal kyphosis and dorso-lumbar
scoliosis with concavity to the right. There are two good stereoscopic
photographs of the case, but there is unfortunately no chart of the loss
-of sensation. W. H. B. Stoddart.

A Case of Cerebral Hcemorrhagic Pachymeningitis with Pseudo-bulbar
Palsy . ( Joum . Nerv. and Ment. Dis., Oct., 1899.) Burr and
McCarthy.

This is the clinical and post-mortem record of an alcoholic male
patient, aet 43, in whom there co-existed left frontal tubercular tumours
and internal haemorrhagic pachymeningitis over the greater part of the
left cerebral hemisphere, and also round the cervical portion of the
cord.

The case was clinically one of left frontal tumour. The gross and
minute morbid anatomy of the case are very carefully described.

In the remarks which follow, the authors attach importance to alcohol
and tuberculosis in the causation of haemorrhagic pachymeningitis.

W. H. B. Stoddart.

Digitized by

Google

RETROSPECTS.

1900.]

589

Facial Paralysis, Congenital , Unilateral, and of Unique Distribution,
(Joum. Nerv, and Ment. Dis., Oct., 1899.) Langdon, F. W.

This is a description of the case of a man, aet. 33, who had congenital
facial paralysis. The unique distribution is probably to be explained by
partial recovery of the condition. W. H. B. Stoddart.

Mai Perforant-Buccal. (Rpt. Ann. Meet. Queb. Med.-Psych. Soc.,

June 23rd, 1899.) Chagnon.

The paper contains a case of the above disease. The patient was
admitted, in 1895, suffering from acute mania, which turned out to be
due to general paralysis. He had had syphilis. In 1897, the teeth of
the left upper maxillary became loose except the second and third
molars. The loose teeth were removed and found healthy; two months
after this, the alveolar margin came away as a sequestrum and a com¬
munication formed between the mouth and the maxillary sinus. The
loosening affected the other teeth later, and during its spread, the first
affected parts cicatrised. W. J. Penfold.

Notes on Four Cases of Syringomyelia. (Dubl. Joum. Med. Sc., Oct.,
1899.) DFerrall, L. M. ,

One of the four cases was interesting in showing no sensory dissocia¬
tion. Another gave some difficulty in diagnosis, the deformities of the
hand causing it to be looked on as progressive muscular atrophy, while
at a later stage it was diagnosed as amyotrophic lateral sclerosis.

The cases showed otherwise athermia, analgesia, painless whitlows,
joint troubles, spastic gait, muscular atrophy, and weakness and
scoliosis. W. J. Penfold.

Tumour at the Base of the Brain in the Pontine Region. (Joum. Nerv.

Ment. Dis., Feb., 1900.) Lloyd, J. H.

A tumour, the size of a hen’s egg, connected with the membranes, lay
in the sulcus between the pons and left cerebellar lobe, exerting pressure
on these structures, causing some softening of the pons, and erosion
of the petrous bone. The symptoms produced were increasing para¬
lysis of both sixth nerves, and of the left seventh and eighth nerves.
Optic neuritis with haemorrhages caused total blindness. Inco-ordination
of gait occurred, and finally stupor with death after a slow course of a
year’s duration. There was an absence of paralysis and loss of sensation
in any region of the body.

Purulent Encephalitis and Cerebral Abscess in the New-born, resulting
from Infection through the Umbilicus. (Joum. Nerv. Ment. Dis.,
Nov., 1899.) Hinsdale, G .

This is a brief note on a child of thirteen days dying with purulent
exudation around brain, a pus cavity in left and a large haemorrhage in
right frontal lobe, which followed infection through the umbilicus.

Gastric Tetany, with an Account of the Microscopic Appearances found
in the Medulla and Spinal Cord. (Glasgow Hosp. Rep., 1899.)
Hunter, W. K.

An adult female, believed at first to be suffering from some form of
poisoning, came under observation with headache and vomiting; she

Digitized by VjOOQle

590

RETROSPECTS.

[July,

became delirious and then apparently unconscious. At this time, she
lay with eyes fixed and wide open, pupils of medium size and normal
reactions. Spasmodic contractions with occasional twitchings of the
facial, arm, and leg muscles occurred. The hands and feet assumed
the characteristic attitude of tetany, and any attempt to straighten the
arms led to violent muscular contractions. A small amount of albumen
was present in the urine. She passed into a state of stupor with twenty-
four hours coma before death, which occurred seven days after the
onset of the illness.

The kidneys showed both an early interstitial and parenchymatous
condition. There was great atrophy and disintegration of the mucous
membrane of the stomach. The nerve lesions found were (i) excess
of yellow pigment in the ganglion-cells throughout the pons, medulla,
and cord, the Nissl bodies being often entirely displaced, and (2)
marked hyaline degeneration in the majority of the vessels.

6. Pathology of Insanity.

A Contribution to the Pathological Anatomy of General Paralysis
[Beitrag zur pathologischen Anatomie der progressiven Paralyse ].
(Monats. f. Psychiat. u. Neur. y B. vii , H. 1.) Starlinger^ J.

Dr. Starlinger begins his paper by recounting two cases observed by
him in 1895. One of these is interesting from the fact, among other
things, that there was a history of syphilis not acquired through sexual
intercourse. In the other case syphilis was probable. Both cases pre¬
sented the ordinary signs of general paralysis. Both suffered from
convulsive seizures, followed by hemiparetic troubles, deepening after
repeated attacks into hemiplegia. Post-mortem both presented uni¬
lateral degeneration of the white matter from the cortex of the central
convolutions, where association and projection fibres were equally
engaged, down into the crossed pyramidal tract of the cord.

Subsequently similar cases were described by Boedecker and Julius-
burger, and by Muratow.

Starlinger now describes the result of his study of twenty-one later
cases, which he carefully examined by the method of Marchi for degene¬
ration in the pyramidal region. He divides them into three groups :—
(1) Those which exhibited intense unilateral degeneration of the medul-
lated fibres, six cases; (2) those which exhibited distinct degeneration
in one or both tracts, nine cases ; and (3) those in which degeneration
was not certainly present, six cases.

The first six cases are given in detail and summarised thus :—Their
common features were that in all paralytic attacks appeared one or two
months before death, with clonic spasms exclusively or chiefly confined
to one side, with or without subsequent permanent paresis or unilateral
paralysis, and all exhibited similar anatomical conditions, inasmuch as
in all there was an intense degeneration of the pyramidal tracts. The
correspondence between the clinical phenomena and the microscopic
appearances was further shown by the fact that the complete hemiplegias
occurred in the cases of most profound degeneration. Commenting on
these cases, Starlinger notes that four had certainly, and the other two

Digitized by VjOOQle

1900 .] RETROSPECTS. 591

probably, suffered from syphilis—a circumstance which, taken in con¬
nection with the history of his earlier cases, he holds cannot be without
significance.

In the second group, containing nine cases, the evidence of degenera¬
tion, though slight, was distinct, the dark coloration produced by the
Marchi method being unmistakable, and the medullary sheath showing
the characteristic moniliform appearance where seen obliquely or some¬
what longitudinally, as at the decussation of the pyramids. Thus in
fifteen out of twenty-one cases of general paralysis pyramidal degenera¬
tion was found. In a way this is not to be wondered at, considering the
frequency of motor trembles in that disease, and the author throws out
the conjecture that perhaps in degeneration of the pyramids a patho¬
gnomic criterion, hitherto wanting, may be found.

He holds that the degeneration in his cases is secondary for the
following reasons:—The appearance of the degenerated fibres was the
familiar form of parenchymatous change, such as occurs when a fibre is
cut off from its ganglion cell. No trace of interrupting lesion (focus of
softening, haemorrhage, residual pigmentation, sclerotic patch, or the
like) was found, though carefully sought. The degeneration was not
compact, but showed intact fibres even amidst the most intensely
degenerated. The degenerated fibres could be followed from one mass
of grey matter to another, and in the interval no increase of the degene¬
ration occurred, but there was merely to be seen the mass of degenerated
fibres which issued from the grey matter; for example, from the cortical
grey matter.

In the cortex, Starlinger points out, we have every reason to believe
that the most vulnerable element is the nerve-cell, and that any gener 7
ally noxious agent will exercise its injurious influence first upon the
cells. The experiments of Stenson by tying the abdominal aorta, and
of Rothmann, prove that before the nerve-fibres suffer, the ganglion
cells of the cord show advanced and irreparable injury. Similarly, the
experiments of Sukhonoff show that cerebral anaemia first affects the
cells. Such facts and others demonstrate that generally noxious
agencies act first upon the cells, and secondarily upon the fibres.
Whether the detrimental factor in general paralysis be a circulatory dis¬
turbance or a direct poison circulating in the blood, the cells and fibres
are equally exposed to it; but it strikes the cells first, as being more
vulnerable. Hence there is scarcely a doubt that the degeneration in
the pyramidal tracts shown by the Marchi method is secondary, and has
its true source in the cortical cells of the central convolutions. With
respect to the cortical or subcortical origin of the irritative and paralytic
phenomena in general paralysis, the author notes that since he has him¬
self watched closely the order of events in paralytic seizures, and
instructed his staff to observe the precise course of the convulsive move¬
ments, he has found the more irregular and generalised convulsions less
common, and the regular localised convulsive movements always more
frequent.

As the result of his observations, Starlinger is inclined to contest the
prevailing idea that general paralysis always represents a diffuse form of
brain mischief. He mentions the change to be observed in the cells and
in the vessels by the Marchi method, which is, however, ill adapted for

Digitized by VjOOQle

59 2

RETROSPECTS.

[July,

the study of either of these structures. He pleads for the systematic
examination of the hemispheres in general paralysis by the Marchi
method, and by means of a succession of frontal slices, followed up
where degeneration is found by serial sections. Admitting the tedious
and troublesome nature of the process, he believes that the results are
commensurate with the trouble and time expended.

The paper is illustrated with several plates, one of which shows the
author’s instrument for cutting sections of the entire hemisphere. For
a fuller description of the instrument he refers to his paper in the
Zeitschrift f wissenschaftliche Mikroscopie und microscopische Technik,
B. xvi, p. 179. C. N.

Cerebral Atrophy in General Paralysis [ L'atrophie cerebrate dans la
paralysie generale\ {Rev, de Psychiat., Jan., 1900.) Brunet\

In the last Report of the London County Asylums Dr. Mott drew
attention to the difference in weight between the two cerebral hemi¬
spheres of general paralytics. He pointed out that, although the left
hemisphere normally weighs more than the right, in general paralytics
the right hemisphere weighs more than the left in the majority of cases.

In the above paper Brunet comes to the same conclusion from the
examination of a much larger number of cases. In Brunet’s series the
right hemisphere was the heavier in 102 cases, the left was the heavier
in 76 cases.

The author also demonstrates the general atrophy of the cerebrum in
general paralysis. It is more marked in women than in men, the
disease generally running a more chronic course in the former. He also
points out that the atrophy is most marked in brains and in hemispheres
where there is most adhesion of the pia to the cortex.

W. H. B. Stoddart.

The Pathology of General Paralysis [Zur Pathologie der Dementia para
lytica], {Psychiat. Woe hens., No. 21, 1899.) Dees .

Dr. Dees first criticises the position of Dr. Lutz, who believes general
paralysis to be characterised by mania, and its mental symptoms to be
of great importance in its diagnosis. Meynert is quoted to the effect
that general paralysis is more distinctly a separate entity anatomically
than clinically. Meynert describes eight different clinical types. Mendel
is further quoted to the effect that dementia paralytica is the most common
clinical form. Lutz seems further to have gone astray in stating the
general paralysis is characterised by “ absolute paralysis,” while its
essential motor disturbance is a wide-spreading cortical ataxia, although
paralysis may occur in the later stages (Meynert).

Dees gives a very interesting case in which a woman had an illegiti¬
mate child, and was infected with syphilis before her marriage. She
was married in 1880. Her character changed in 1894. Dementia and
inco-ordination showed themselves, the latter especially affecting speech.
Pareses and paralyses followed, and death occurred in 1896. The post¬
mortem showed typical appearances of general paralysis. A child bom
the year of her marriage became in 1891 demented, and showed speech
disturbances. These remained stationary till 1894; they then became
rapidly aggravated, and she died in 1897. Post mortem were found the

Digitized by

Google

1900.]

RETROSPECTS.

593

appearances typical of general paralysis. He makes this case the basis
for discussing the time-honoured question of the syphilitic origin of
general paralysis. Before closing his paper he shows how mercury pro¬
duces on the nervous system effects similar to those of syphilis.

W. J. Penfold.

The Asphyxia/ Problem in Convulsive Seizures, (Brit, Med, Joum,,
Sept, 23rd, 1899.) Briscoe, J, F,

The first part of this paper consists of a discussion of the post-mortem
appearances in cases dying from asphyxia, their mode of occurrence,
and the various fallacies which arise due to the methods of making the
autopsy and to post-mortem changes. The writer finally gives adhesion
to the views of G. Johnson (Lancet, April nth, 1891) that the distension
of the right side of the heart is due to contraction of the pulmonary
arterioles, there being arterial anaemia of the lungs and corresponding
defective blood-supply to the left side of the heart. He next goes on
to state the conditions under which convulsions may occur, namely,
(1) in cases where the arterial contraction is purely reflex-nervous ; (2)
in cases where similar contraction is due to blood poisoning. The
former occurs in epilepsy, the latter in uraemia. When the healthy respi¬
ratory act is restored, the venous congestion of the various organs sub¬
sides. In status convulsivus, however, the venous system becomes
gorged, and if unrelieved the patient dies from asphyxia. He is of the
opinion that in this state it is not safe, and, in fact, almost impossible,
to administer drugs. Only three things can be done; chloroform or
nitrite of amyl can be used, or venesection performed. The former he
dismisses summarily. Nitrite of amyl is objected to because it turns
haemoglobin to methaemoglobin, and thus hinders oxidation of the
tissues. The final resource is venesection. He believes that the pul¬
monary spasm is due to disturbance of the vaso-motor apparatus in the
bulb. The changes in the chromatic substance of the cortical pyramidal
cells and the oedema of the perivascular and perineural lymph spaces
described by Mott are, according to the writer, due to venous conges¬
tion. If this engorgement is not relieved extravasations of blood are
prone to occur in various organs. He strongly advocates venesection.

, J. R. Lord.

7. Treatment of Insanity.

Some Points connected with Sleep, Sleeplessness, and Hypnotics, (Croonian
Lectures, Lancet, June and July, 1899.) Bradbury, J, B,

Under the “physiology of sleep” the remarkable achievements in
the histology of the central nervous system are discussed. The
“ neuron,” consisting of cell body with its branching processes (dendrons
and dendrites) and its axis-cylinder (axon or axite), from which
branchings also proceed, is fully described. From the description of
the structural nervous unit, whose complex relationship to other units
is set forth, we are led to theories of sleep based upon these new data.
The theory of an amoeboid movement of the neurons, whereby the

Digitized by VjOOQle

594

RETROSPECTS.

[July.

terminal branchings of the dendrites might be approximated or sepa¬
rated, has thus arisen, sleep being represented histologically by a
retracted state of the neurons with consequent diminished facility of
passage of the stimuli from one neuron to another. This is Lepine and
Duval’s theory. Lugaro, taking the same data, supposes sleep to be
the result of an expanded state of the branchings of the neurons,
which, causing an opening up of nervous paths, leads to an unrestricted
flow of nerve impulses, manifesting itself by confusion of thought and
loss of consciousness. The vaso-motor chemical and psychological
theories of sleep follow. Then Dr. Bradbury deals with the question
of hypnotics and the fascinating subject of the relation between chemical
structure and physiological action,—here, of course, in respect of hyp¬
nosis. Nothing that might be called new light is here forthcoming,
but the subject is intricate to a degree. Practice, alas ! makes no very
great figure after these brave theories have been passed in review. We
learn that we must attack the causes of insomnia, and these are
marshalled as (i) irritative, (2) toxic, (3) psychical , (4) relative to change
in the mode of life . Germain See’s divisions into dolorous, digestive,
cardiac and dyspnaal, ccrebro-spinal and neurotic , psychic (insomnia), of
fatigue, genito-urinary, febrile and toxic , suggest, perhaps, a more
practical grouping. Accepting Dr. Bradbury’s classification, we find
suggestive hints as to the treatment of the insomnias according to their
causation. The insomnia of the insane is treated by bromides, chloral,
hyoscine, hydrobromide, etc. In melancholia, where arterial tension is
high, paraldehyde “ in doses of from 40 to 90 minims or more ” is
described as a valuable hypnotic (is the dose of 40 minims ever
effectual ?), also morphine; but in certain of these cases Dr. Bradbury
says that erythrol tetranitrate in 1-grain dose will often act better than
anything else by its lowering of arterial tension.

Of treatments for the insomnia of delirium tremens, the use of
capsicum, in a bolus containing 20 grains, is mentioned as a favourite
remedy among medical officers of the American army; this treatment
has been advocated elsewhere. Harrington Sainsbury.

Sleeplessness. (Lancet, Jan. 27 th, 1900.) Broadbent, Sir IV. If.

The theories of sleep are passed by without discussion, though Sir
W. Broadbent cannot refrain from asking the question, re the influence
of the circulation, why are the arteries of the pia mater supplied with
muscular fibres if there is no vaso-motor control, as Dr. Leonard Hill
maintains ? Broadbent states, moreover, that Dr. Alexander Morison
has preparations showing very clearly the vaso-motor nerves of the pial
vessels. The practical consideration of insomnia is discussed from the
aetiological standpoint, and among the causes indigestion is stated to be
44 by far the most common.” Much brain work, sedentary occupations,
grief, and worry may all cause insomnia vid a deranged digestion; nor
need we be conscious of gastric or intestinal pain or of the distension
of the alimentary tract by flatulence, for dyspepsia still to be the true
disturbing cause. To dyspepsia Broadbent ascribes some of the cases
of insomnia after tea and coffee, but to us he seems to put this more
tentatively than is needful, for without doubt coffee or tea wakefulness
is often conjoined with marked dyspepsia, and an appropriate dose of

Digitized by VjOOQle

RETROSPECTS.

I 900 .]

595

alkali and carminative may then remove rapidly the palpitation, pulse
excitement, and wakefulness.

To the value of hypnotics and soporifics in suitable cases Broadbent
testifies, though he protests that “ nothing is easier than to obtain a
cheap kind of credit by prescribing a sedative, especially if its name is
new; ” and he goes on to say that he would rather be a victim to
morphia or to opium than to chloral, or sulphonal, or trional. This is,
indeed, a choice of evils. Harrington Sainsburv.

Headaches and their Treatment. (Brit. Med. Joum., Nov. 4th , 1899.)

Lauder Brunt on, T.

The nature of headaches and of the associated phenomena—visual,
auditory, linguistic (aphasia)—is first described, and then their depend¬
ence upon circulating toxines, peripheral irritations, intra-cranial tumours,
periosteal inflammation, etc. The mechanism of the recurrent head¬
ache, its possible rationale , is suggested, and in particular the part
played by the liver. Lauder Brunton always writes suggestively, and
his theories are generally attractive. His treatment of headaches
presents nothing very novel, but his view of the mode of action of
salicylate of soda or of salicylic acid as an hepatic stimulant, “ the most
powerful cholagogue known/’ is scarcely the current clinical view. He
finds great value in the use of salicylate of soda combined with a dose
of bromide taken overnight as a preventive of headaches in those who
are liable. Tincture of cannabis indica he finds useful in some forms
of headache in the dose of 10 minims thrice daily, gradually increased.
He concludes with the warning, whenever you get an intense headache
which drugs fail to treat, look out for glaucoma.

Harrington Sainsbury.

The Pathology of Epilepsy, with an Introduction to a New Treatment.

('Bull, of the Lab. Mount Hope Retreat / 1899.) Hill , C. J.

It is to be regretted that a new treatment for so venerable a disease
should be discussed so sketchily as is the case in the above paper. In
the pathology of the disease the presence of a toxine is postulated, and
the modus operandi, by way of a hyperaemia, induced by the toxine. In
evidence of the toxine, experiments with the secretion of the epileptic
are cited, e.g. with the gastric juice and the sweat, also experiments
with the blood. Krainsky’s experiments with the latter fluid are of
particular interest, and they indicate that the blood of the status
epilepticus is toxic, and capable of producing an epileptiform seizure.
The toxic agent is carbonate of ammonium, according to Krainsky, who
finds this substance greatly increased in the blood during the seizure.
Voisin Jeron’s investigation of the toxicity of the urine before, during,
and after the seizures is of interest here. Krainsky explains the value
of the alkaline bromides by supposing the conversion by double de¬
composition of the ammonium carbonate into bromide of ammonium,
and sodium or potassium carbonate; but we may ask, Has ammo¬
nium bromide itself no value as an antiepileptic? and if so, what becomes
of this theory ?

The new treatment is by means of extract of supra-renal capsule, but
upon what theory this agent, which raises blood-pressure, should act, we

Digitized by VjOOQle

596

RETROSPECTS.

[July,

are not told, Dr. Hill having previously explained the seizure as the
result of a brain hyperaemia caused by a rise of blood-pressure. To his
statement that he has obtained marked success no objection can be
raised, but as no statistics are given the value cannot be gauged. To
his formula one might take exception, since it combines with the supra¬
renal capsule extract, sodium bromide—the latter, it is true, in small
dose, viz. 5 grains. From one or two statements as to results it is
evident that the use of supra-renal extract must proceed very cautiously.
To us the subject is very imperfectly dealt with.

Harrington Sainsbury.

Hydrotherapy and Balneotherapy . ( Allgem . Zeits. Psychiat ., B. Iv,

H. 6.) Thompsen , R.

Dr. R. Thompsen publishes here a long paper on the use of baths in
mental diseases. Basing upon the experiments of Winternitz, he thus
states the effect of baths upon the system :—Fleeting applications of
heat to the skin heighten the sensibility of the parts, longer diminish it.
Local cold applications induce narrowing of the blood-vessels, and in¬
crease the tone of the peripheral vessels. The cold shower-bath dimin¬
ishes the calibre of the vessels of the skin, the pulse becomes slower
and stronger, the blood-pressure is heightened, and the elasticity of the
walls of the vessels is increased. This is succeeded by a widening of
the vessels with heightened tone. A shower of cold water on the back
has the same effect. A hot bath heightens the blood-pressure and
increases the frequency of the pulse, which becomes fuller and softer.
When the trunk of a vessel or nerve is affected by cold the vessel con¬
tracts, the temperature of the part affected sinks, and the nourishment
and function of the parts involved are diminished. The area thus
affected through the brachialis is the forearm, through the carotids the
encephalon. All the vessels of the superficial parts are made to con¬
tract through a cold bath ; the blood is forced to the interior, and there
is a plethora with alteration of function in the organs within the cavities
of the body. The blood-pressure is increased, and when the cold is
withdrawn there is a reaction, and the cutaneous blood-vessels again
widen. Where the vessels of the internal organs are weak through
disease, cold baths may thus be the cause of internal haemorrhage.
From the experiments of Naumann it appears that applications of cold
and hot water act through the nerve terminations upon the nerves of the
vessels. It was found that when heat or mechanical stimulation was
applied to the skin of the leg in the frog, although the only connection
between the limb and the body was through the sciatic nerve, there
was acceleration of the circulation in the mesentery with narrowing of
the vessels. When the vessels became dilated the circulation was
slowed down to stagnation. After strong stimuli the temperature of
the body was raised, again to fall. On cold application to the surface
there is a slight rise of temperature in the deeper parts if the patient
remains still. If he moves about the temperature sinks along with the
number of pulsations. After the reaction, that is the return of heat to
the surface, the central temperature, the blood-pressure, and the force
of the heart beats all sink.

The experiments of Schullers upon the effects of hot and cold water

Digitized by VjOOQle

1900.]

RETROSPECTS.

597

on the vessels of the pia in the rabbit are also cited. Cold compresses
upon the belly and back diminish the calibre of the vessels of both the
skin and mesentery, and by reflection there is a widening of the vessels
of the pia and a slowing with increased force in the pulsation of the
brain. Warm compresses widen the vessels of the skin and mesentery,
and by reflection cause a narrowing of the vessels of the pia and
increased frequence with weakening of the pulsations. Cold baths of
the whole body act like cold compresses. If prolonged there follows
narrowing of the pial vessels and sinking of the brain. This contraction
of the vessels lasts a long time after the bath. Warm baths first cause
a rapid dilatation, and afterwards a marked narrowing with sinking of
the brain. Warm wrapping about 270° Reaumur causes a loss of tempe¬
rature from i° to 2 0 , which lasts from two to three hours.

After quick but fleeting dilatation the vessels of the pia become
contracted, the brain sinks, and its heavings are slower. This lasts for
hours. After unwrapping there is a strong dilatation of the vessels,
then a return to the normal. Cold douches cause irregularity in the
calibre of the vessels.

Dr. Thompsen thinks that all water-baths, especially cold ones, have a
powerful effect upon the nervous system, on the blood-pressure, strength
of the heart, and circulation. He observes that cold increases the
exhalation of carbonic acid and the absorption of oxygen, while heat
diminishes these processes. He recommends that hot baths be used in
the treatment of all psychoses and neuroses. The temperature should
be between 25 0 and 15 0 C., and the head and face should be cooled
before the bath. It should last from six to eight minutes He does
not approve of the cold bath, but makes use of douches, which are so
much valued by the French physicians. Dr. Thompsen remarks that
washing (Abwaschung), the mildest of all hydriatic procedures, may be
regarded as a preparation for other applications of this fluid for very
sensitive persons. He uses the wet pack in all cases of irritability and
excitement, especially in maniacal states. Kraepelin treats mania with
warm baths which last hours, even days. If there be congestion at the
same time he applies cold to the head. After the bath he uses cold
affusions or rubbing. Dr. Thompsen rightly observes that our notions
both of the pathology of insane states of the brain and of the means of
treating them through baths are yet somewhat empirical. No doubt
there is a wide difference between the delirium of acute mania, the
excitement of general paralysis, epilepsy, delirium tremens, and para¬
noia, and the conditions of melancholy with stupor, paralytic and
epileptic depression, and simple melancholia. We know little of the
pathological substrata of these varying mental derangements to gain
guidance for our therapeutic arrangements. In treating insanity by
hydrotherapy we generally assume either a hyperaemia or an anaemia of
the brain. Thus the affections most likely to derive benefit from such
treatment are mania, melancholia, and the acute delusional form of
paranoia. For apathetic and stupefied patients Dr. Thompsen uses
warm baths followed by affusions of cold water. W. W. Ireland.

Digitized by VjOOQle

598 retrospects. [July,

The Practice of Bloodletting, (Clin, Joum,, Aug, gth and Sept, 20/A,
1899.) Briscoe\J. F,

In this brochure, the writer, in the first place, gives a general outline
of “ the past and present of bloodletting.” He traces the practice from
the time of Hippocrates down to the sixties, making a serious digres¬
sion, dangerously controversial, as regards the prevalence of nervous
disease, the struggle for existence, and the marriage of “ degenerates,”
for which a very necessary apology is forthcoming. As regards a
rational basis for bloodletting the following is given :—“ Bloodletting
will always occupy an important position, since capillary attraction, an
important physiological function, is decidedly encouraged after a
bleeding. The muscles and all the tissues of the body become obvi¬
ously drained, and thus pathological depositions are carried along the
gutters of the circulation. This, then, is the main object of vene¬
section, namely, the relief of congestive areas.” Two ounces form
a maximum depletion with few exceptions, but in many cases a less
quantity is stated to answer the object of the phlebotomist. He next
describes the methods of bloodletting, and finally the conditions in
which such are indicated, discussing also “ status epilepticus.”

J. R. Lord.

8 . Sociology.

International Conference on the Prophylaxis of Syphilis and Venereal
Diseases, ( Gaz, des Hdp ., Sept, 12M, 1899.)

Fournier states briefly but very clearly the many ways in which
syphilis threatens the individual and the community. Under individual
liabilities he includes not only those morbid conditions directly attribut¬
able to the syphilitic poison and capable of specific treatment, but those
indirect states— e. g. tabes, general paralysis of the insane, leucoplakia
buccalis, etc.—which he names parasyphilitic, and which are not amen¬
able to antisyphilitics. He urges that this social plague, which, with
alcoholism and tuberculosis, constitutes “ la triade des pestes contempo-
raines,” should be combated as vigorously as the last two.

Drs. Verch&re and Pilar, of Paris, regard prostitution as the primary
and preponderating danger to the community, and they urge a more
systematic aqd thorough regulation of State control. Professor Lassar,
of Berlin, accentuates the many ways outside prostitution by which the
disease is spread, and he calls for more dissemination of knowledge
respecting the sources of infection among young people and parents.
M. Blaschko, contrasting the results in those countries under State con¬
trol with those where control is not, points out the extreme difficulty of
obtaining really trustworthy comparable statistics. He thinks that all
systems of control commit the error of regarding professional (regis¬
tered) prostitution as the almost exclusive source of venereal diseases.
He regards as an impossible task the efficient policing of clandestine
prostitution, certainly in the larger towns; and therefore he holds it
most important that State control should be supplemented by other
measures— e, g, hygienic—which are at our disposal.

No general consensus of opinion as to the means of combating

Digitized by

Google

RETROSPECTS.

599

1900.]

syphilis was ultimately arrived at, with the exception that all were agreed
upon the necessity for more systematic teaching and study of vene¬
real diseases as an obligatory part of the medical curriculum. Most
speakers advocated also the desirability of greater facilities for the treat¬
ment of this disease at the general hospitals.

Harrington Sainsbury.

Insanity in German and Anglo-American Law \Geisteskrankheit in
amcrikanisch-englischer und in deutscher Rechtsprechung\. (Archiv

f. Krim.-Anthropl. w. Kriminalistik , ix .) Kornfeld , H.

The treatment of insanity from the legal standpoint varies widely in
different countries. A striking example of the above is the recognition
in England and America of a partial insanity, /. e. an insanity in which
only part of the mind is affected, certain faculties remaining quite
healthy. This is quite opposed to Continental ideas. If a man who has
delusions, but is legally able to manage his property and make a will,
commit a crime, in England he is responsible, in Germany he is not.
Dr. Kornfeld takes up a number of points from Clevenger’s Medical
JurisprudeTue of Insanity. He considers a large number of legal
definitions of insanity which are interesting, but unsatisfactory. The
indications of criminal responsibility are discussed at great length.
Dr. Kornfeld remarks that moral insanity is not recognised legally in
England, if a disturbance of the reasoning power as an inability to tell
right from wrong, is not present. W. J. Penfold.

Simulation of Insanity by a Criminal \LOdyssee dun delinquant Simula -
feur]: Contribution to the Study of the Simulation of Insanity.
(Arch, de Neur^Jan., 1900.) Gamier , S.

An expert, who examines a criminal suspected of being insane, should
always remember the possibility of simulation. Tardieu thought these
cases rare, but Dr. Gamier has observed a number of cases in his ex¬
perience as Superintendent of Dijon Asylum—criminals simulating
epilepsy, mania with megalomania, sexual inversion, etc. One case
had studied carefully the symptoms of impulsive insanity. The case
(Cing—) described in this article by Dr. Gamier is that of a man
who had passed himself off as a lunatic, and was in an asylum for two
years. The insanity simulated was successively hysteria major with
suicidal ideas, and then delusional insanity of persecution with megalo¬
mania. When examined by Dr. Gamier, on the occasion of a charge of
theft some time after his discharge from asylum, the culprit confessed
that he had “taken in” the expert on the first occasion.

The history of the individual’s exciting career is one of repeated
criminal acts (thefts, falsification of certificate, etc.). Incidentally, as
showing the uncertainty of views concerning stigmata of degeneration,
it is interesting to find that the first expert, who certified that Cing—
was insane, drew attention to the signs of degeneration which he pre¬
sented : Asymmetry of the face, microcephaly, irregularity of teeth,
ogival palatine arch, and convergent strabismus. Dr. Gamier only
agreed to the last two signs, but saw nothing abnormal about the head,
face, and teeth.

As regards the hystero-epilepsy, it is noteworthy that the super-

Digitized by VjOOQle

600

RETROSPECTS.

[July,

intendent of the Asylum in which the patient remained two years never
witnessed an attack. Dr. Gamier coaxed the patient into simulating a
fit, which, although a fair imitation, could easily have been unmasked
as an attempt at deception. Although irritable and cantankerous,
Cing— was fairly frell endowed mentally, his memory was good, and
one could not even say that he was morally insane.

The polymorphous character of the insanity observed in Cing— was
calculated to excite suspicion; for delusional insanity of persecution,
associated with hysteria with a sudden transition to delusions of
grandeur with varying hallucinations, is a rare clinical picture. After
discussing the whole history of the patient, and after a careful exami¬
nation of the man’s antecedents and present mental condition, Dr.
Gamier concluded that:—

1. Cing— was in the full enjoyment of his mental faculties.

2. That he had never been insane, and therefore that there were no
circumstances to warrant an attenuation of his responsibility for his
criminal act.

3. Justice must take its course.

The man was condemned to six months’ imprisonment. Other in¬
cidents mentioned concerning Cing— support the view that he was a
smart criminal and nothing more. H. J. Macevoy.

A Case of Morphinism associated with Theft. (. Rpt. Ann. Meet. Queb .

Med.-Psych. Soc., June 23r/f, 1899.) Villeneuve.

Dr. Villeneuve communicates a medico-legal report on a case of
theft committed by a subject addicted to the use of morphia.

The accused, whose reputation for honesty was always very indif¬
ferent, was caught in the act of purloining some small articles in a
shop. The plea of irresponsibility was raised on the ground that the
offence was committed under the influence of morphia intoxication.

From his examination of the accused Dr. Villeneuve concluded—
(1) The morphia habit had originated from medicinal use of the drug,
not from special neuropathic predisposition. (2) It had not ptoduced
a condition of definite alienation. (3) On the day of the offence the
accused had had his customary dose, and had enough money to make
further purchases of the drug, therefore he was not driven to the theft
by craving for morphia. (4) His memory of the details of the offence
was perfect, differing only from that of the witnesses in that he
explained as accident what they attributed to criminal intent; thus the
offence had not the character of an act committed in a state of cerebral
automatism.

For these reasons the reporter rejected the theory of total irresponsi¬
bility, but at the same time admitted as an extenuating circumstance the
undoubted morphinism of the accused. Effect was given to this view
by special leniency in the sentence. W. C. Sullivan.

On Criminality in Rome and the Provinces [La Criminalita a Roma e
nella Provincia\ (Arch, di Psichiat ., vol. xx,fasc. 4.) Verotti.

In the continuation of his elaborate paper on this subject, Veroni
shows that crime cannot be treated as a result of atavism, neurasthenia,

Digitized by

Google

1900.] NOTES AND NEWS. 601

or degeneration, or of faulty education, or bad social conditions, but
that it is the outcome of many influences acting together. He shows
by elaborate statistics that riches and crime stand in an inverse relation
to one another, and that crimes such as robbery, extortion, revenge,
arson, and damage to property are found to increase with the rise in the
price of provisions, bread, meat, and wine. He finds that more spiritu¬
ous liquor is consumed in the Romagna than in the colder regions of
Northern Italy, and crimes against the person are commoner.

W. W. Ireland.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

General Meeting.

A General Meeting was held at the Rooms of the Association, London, on May
10th, 1900, under the presidency of Dr. J. Beveridge Spence. A meeting of the
Council was held earlier in the day.

Members present at General Meeting:—Drs. C. A. Mercier, J. B. Spence, H. H.
Newington, W. R. Dawson, Robert Jones, James Chambers, R. D. Hotchkis, J. G.
Soutar, R. Percy Smith, W. Crochley Clapham, J. Carlyle Johnstone, P. W.
MacDonald, Fletcher Beach, H. A. Benham, David Bower, T. Outterson Wood,
Ernest W. White, S. R. Macphail, T. W. McDowall, J. R. Whitwell, G. Braine-
Hartnell, A. W. Campbell, J. Stirling Christie, W. Douglas, T. B. Hyslop,
Maurice Craig, G. E. Mould, Guy Wood, H. C. MacBryan, W. Rawes, David
Blair, H. J. Macevoy,C. Aldridge, R. Langdon-Down, J. F. Briscoe, Wilson Eager,
Elliot Daunt, Rothsay Stewart, Herbert Smalley, R. Brayn, W. H. Kesteven, F. C.
Gayton, G. F. Blandford, G. A. Waters, J. C. Corner, F. R. P. Taylor, T. Telford-
Smith, L. W. Rolleston, L. A. Weatherly, F. G. Crookshank, W. C. Sullivan, C.
K. Hitchcock, W. H. R. Rivers, A. N. Boycott, W. J. Donaldson, R. H. Cole, H.
Rayner, John Baker, James Scott, Eric France, G. E. Shuttleworth, R. H. Steen,
T. Seymour Tuke, G. A. Rorie.

Visitors:—Drs. W. J. Koenig, Francis Warner, F. E. Batten, A. P. Tredgold,
Harry Campbell; Messrs. H. Langhorne Orchard, E. C. Benecke, Henry Power,
Shadworth H. Hodgson, A. F. Shand, H. W. Carr, D. Milsom Rees, Earl Barns
(Leland Stanford University, California), and Rev. F. Mann.

Apologies for non-attendance were received from the following members :—Drs.
D. M. Cassidy, A. R. Turnbull, A. D. O’C. Finegan, A. R. Urquhart.

The following candidates were elected ordinary members:—Joseph Shaw Bolton,
M.D., Sydney John Cole, M.B., Ernest Coleman, M.B., F. W. Edridge-Green,
M.D., Harry Armitage Robinson, M.B., Ernest William Skinner, M.D., Esther
Molyneux Stuart, M.B.

The President announced that the Council of the Association had that
morning proposed a resolution congratulating Sir John Batty Tuke on the honour
bestowed upon him by the electors of the Universities of Edinburgh and St.
Andrew’s in sending him to represent them in Parliament. On the motion of
the President it was unanimously resolved that the congratulations of the Associa¬
tion be conveyed to Sir John Batty Tuke.

Dr. A. W. Campbell gave a microscopic demonstration illustrating the arrange¬
ment of nerve-fibres and nerve-cells in the cerebral cortex of a series of idiots’
brains.

A report of this interesting contribution will appear in a future number of the
Journal.

Digitized by VjOOQle

602

NOTES AND NEWS.

[July,

Dr. Koenig read a paper entitled, “On Pupillary Anomalies in Paralysed and
Non-paralysed Idiot Children, and their relation to Hereditary Syphilis." (See
page 427.)

Dr. Maudsley gave an address on ** The New Psychology: Critical Remarks
on its Methods ana Aims, especially in Reference to Psychology of Children and
Psycho-physical Research." (See page 411.)

Members afterwards dined at the Cafe Royal.

Council Meeting.

Present:—Drs. J. Beveridge Spence (President), H. Rayner, H. Hayes
Newington, T. Outterson Wood, Fletcher Beach, Charles Mercier, J. G. Soutar,
R. Percy Smith, A. M. Campbell, J. Carlyle Johnstone, W. R. Dawson, E. W.
White, J. Chambers, R. D. Hotchkis, P. W. MacDonald, H. A. Benham, J. R.
Macphail, H. T. O. Aveline, and Robert Jones.

Apologies were intimated from Drs. Turnbull, Urquhart, Cassidy, and Finegan.

At the meeting of Council it was resolved that the following members should
serve on the Tuberculosis Committee:—Drs. D. M. Cassidy, A. Campbell Clark,
T. S. Clouston, T. Elkins, E. France, Mr. G. T. Hine, Drs. F. W. Mott, Conolly
Norman, R. Percy Smith, J. Beveridge Spence, L. A. Weatherly, J. R. Whitwell,
and J. Wiglesworth [This Committee had a preliminary meeting on the 22nd
June, and arranged for a further meeting on Wednesday, July 25th, at 4 p.m.
We are assured by a perusal of the names that it will set to work vigorously and
formulate conclusions of definite value. No doubt there will be a very deep and
widespread interest in the operations of a committee charged with such an
important research.— Ed.]

SOUTH-WESTERN DIVISION.

A meeting of the Division was held on Tuesday, April 24th, at Bailbrook
House, Bath, in response to an invitation by Dr. Weatherly, whose kind
hospitality was warmly appreciated by a large gathering of members. The day
being delightfully fine, the business proceedings took place on the balcony. Dr.
Deas was voted to the chair, and there were also present Drs. Soutar, Noott
Ligertwood, Weatherly, Forsyth, Aldridge, Stewart, Morton, Morrison, Wade,
Eager, Rutherford, Benham, Aveling, Hartnell, Turner, MacBryan, Walters, and
MacDonald (Hon. Sec.).

The minutes of last meeting having been read and confirmed, the following
candidates were elected ordinary members of the Association:—David Lauder
Lindsay, L.R.C.P. and L.R.C.S.Edin., Assistant Medical Officer, Devon County
Asylum; John Ogilvie Veitch, M.B. and C.M.Edin., Assistant Medical Officer,
Worcester Asylum; Harry Bacon Wilkinson, M.R.C.S., L.R.C.P., Assistant
Medical Officer, Worcester Asylum; Herbert C. Manning, M.R.C.S., L.R.C.P.,
Assistant Medical Officer, Cotford Asylum, Somerset; Joseph S. Barnes, L.R.C.P.,
M.R.C.S., Assistant Medical Officer, Portsmouth Asylum.

It was resolved to nominate Dr. MacDonald as Hon. Sec., and the names of
two members were submitted as willing to serve if elected on the Council.

The vacancies on the Committee of Management were filled by the election of
Dr. Davis and Dr. MacBryan.

The Lunacy Bill was freely discussed, but no definite resolution on any of the
clauses was submitted. The Hon. Sec. read a communication from Dr. Neil, of
the Warneford Hospital, with reference to Clause 17.

Letters of regret and apology were received from the President, President-elect
Dr. Brayn, and others.

Dr. Weatherly opened a discussion “ On the Care and Treatment of Phthisical
Patients in Asylums for the Insane.”

It was unanimously resolved that Dr. Turner’s paper on “ Asylum Dietary”
should form the subject of discussion at next meeting.

The members dined afterwards at the Grand Pump Room Hotel.

The Autumn Meeting will be held at Broadmoor Asylum towards the end of
October.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

603

NORTHERN AND MIDLAND DIVISION.

A meeting of this Division was held at the County Asylum, Whittingham, near
Preston, on April 18th, 1900.

Members present. —Drs. Stanley Gill, Wilcox, G. E. Mould, C. Mabel Blackwood,
Holmes, G. W. Mould, Hitchcock, Edgerley, Perceval, A. W. Campbell, Shoyer,
Adair, Eades, Blair, and Crochley Clapham.

Visitors. —Drs. Simpson, Orr, Bresland, and Clark.

Dr. Perceval having been voted to the chair, the minutes of the last meeting were
read and confirmed. Dr. Crochley Clapham was nominated for the post of Hon.
Secretary, and Drs. Miller, of Warwick, and Hearder,of Wakefield, to fill vacancies
on the Council of the Association.

The date of the autumn meeting was fixed for the first Wednesday in October,
and its place left in the hands of the Hon. Secretary.

The Lunacy Bill.

Dr. Mould (Cheadle) opened a discussion on the new Lunacy Bill, which was
joined in by Drs. Perceval, Gill, Holmes, Hitchcock, and others.

Dr. Mould said he considered this subject was of the greatest importance, and
proceeded to criticise the Bill in detail. He regarded the existing Urgency Order
as a valuable provision. He thought there should be great facilities afforded for
permitting certified patients in registered hospitals to have a change of residence
on leave of absence for health. With regard to the boarding out of pauper patients,
Dr. Mould thought it should be possible for as many as twenty to reside together
in a suitable house. He considered that Section 14, which deals with “special
inquiries as to lunatics,” required amending. As to voluntary boarders, he was of
opinion the provision for their reception met a decided want, and he said he had
in practice given a liberal interpretation to it. When referring to Section 16,
which deals with the number of patients to be received into existing registered
hospitals, Dr. Mould said he could not understand why there was such a distinction
made between county asylums and the hospitals. He criticised adversely the pro¬
posed change in the management of hospitals, and he did not consider it would be
practicable to have “branch establishments” registered. He concurred as to the
desirability of providing for cases of injury to the staff; but he thought the Work¬
men’s Compensation Act would best meet such cases. He did not approve of the
proposed method of dealing with incipient insanity. Finally, he expressed the
hope that, as the latest attempt to amend the Lunacy Acts had itself so many
imperfections, the whole matter should be thoroughly investigated with a view to
obtaining decided alterations in the Bill.

Dr. Gill expressed approval of the existing Urgency Order. He was of opinion
that any house in which insane patients are received should be registered.

Dr. Holmes considered the proposed treatment of incipient insanity might prove
beneficial.

After some further discussion by Dr. Crochley Clapham and Dr. Hitchcock
regarding the admission of voluntary boarders into existing institutions, Dr. Mould
said he hoped to see established separate hospitals or reception houses for
boarders.

Dr. Catherine M. Blackwood, of Wadsley, then read a paper on “A Glioma
of the Corpus Callosum,” and a paper contributed by Dr. F. O. Simpson, of Rain-
hill, on “Foreign Bodies in both Bronchi,” was read by his colleague Dr. A. W.
Campbell. (See pages 512, 515 )

Previous to the business meeting the members were entertained at luncheon and
shown round the asylum by Dr. Perceval, to whom a vote of thanks was given for
both attentions. Members dined together in the evening at the Park Hotel,
Preston.

SOUTH-EASTERN DIVISION.

The Spring Meeting was held at the City of London Asylum, near Dartford, Kent,
on Wednesday, April 25th. From 11.30 a.m. to 1 p.m. the members inspected the
asylum and grounds. From 1 p.m. to 2.30 p.m. luncheon was served. The Divisional
XLVI. 41

Digitized by VjOOQle

604

NOTES AND NEWS.

[July,

Committee then met, and at 3 p.m. the general meeting was held. There were
present:—Drs. H. G. Hill, E. Daunt, C. Caldecott, E. W. White (Hon. Sec.),
A. E. Patterson, J. P. Richards, R. P. Smith, F. R. P. Taylor, J. F. Briscoe, R.
Worth, D. Bower, D. G. Thomson, J. Chambers, J. G. Havelock, A. S. Newing¬
ton, F. Beach, P. E. Campbell, A. N. Boycott, H. Kidd, C. H. Bond, T. B. Hyslop.
Visitors: Rev. O. Hewitt, Dr. P. Bayley, Mr. C. Fitch, and Mr. Stikeman.

Dr. Beach (President Elect) was voted to the chair.

Dr. White read a telegram from the President regretting his inability to
attend.

The minutes of the last meeting were read and confirmed.

Dr. Beach expressed his regret that Dr. White was resigning the secretaryship
after three years of office.

Dr. White proposed that Dr. Boycott be asked to take the secretaryship. This
was seconded by Dr. Percy Smith.

Dr. White stated the time had come for him to resign ; that Dr. Boycott, of the
New Hertford Asylum, was fully qualified for the post, and had a great claim in
view of his being a superintendent, and recently a medical officer, therefore in
touch with both sections.

Dr. Boycott was duly elected.

Drs. Bower, Moody, and Thomson, three members of the Divisional Committee,
retired by rotation, and Drs. Alexander, Alexander Newington, and Ernest W.
White were elected to fill the vacancies. Dr. Gardiner Hill and Dr. Bond were
nominated for the probable vacancies on the Council. The former was proposed
by Dr. White and seconded by Dr. Thomson ; the latter was proposed by Dr.
Taylor and seconded by Dr. Bower.

The Chairman then proposed a vote of thanks to Dr. White for his services as
Secretary for the past three years. He said the successful state of this division
showed that their action in selecting Dr. White to be the first Secretary was right.
There were now 170 members, which was entirely due to the energy displayed by
Dr. White. He had practically worked up the Division from its initiation, and
should be accorded a very hearty vote of thanks.

Dr. Bower also added his word of thanks, and expressed appreciation of Dr.
White’s services, marked as they were throughout by tact and energy.

The vote was carried by acclamation.

Dr. White, in reply, thanked the meeting most heartily for the kind way in
which this vote had been passed.

In the consideration of the Lunacy Bill, 1900, and the Pensions question, the
Chairman was of opinion that, as the matter was in the hands of the Parliamentary
section, nothing could be done at this meeting. The members were, however,
urged to oppose the Bill if the Pensions clause was not inserted.

Dr. Newington’s invitation to hold the next meeting at Ticehurst in October was
accepted.

Dr. White then read a paper on “The Remodelling of an Old Asylum.” (See
page 4 S 7 -)

After the discussion on Dr. White’s paper, Dr. Patterson read a paper on “ An
Analysis of 1000 Consecutive Admissions at the City of London Asylum since
1892.” (See page 473.)

The Chairman expressed regret that time would not permit a discussion of the
paper, and this was accordingly adjourned till the next meeting.

Dr. Boycott regretted that he was not present when elected to the secretary¬
ship. He thanked them for the honour. He would accept the office with pleasure,
and would discharge the duties to the best of his ability.

Votes of thanks were passed in conclusion to the Visiting Committee of the City
of London Asylum, Dr. White, and the Chairman of the meeting, and in the
evening the members and visitors dined together at the Cafe Monico, Piccadilly
Circus, London, W.

IRISH DIVISION.

A meeting of the Irish Division of the Association was held on Tuesday, April
10th, 1900, at the College of Physicians, Kildare Street, Dublin.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

60S

The following members were present:—Dr. Conolly Norman, Dr. Mercier, Dr.
Rambaut, Dr. Cullinan, Dr. Donelan, Dr. Nolan, Dr. O’Mara (Limerick), Dr.
Dawson, Dr. Lawless, and Dr. Finegan (Secretary).

On the motion of Dr. Nolan, seconded by Dr. Finegan, the chair was taken by
Dr. Conolly Norman.

The Secretary read the minutes of the previous meeting, which were confirmed
and signed. He then read a number of letters of apology for non-attendance from
members of the Association, including Dr. J. Beveridge Spence (President), Dr.
Hetherington, Dr. Harvey (who was to have read a paper), Dr. Woods (Cork),
Dr. West, Dr. Oakshott, Dr. Petit, Dr. O'Neill, and Dr. O’Mara (Carlow).

On the suggestion of the Secretary, it was, after some discussion, unanimously
resolved that the next meeting should be held at the new Portrane Asylum on
Thursday, June 28th.

The following were elected ordinary members of the Association:—Patrick
Coffey, L.R.C.P.I., Assistant Medical Officer, District Asylum, Limerick; and
Thomas Francis Y^hite, L.R.C.P.I., Assistant Medical Officer, District Asylum,
Waterford.

Dr. W. R. Dawson, Farnham House, Finglas, read a paper on “ The Best
Method of Dealing with the Pathological Work of the Irish Asylums.” (See page

487-)

Local Government Act (Ireland).

Dr. Finegan, the Secretary, opened a discussion on the operation of the Local
Government Act (Ireland), which has increased the work and responsibilities of
medical superintendents of asylums, and proposed a resolution with a view to the
best mode of securing proportionate compensation for these officers. He said:
Before this Local Government Act was introduced, we were governed by, or at
least we took as our standard the Privy Council Rules. These rules had no
specific orders,as far as I know, beyond that of general superintendence, whereas
under the Local Government Act there has been issued a General Order and also an
Asylum Accounts Order. This Asylum Accounts Order involves thirty-five new
books to be opened in every asylum. The General Order gives a new title
to the superintendent, and calls him an accounting officer. The duties devolved
on this accounting officer are that the superintendent must periodically examine
the clerk’s and storekeeper’s books, and be responsible for them being properly
written up. The General Order further directs superintendents to prepare
the stock list twice in each year, and submit this stock list, with a report, to
their committees of management. It further commands that all paying orders and
orders for payment should be signed by the resident medical superintendent, and
all orders passing out of the asylum under all circumstances whatever must be
signed by the medical superintendent. In addition to these there is another
account to be introduced, called the Subsidiary Account, which practically means
that the superintendent has to keep a record of every penny piece in the matter of
petty cash and open an account in the bank in his own name, for which he is
responsible. That subsidiary account in itself means a considerable amount of
work. Again the superintendent is ordered by Article 9 of the Orders to prepare
an abstract of the entire accounts of the asylum twice in each year, to be submitted
to the auditor, and to do a number of other of the clerk’s duties, for which he is
made responsible, such as publishing the audit on the asylum gates. Under the
old arrangement these were not the duties of the superintendent. I think superin¬
tendents are entitled to a certain remuneration, and the question for us to decide
is this—what is the best way to approach our committees? Under the cir¬
cumstances I have drafted a resolution which, if adopted by the Association, I
would propose be sent to each superintendent in Ireland, and let him bring
it before his committee, and make what use he can of it to his own advantage.
The resolution is as ’follows:—“ The duties and responsibilities of Resident
Medical Superintendents of Irish District Asylums having been greatly increased
by the operation of the Local Government Act of 1898, and Section 115, Sub¬
section 18, having provided that adequate remuneration can be fixed for extra
duties performed under the Act, or under orders arising thereon, we are of opinion
that the resident medical superintendents should bring this matter under the

Digitized by LjOOQle

6 o6

NOTES AND NEWS.

[July.

notice of their committees, with a view to a fair and reasonable readjustment
of their salaries, in view of the increased duties and responsibilities referred to.”

Dr. Lawless. —Do you suggest what remuneration would be adequate ?

Dr. Finegan.— No; I think it would be a matter for each individual.

Chairman.— There is a provision in the Local Government Act that the
salaries of employees under that Act may be considered and augmented in case
of augmented duties, and it occurs to me very great care is required in draw¬
ing up any resolution to show precisely how our duties have been augmented.

Dr. Nolan. —There is one thing which the Secretary has overlooked. This
new Act abolishes the Board of Control, and that puts a good deal of extra work
upon superintendents who have any building operations going on, or where
land is being purchased, and owing to the letters and correspondence which
have to be attended to, a considerable amount of real responsibility and work
has been put upon superintendents. In my opinion in any resolution adopted
an approximate percentage for the increased work should be stated; then it
would be for every superintendent to make his own arrangements, because
everything would depend upon the locality in a case like that.

After some further discussion, in which Dr. Lawless and Dr. O’Mara joined,
Dr. O’Mara seconded the resolution, which was adopted unanimously.

Nursing in Irish Workhouses.

The Secretary stated that at the last meeting a resolution on this subject was
passed unanimously, and ordered to be sent to the Irish Local Government
Board. He had done that, and the replies received from the Local Government
Board went to show that something was done, and that considerable advance
was made with this nursing question. He read the resolution and the subsequent
correspondence. The resolution, which has already appeared, affirmed the opinion
of the Association that as long as the insane are retained in Irish workhouses
attendants should be properly qualified and certificated persons. To this
the Irish Local Government Board replied that they are willing to establish
a register for asylum-trained and certificated mental nurses. Subsequently, as a
number of letters showed, the Local Government Board had insisted at various
workhouses on the appointment of properly trained persons to look after the
insane, and had in others suggested that such salary should be given as would
induce asylum attendants to Took for the post.

Dr. Finbgan, continuing, said similar communications have gone practically to
every union in Ireland. The certificate of the Psychological Association is recog¬
nised by the Local Government Board, and there will be a very large number of
appointments open in the Irish Poor Law Service for those holding the certificate
of the Psychological Association, so that the resolution has done a considerable
amount of benefit to holders of the certificate, because the Local Government will
not sanction any appointment over the insane for workhouses without it. The
result from this would be that the Guardians, when they find they have to pay
adequate salaries for attendants on the insane, will either send them back to the
asylum or make proper provision for them.

The Chairman. —The correspondence shows the action, which at Dr. Finegan’s
suggestion we took, has produced some effect.

The Secretary was directed to prepare the abstract of the correspondence for
publication.

Papers by Dr. Conolly Norman, “ Notes to serve for the Study of Fractures
of the Ribs in the Insane; ” and by Dr. Bagnall Harvey, “Notes on an Inter¬
esting Case of Foreign Bodies in Stomach and Intestines ” were by consent held
over till next meeting.

Dr. Rambaut read a paper entitled, " Notes on Gangrene of the Lung in the

Insane.” f

The Chairman. —I have to make the confession that I drew the attention of
Dr. Rambaut and his colleagues to the method of feeding described by Dr. Newth,
in the October, 1899, number of the Journal of Mental Science , and I now regret
having done so. I see this description copied into some German journals, and it
is quite possible it may do a great deal of mischief. We ought to be obliged to
Dr. Rambaut for bringing the matter forward.

Dr. Mercier. —He appears to have an unusual experience of gangrene of the

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

607

lungs too, more than I have had. I think the dangers of feeding with the tube
are greatly exaggerated; 1 don’t think there is the slightest suspicion of harm
in feeding with the tube if carried out with care and intelligence. If carelessly or
coarsely it may have caused harm, but if used with ordinary care 1 never saw any
harm.

Dr. Donelan. — Everything is in favour of the tube. It is the readiest and
the easiest way.

Dr. Lawless said he used the tube in a great many cases, both nasally and
through the mouth, and never had an experience of any symptoms of unpleasant¬
ness from it.

Dr. Rambaut also read a paper entitled “ Post-mortem Appearance in a case of
Alcoholic Neuritis,” which was accompanied by a demonstration of the histology
of the various viscera and nerves. Dr. Rambaut added that there were still some
parts of the case to be examined,—

Dr. Mercibr remarked that the condition of the heart was most extraordinary,
and it was very difficult to understand how it carried on its functions. He asked
Dr. Rambaut if he had ever seen such an appearance before ?

Dr. Rambaut. —No.

Dr. Dawson asked if any examination was made of the nerves of the heart,
either intrinsic or extrinsic, as he did not quite gather whether there was or not, or
whether it proves the condition of the heart was due to the effect on the nerves of
the heart or to the direct action of alcohol on the heart-muscle?

Dr. Rambaut having briefly replied, the proceedings then concluded.

SCOTTISH DIVISION.

A special meeting of the Scottish Division was held in the Royal College of
Physicians, Edinburgh, on Saturday, June 2nd.

Present: Sir John Sibbald (in the chair), Drs. Clouston, Havelock, Campbell
Clark, Watson, Carlyle Johnstone, Robertson, R. B. Mitchell, Keay, Urquhart,
Ronaldson, and Turnbull (Secretary).

The minutes of the last meeting were read, approved, and signed by the Chair¬
man.

The Secretary reported that he had ascertained the feeling of members resident
in Scotland relative to the most suitable day of the week for holding the Divisional
Meetings. There was a large majority in favour of a change from Thursday, as at
present, to Friday. Having regard to the General Meetings he moved that the
Scottish Division should, in future, hold meetings on the fourth Fridays of March
and November. This was seconded by Dr. Havelock, and carried unanimously.

Dr. Carlyle Johnstone referred to the nomination of Examiners for the certificate
of proficiency in Mental Nursing, and asked the Division for an expression of
opinion as to representation on that Board. He held that Scotland should be repre¬
sented by Dr. Campbell Clark, who had taken a leading part in instituting these
examinations. After some discussion Dr. Clark intimated that he would be will¬
ing to accept office, Dr. Clouston expressing the mind of the meeting in saying
that they were most deeply indebted to him.

Dr. Carlyle Johnstone moved that Dr. Campbell Clark should be nominated
as one of the Examiners in Nursing, under the new regulations. This was unani¬
mously approved.

Report of the Committee on Asylum Nursing and Administration.

This report was discussed at great length, and adjusted in detail. On the mo¬
tion of Dr. Urquhart, it was then received and entered on the minutes. Various
suggestions were made and discussed. These were referred to the Committee for
adjustment, on the understanding that they would submit a series of recommenda¬
tions or resolutions to the next meeting of the Division.

Dr. Clouston moved a vote of thanks to the Committee, and especially to the
Convener, Dr. Campbell Clark, who had done so much work in regard to this
matter, and especially in presenting a full synopsis of the replies to the questions
placed before the Scottish superintendents.

Sir John Sibbald was accorded a hearty vote of thanks, on the motion of Dr.
Watson, for his conduct in the chair.

Digitized by LjOOQle

6o8

NOTES AND NEWS.

[July,

ASYLUM WORKERS’ ASSOCIATION.

The Annual Meeting of this Association was held on May 14th. Sir James
Crichton-Browne presided, and delivered an eloquent and sympathetic aadress,
which dealt fully with the aims and activities of the Association.

A detailed report of the year’s work was presented to the meeting; appended is
an abstract of this Report:

“The roll of Members has increased from 2890 in December, 1898, to 3006 at
the end of 1899, this number including 61 life members and 37 associate members;
1010 new members were elected during 1899 ; and had all old subscriptions been
renewed, the Association would by this time approach 4000.

M Representatives of thirty-one Asylums (in England, Wales, Scotland, Ireland, and
the Colonies) not previously represented, had joined the Association during 1899 ;
and recently members had been elected from the Royal Edinburgh and Royal
Glasgow Asylums. Reservists on active service had been retained on the roll
without payment of subscription for the present year.

“The Financial Statement shows that the aggregate receipts for 1899 amounted
to ^256 1 os., as compared with ^254 7s. 9 d. during 1898. The advance in receipts
would have been larger but that the collecting cards for Home of Rest Fund
brought in only £26 is., as compared with £61 19s. 6d. in 1898. The credit
balance at end of 1899 amounted to ^143 2 s. 4 d., against ^137 14s. 3d. at end of
1898. '

“ Nine cases had received grants from the Home of Rest Fund, which was
assuming much of the character of a mutual benefit society, being mainly sup¬
ported by Asylum Workers themselves, though contributions from others were
welcome.

“ Impending lunacy legislation had engaged the anxious attention of the
Executive, and every effort had been made to obtain the introduction of a clause
providing for assured pensions for Asylum Workers.

“ The Association is to be congratulated on the willingness of Sir James Crichton-
Browne, M.D., F.R.S., to undertake for a third year the office of President.

“The Executive Committee desire to place on record their keen appreciation of
the continued services of the Honorary Secretary, Dr. Shuttleworth, to whom the
growth of the Association is largely due, and of the valuable aid of Mr. J. B. W.
Wilson as Assistant Secretary.”

PARLIAMENTARY NEWS.

Lunacy Laboratories. — 29 th March.

In reply to Sir J. A. Pease, Sir Matthew White Ridley said that he had no
information to lead him to believe that the research for which the laboratories
might be established would involve necessity for licences or certificates. He
promised to consult the Lunacy Commissioners on the subject.

Rating of Institutions for Imbeciles.— 2nd May.

On a Bill being introduced to exempt from poor and other local rates all
registered institutions for the care of idiots and imbeciles, Mr. T. W. Russell said
that it would be necessary to have an inquiry by a Select Committee before arriving
at a conclusion. In the inquiry hospitals would be included. The Bill was with¬
drawn.

Mrdical Officers and the Certification of Lunatics.—5 th April .

Sir Mancherjre Bhownaggree asked the President of the Local Government
Board whether he received from the Bethnal Green Board of Guardians a commu¬
nication to the effect that gratuities had been paid on a large scale to relieving
officers by medical officers in respect of the certification of lunatics, as well as by
certain metropolitan licensed houses; and whether he intended taking any steps to
prevent a repetition of such practices.

Mr. Chaplin replied: The facts are as stated in the question. I have com¬
municated with the Lunacy Commissioners, and I find that they have cautioned the

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

609

proprietors of metropolitan licensed houses that wherever the practice of giving
relieving officers gratuities of the kind referred to has obtained it must be at once
discontinued, and the Commissioners have no reason to doubt that their require¬
ment will be respected. They have also communicated their views to the Wilt¬
shire Justices, as one of the licensed houses affected was licensed by those Justices.
As regards the officers of the Guardians, I have directed that an inquiry shall be
held by an Inspector of the Local Government Board. The inquiry will take place
as soon as possible, and on receipt of his report I shall have to decide what further
steps, if any, it will be necessary for me to take in the matter.

Sir Mancherjee Bhownaggree: In view of the facts now disclosed, will the
Home Secretary insert adequate provisions in the Lunacy Bill so as effectually to
check this practice ?

Mr. Chaplin : I will consult the Home Secretary on the matter.

Post-mortem Examinations.— nth May .

The Lunacy Commission came under discussion on the Estimates, and complaint
was made of the low percentage of post-mortem examinations in the criminal lunatic
asylum.

[If Broadmoor were specially referred to, the complaint would appear to have
been ill-founded.— Ed.]

The system of boarding-out criminal lunatics in ordinary borough and county
asylums was also criticised as undesirable in the interests of these institutions, but
it is a necessity until more State accommodation is provided.

Royal Lunatic Asylums.—17 th March .

Mr. Weir asked the Lord Advocate whether the Secretary for Scotland had re¬
ceived memorials from certain parish councils in Scotland urging that parish
councils should be represented on the Board of Royal Lunatic Asylums, and that
there should be a public audit of the accounts of those boards; and what action
was proposed in the matter ?

The Lord Advocate : The memorials were received, and the Secretary for
Scotland met a deputation, when the whole subject was discussed. To give effect
to the proposals would require legislation, which it is not intended to propose at
present.

Lunacy Commissioners.

Mr. Weir asked the Lord Advocate if his attention had been called to the recom¬
mendation contained in the Forty-first Annual Report of the Commissioners in
Lunacy for Scotland to the effect that measures should be taken to give district
lunacy boards permissive powers to provide accommodation for the poorer class of
private patients; and what action it was proposed to take ?

The Lord Advocate: The answer to the first part of the question is in the
affirmative. The Secretary for Scotland does not propose to take any action at
present.

Lunacy Board (Scotland) Bill.— 19 th February .

The Lord Advocate introduced a Bill to make further provision for the number
and salaries of the staff of the Lunacy Board for Scotland, and for the remuneration
of certain of the Commissioners.

9 th March.

The Lord Advocate said that this was a purely formal Treasury Bill. Unfor¬
tunately the salary of the Secretary of the Scottish General Board of Lunacy was
fixed by statute, and there was a provision that only one clerk should be appointed.
With the increase of lunacy in Scotland temporary clerks had been employed under
the sanction of the Treasury. But an excellent official was being retained at a
much less salary than that to which he was entitled. The present Bill was to put
the staffing of the office on the ordinary footing, the Treasury fixing the salaries in
the ordinary way, and to allow certain payments to the unofficial Commissioners
and an increased payment to the Secretary. The matter had been arranged between
the Treasury and the Scottish Office.

Objections were raised by several members and information was asked as to the
duties of the Board, etc.

Digitized by VjOOQle

NOTES AND NEWS.

[July,

610

2nd April .

The Lord Advocate, in moving the second reading of the Bill, said he should
have thought that the Bill might well have been allowed to pass without much dis-
cussion, in the belief that the Treasury would not readily lend themselves to a
contribution of Imperial money unless they felt that the demand could not be con¬
troverted. But owing to the remarks that had been made he felt it necessary to go
into details as to theliistory of the Board and the increase of the work imposed
upon them. Proceeding, he said that in 1858 there were in asylums 4020 patients,
and in private dwellings 1804; and in 1898 there were 12,139 and 2767 respectively.
Moreover, not only were the Medical Commissioners bound by statute to inspect
every asylum twice a year, and there were 7 royal, 15 district, and 5 private
asylums, but it was their practice in the course of every visit to make a personal
domiciliary visit to every single patient. That meant over 29,000 visits a year.
The Deputy Commissioners visited every patient who was boarded out in private
houses, and had for this purpose to travel over the length and breadth of Scotland.
Their visits in 1858 were 753, and in 1898, 3690. These visits occupied the whole
time of the Deputy Commissioners. It was physically impossible for them to do
more work. In the present circumstances it was absolutely necessary to have more
medical time, and the question was how to get it. They could appoint another
Medical Commissioner, but that would mean another salary of not less than j£iooo a
year, and it would also be open to the objection that the professional element would
preponderate over the lay element—the Chairman and two legal members.

After consultation with the General Lunacy Board, Lord Balfour thought that
by a re-arrangement of the duties of the office more medical time could be obtained
from the Commissioners as at present constituted if they could be relieved of certain
administrative work. The Chairman had not been idle; not only did he attend
the regular board meetings, but he frequently was at the office at other times. He
had to see prospective sites for asylums and investigate plans for buildings, etc.
The legal members had given excellent attendance at the board meetings, and if
the Medical Commissioners were to be more and more taken away, the Secretary
would require someone to advise him. So far as the Secretary for Scotland was
concerned, it would be the same to him whether they appointed an extra commis¬
sioner or utilised the Medical Commissioners in entirely medical work and took a
proportion of the time of the unpaid Commissioners. This would entail a certain
amount of remuneration. The provision in the Bill was that a sum might be paid
by the Treasury to the three unpaid Commissioners, provided that in any year it
did not amount to more than ^500. He put this Bill as a necessary measure before
the House—necessary if they were to have a proper working of a very useful and
efficient department.

Mr. Caldwell said there should be no difficulty in getting a Commissioner who
would perform the duty unpaid, and it had not been proved that they should offer
inducements to men to fill this office.

Sir J. Stirling Maxwell would not vote for the Bill. Officials holding im¬
portant posts should either be paid or unpaid, but the Bill proposed to create
officials who would be neither one kind nor the other. If there was strong ground
for creating another paid post in the Department, he should have gladly voted the
necessary amount for that purpose; but the present proposal seemed to him to be
giving the sum of ^500 where it was not wanted, and for which the country was
not likely to get any adequate return.

Sir T. Gibson Carmichael, a former Chairman of the Lunacv Board, said he
thought that the present Secretary of the Board discharged his duties most
efficiently, but the clerical staff were very much over-burdened with work. If they
agreed to the first clause of the Bill he thought they would be doing a good thing
for Scotland. But why should the benefits of that clause be confined to the
Secretary and clerks ? There were other officials of the Board; there were the
paid Commissioners and the Deputy Commissioners, and he believed their work
had increased quite as much as the others. The legal members of the Board were
extremely useful, and gave the Board advice upon technical matters which he could
not have given to the medical members. If the Lord Advocate assured him legal
members were not willing to discharge these duties on the Board without being
paid, then he must agree to the proposal. He was going to vote for the second

Digitized by VjOOQle

NOTES AND NEWS.

1900.]

6l I

reading, but he did not feel convinced that the Chairman ought to be paid. He
hoped the Government would not press for a salary for the Chairman of the Board.

Mr. Renshaw regarded it as an unfortunate feature of the proposals of the Bill;
for it for the first time proposed the partial payment of those who were connected
with public offices in Scotland. It seemed to him that what was most needed was
the appointment of another Assistant Commissioner, or they might get rid of one
of the two legal advisers.

Other members having given utterance to similar objections, Captain Sinclair
paid a tribute to the admirable administration of the Scottish Lunacy Board. He
said that the salaries were limited by a statute, dating so far back as 1864. The
English statute did not limit the salaries, and he maintained that the Government
should pay the Scottish Commissioners well, and no one could contend that at pre¬
sent they were sufficiently paid.

The Lord Advocate said he was sure he was not doing too much in saying that
he would take upon himself to bring to the notice of Lord Balfour the views that had
been expressed upon matters of principle. They were perfectly willing to consider
them, and he could promise the House that in the light of the remarks which had
been made his noble friend and himself would consider the circumstances, and
whether it might or might not be more prudent to provide for the extra assistance
in another way. On that understanding he hoped the House would allow the
Bill to be now read a second time.

Mr. Caldwell thereupon withdrew his amendment, and the motion for the
second reading of the Bill was agreed to.

Edinburgh District Lunacy Board. — 10 th May.

On the motion for the second reading of this Bill, Mr. Ure moved its rejection,
urging that it was of an unprecedented character. The statutory powers of the
Lunacy Board had nothing whatever to do with constructing and maintaining a
railway, with selling water as a water company, and with the work of a sewage
contractor. He opposed the Bill, not only on general grounds, but in the interests
of the town of Bathgate, which, with its small rateable value and limited water
supply, had a claim on a portion of the large catchment area the Lunacy Board
proposed to acquire.

Mr. Jonathan Samuel seconded the amendment.

Sir Lewis M'Iver said he hoped that the Hon. Member for Linlithgowshire was
now prepared to allow the House to go on with the business before it. Bathgate
had arrived at the decision to drop opposition to this Bill. It would be a grave
departure from Parliamentary traditions to oppose on the second reading a Bill
which had passed a Committee of the House of Lords, and to refuse it the courtesy
of a hearing by a Committee in that House.

Mr. Ure, by leave, withdrew his amendment, and the Bill was read a second time.

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mercier.

[The editors request that members will oblige by sending full newspaper reports of
all cases of interest as published by the local press at the time of the assizes.]

Eady v. Elsdon.

The plaintiff was a schoolmaster, who brought an action against a schoolboy to
recover damages for having wilfully set fire to the plaintiff’s school and destroyed
his furniture. The defendant denied liability, and pleaded that if he did the act
complained of he was temporarily insane; and further, that the plaintiff volun¬
tarily took him as a pupil, knowing that he was mentally affected, and failed to
exercise proper discipline and control. The plaintiff advertised for bovs who
were idle, disobedient, or difficult to manage, and it was as a pupil of this aescrip-
tion that the defendant was placed with him. It was alleged that the defendant
had previously set fire to another school, and his mother stated that he needed
constant watching and flogging, and could not be restrained. He had repeatedly

Digitized by VjOOQle

612

NOTES AND NEWS.

Qu'y.

run away from home and from school. The defendant was called as a witness and
gave evidence with considerable intelligence, and admitted instances of. his own
mendacity and vice, and that he had caused the fire. The judge told the jury that
the recognised relation between master and pupil was that for the ordinanr acts of
the boy the master undertook the risk—namely, the wear and tear of school
furniture by knocking about, kicking the doors, and so forth. But it was clear
that he did not take upon himself the risk that the pupils would set fire to the
school. To fix him with that risk it must be shown that there was a bargain to
that effect. In the present case the crucial test was whether or not it was part of
the bargain between Mrs. Elsdon and the plaintiff, that he should undertake such
a risk as this. If it was, then the action could not be maintained. If not, and he
only undertook the ordinary risk, then the plaintiff was entitled to damages.
There was another question : Was the boy mentally deranged P It was put before
them as a sort of defence, and although he could not see why, he would put the
jury that question. The main question was, Was it part of the bargain that
plaintiff should undertake the risk ? It was one thing to say, “ I know that he is
unruly, and I can manage him,” and another to say, “ I know that he is likely to
set fire to the house, and I will take the risk.” Unless they thought that the
defendant had made out a special contract, the risk was outside the ordinary
contract in such cases. The jury found that the defendant was not insane, and
that there was no special bargain, and assessed the damages at ^450.—2 B. D.,
February 20th and 21st (Mr. Justice Ridley).— Times, February 21st and 22nd.

The interest of this case to those who have charge of mischievous and unruly
persons is manifest. Supposing that the incendiarism had been committed, not
by a schoolboy in a school, but by a lunatic in an asylum, would the lunatic be
answerable in damages for his act ? By the ruling in this case it would appear
that his liability would depend upon the nature of the bargain made by his friends
at the time that he was placed under care, unless it were assumed that incendiarism
was one of the “ordinary acts” of a lunatic. Is incendiarism as much an
“ ordinary act ” of a lunatic as cutting his name on his desk, or kicking the doors
is an “ ordinary act ” of a schoolboy P Probably the managers of lunatic asylums
would say that it was not, and probably the relatives of lunatics would say that it
was. And does the rule, whatever it may be, apply as well to other forms of
wilful damage as to incendiarism ? A plausible view would be that while the
breakage of windows and of crockery, and the tearing of clothing were as “ ordinary
acts ” of the lunatic as the cutting of his name on a desk or the kicking of doors
were of the schoolboy, yet, that incendiarism in the former was on a par with the
breaking of windows in the latter, for which an extra charge is usually made.
Until the question has been judicially decided, it would be rash to act upon this
view, and the managers of institutions for lunatics, who desire to be secure against
the consequences of exceptionally destructive acts on the part of those under their
care, would do well to specify in the bargains that they make precisely how much
of the property destroyed or damaged by their patients they are willing themselves
to make good.

Charleston v. Stewart.

This case was referred to in the last number of the Journal. It was an action
for breach of promise of marriage, in which the defender pleaded, inter alia , that
several of the pursuer’s relatives, both on her father’s and mother's side, had
suffered from insanity. At the trial counsel for the defender admitted that “the
existence of a weakness of this sort in the family of the woman was not a sufficient
defence to an action for breach of promise of marriage, for the reason that the man
ought to have inquired beforehand . The judge ruled that evidence of the fact that
the parent or grandparent of the lady had suffered from insanity was admissible,
because it might tend to affect the question of damages. Counsel acquiesced, and
said that he would not found upon the evidence as a substantial defence.—Court
of Session, March 27th and 29th (Lord McLaren)— Scotsman , March 28th
and 30th).

It is interesting to know that, in Scotland at any rate, a lover is supposed to
make inquiries as to the sanity of the relatives of the inamorata before he puts to
her the decisive question, and that their insanity is no defence for him if he
subsequently repudiates his engagement.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

613

Mackenzie v. Anderson and others.

An action for damages for slander. The pursuer sued the defenders for writing
and publishing in newspapers an account of proceedings headed “ Astounding
proceedings at Stornoway—Farmer carried off to a Lunatic Asylum.” The
defenders pleaded justification and privilege. The judge said that the vital
question was whether the publication warranted the innuendo that it charged the
pursuer with knowledge that Mr. Fowler, to whom the letter related, was sane.
That was a question of impression which did not admit of quotation of authority,
and hardly of argument, and on that question his lordship was of opinion that it
did not. The question of fact in the first issue was whether the defenders said of
the pursuer that he got his father-in-law confined in an asylum as of unsound
mind. It was admitted that he did so, and it was clear that it was not slanderous
to say that a man did that which, as a matter of fact, he did do. It was a contra¬
diction in terms to say that a true statement was false and calumnious. Further,
it could not be libellous to add that the act was done illegally and wrongfully, for
such words added nothing to the substantial averment of fact; and besides, they
raised a question of law, not a question of fact, for a jury. It was not libellous to
dissent from or to blame an action actually done, or words actually spoken, how¬
ever undeserved the blame might be. Nor could it make the statement libellous
to add that Mr. Fowler was not, in fact, of unsound mind, if it were not said that the
pursuer knew that he was not. That would be merely charging the pursuer with
error of judgment.—Court of Sessions, March 13th (Lord Kincairney).— Scotsman ,
March 14th.

If to say that a man has illegally and wrongfully placed his father-in-law in an
asylum be not libellous in Scotland, we can only suggest that our comments
would be much more freely made and be of greater interest to our readers if this
Journal were published in Scotland, and we commend the suggestion to the
Association. There are several things that we should say if we were not deterred
by the fear of actions for libel.

Hope v. Board of Guardians of Chertsey,

Plaintiff, a medical man, was called in by the relieving officer to examine, with
a view to certification, certain patients in the workhouse. For this he demanded
a fee of a guinea for each examination and certificate. The Guardians disputed
the amount, under their statutory discretion to pay “ such reasonable remuneration
as they thought fit,” and offered three guineas for the eight cases. His honour,
in giving judgment, said that he had to decide what was a reasonable remunera¬
tion. The examination was one of very great responsibility. The public interest
and the fate of the patients were in the balance, and the responsibility attaching to
the medical man was very great. Dr. Hope seemed to have done his work very
thoroughly, and as to his seeing the eight patients in 85 minutes, it did not matter
whether it took him 5 minutes or 100 minutes. It was not a question of time, but
of professional judgment and skill and experience. Defendants had not given a
single instance of a case in which less than a guinea had been paid, but on the
other hand they had ample evidence of the recognised and customary fee in the
profession. His first impression had been that the Act referred to left an absolute
discretion to the Guardians, but the defence had itself admitted that that provision
was merely to protect the guardians from the surcharge of the auditor in case they
paid too much. Dr. Hope was not aware of this section of the Act when he was
called in, and he had asked for what his Honour thought a fair and reasonable sum.
Judgment for the plaintiff with costs on the higher scale.—Chertsey County Court,
April 5th (Judge Lushington).— Surrey Times , April 7th.

Dr. C. H. Broadhurst was summoned at the instance of the Commissioners in
Lunacy for unlawfully for payment, and not under the provisions of the Lunacy
Act, 1890, taking charge of a lunatic in an unlicensed house at Bournemouth.
The patient in question, a Mr. M—, had been in St. Andrew’s Hospital suffering
from various delusions, and had been discharged therefrom (not improved) by
order of his wife. He was taken from St. Andrew’s by Dr. Broadhurst to the
house of the latter, and at the time of his discharge from St. Andrew’s was
considered by the medical officers of that institution to be certifiably insane. Dr.
Morton, to whose care the patient had been removed from that of Dr. Broadhurst,

Digitized by VjOOQle

NOTES AND NEWS.

•614

[July,

deposed that the patient was certifiably insane when he received him. Dr.
Broadhurst deposed that during the time that Mr. M— was in his house he was
not certifiably insane. That he transacted business, and was under no control,
except that sometimes he had to be made to put his clothes on. Dr. Savage
deposed that he examined Mr. M— while in Dr. Broadhurst’s house, and that
while Mr. M— was a confirmed hypochondriac, he was not a person who should
be treated as a lunatic. He was not of sound mind, but he was not certifiably
insane. Dr. Snow, of Bournemouth, said that he had examined Mr. M— while at
Dr. Broadhurst’s, and would not have certified him. At this stage the Court
-adjourned, and on resuming, Dr. Broadhurst’s solicitor announced that his client
was prepared to plead guilty to a technical offence. The solicitor to the Com¬
missioners then assured the Court that he did not ask for a heavy penalty. There
was not the slightest suggestion of impropriety against Dr. Broadhurst, and the
patient had been well treated. It was merely a technical offence. The Bench
inflicted a fine of £1 $.—Bournemouth Police Court, March 24th and 25th.—
Bournemouth Visitors' Directory , March 31st.

Reg. v. Greaves.

Henry Greaves, aged 26, hawker, was indicted for the murder of Henry Smith,
at Enfield. Prisoner hired Smith’s yard, but as he was in arrear with his rent the
•deceased would not allow him to enter it. Greaves thereupon knocked him down,
went away and fetched two scythes, and with these he repeatedly struck deceased
as he lay on the ground, and of these injuries Smith died. The prisoner gave
•evidence, and said that he and the deceased man were the best of friends, and
denied striking him with the scythe. He admitted that he was himself in drink at
the time. Guilty. Sentenced to death, and subsequently hanged.

The plea of insanity was not raised in this case, but it is noticed here as a crime
whose violence and ferocity so far outstripped the provocation as to bring it into
close resemblance with a class of crimes that frequently result from insanity. And
the resemblance is still further increased by the fact that the murderer was at the
time suffering from the transient insanity of drunkenness, and to this there is no
•doubt that tne crime was due. The transient insanity of voluntarily induced
drunkenness is, however, no excuse for crime, and the prisoner was hanged. The
case may be instructively compared with Reg. v. Stoner and Reg. v. O* Byrne in
the last number of this Journal.

INEBRIATE LEGISLATION.

The London County Council’s Committee reports:—“ Having regard to the in¬
sufficiency of accommodation for Protestant women at the Duxhurst Reformatory,
and the refusal of the managers to receive patients of the prostitute class, who form
a large proportion of those who come before the courts, we have been in negotia¬
tion with the Salvation Army, with the managers of various penitentiaries, who, we
understood, had under consideration the question of applying for certificates under
the Act, and have done all we could to find accommodation for those who could
not be received under the terms of our existing agreements. Our efforts have not,
however, been successful, and failing the provision of accommodation in any other
way, the Council, on our recommendation, decided to provide accommodation
itself, and has, for this purpose, acquired the Farmfield Estate, and arrangements
are now being pushed forward as rapidly as possible for the adaptation of the
buildings on the estate for the purpose of a reformatory for females. In order that
no avoidable delay may occur in bringing the buildings into use immediately they
are ready, a superintendent has already been appointed, and we are in conference
with her with a view to the completion of the arrangements with regard to the staff
and other details. We hope to have the reformatory ready for the reception of
patients not later than the middle of June.

“ With regard to the accommodation for male inebriates we have been in negotia¬
tion with the Church Army, who have a reformatory in course of construction near
Dorking, and with the Managers of the Lingfield Training Colony, which has been
visited by our Chairman. The Managers of the Colony are prepared to make
arrangements in the existing buildings at the Colony for the temporary accommo¬
dation of from ten to fourteen inmates within a few weeks, and to proceed with the

Digitized by LjOOQle

NOTES AND NEWS.

1900.]

615.

erection of a permanent reformatory at which they propose to provide accommoda¬
tion for twenty-five inmates. This accommodation they are prepared to make
available for the reception of London inmates on the terms stated in our recom¬
mendation, which is as follows :

“ That an agreement be entered into with the Managers of the Lingfield Training
Colony for the reception of male inebriates from the County of London at the
Colony in one of the existing buildings to be adapted for the purpose pending the
erection of a permanent reformatory at the Colony, and subsequently at such re¬
formatory, the Council to pay a rate of is. per day per head towards the mainte¬
nance of each such patient received and maintained at the Colony. The agreement
to be for a term of not less than four years, and to be subject to the condition that
the Council will arrange that when there are vacancies for the reception of reforma¬
tory patients at the Lingfield Colony, no male inebriate committed from within the
County of London, towards whose maintenance the Council is liable to contribute,
shall be sent to any other than the Lingfield Reformatory during the four years for
which the agreement is to last, and while the arrangements for the care and main¬
tenance are carried out to the Council’s satisfaction ; the four years for which the
agreement is to last to commence from the date at which the temporary accommo¬
dation is available, and that it be referred to the solicitor to complete the agree¬
ment.”

This report, subject to a slight amendment securing to the Council the power of
sending male inebriates to its own reformatory at Horley, was carried nemitte
contradicente.

Fj-om the Manchester Guardian of April 24th we learn that " at a conference of
representatives of county and non-county boroughs, held in the County Hall,
Preston, yesterday afternoon, under the chairmanship of Sir J. T. Hibbert, the
Lancashire Inebriate Acts Board Bill was discussed. The Chairman said the Bill
had been passed by the House of Commons and the House of Lords, and he moved
that the Bill as amended by them be approved. This was agreed to, and it was
decided that representatives on the Board should be appointed at the first quarterly
meeting of the County Council after the Act comes into force. Under the Act the
contributory boroughs with the number of representatives are:—Barrow, 1; Black¬
burn^; Bolton, 2; Bootle,!; Burnley, i; Bury, i; Liverpool, 5; Manchester, 4;
Preston, 2; Rochdale, 1 ; Salford, 2; St. Helens, 1 ; Stockport, 1; and Wigan, 1.”

The Dublin Express of March 29th contains the following:—Several benches of
magistrates having expressed doubts as to their power of committing habitual
drunkards to certified homes under the second Section of the Inebriates Act of 1898,
the Secretary of the Irish Temperance League addressed a letter to the Attorney-
General for Ireland, who has replied as follows:—"In reply to your letter of
March 23rd concerning the Inebriates Act, 1898, I am desired by the Attorney-
General for Ireland to inform you that in his opinion the only rational interpreta¬
tion to be given to the second Section is this:—While many of the offences in the Irish
schedule of the Act are not, per se, indictable, yet they become so when committed
by a habitual drunkard who has, within the twelve months immediately preceding
the commission of the offence charged, been three times convicted summarily of an
ofFence mentioned in the schedule.”

In New York, the Medical Record states that a Bill will be introduced into the
New York Legislature during the present session to establish an institution for the
treatment of victims of alcohol and drug addiction. The Bill provides for the
appointment by the Governor of a Board of Managers, who will receive compensa¬
tion during the time they are engaged in making plans for the institution. After
it is ready for the reception of inmates the managers are to serve, without pay, each
for a term of three years. The institution is to have accommodation for 300 in¬
mates. Incurables will not be admitted. Inebriates may be committed for terms
of five years, but it is proposed to have a parole system similar to the one now in
use in the Elmira Reformatory. Commitments will be made by magistrates,
although persons seeking to enter for treatment will be accepted when there is
room for them. The cost of maintenance of inmates committed by magistrates,
will be charged against the counties from which they have come.

Digitized by CjOOQle

6 i6

NOTES AND NEWS.

[July,

PARISH COUNCILS AND SCOTTISH ASYLUMS.

Lord Balfour of Burleigh, Secretary of State for Scotland, received a deputation
from parish councils on the 23rd January. The deputation appeared in support of
a memorial urging the promotion of legislation to secure direct representation of
parish councils on district boards of lunacy, and on the boards of royal and
chartered asylums. It was stated that 356 parish councils supported the conten¬
tions of the deputation, and that these councils had under care 8377 insane persons,
whereas 450 parishes with 4260 patients had taken no action in the matter.

Lord Balfour, in reply, insisted on the difference between poor-houses and
asylums. He said that asylums have large curative effects, and should be as good
as modem science can devise. He could not promise immediate legislation, but
he pronounced himself entirely in favour of the independent audit of the accounts
of district lunacy boards. Lord Balfour pointed out that the parish councils are
not responsible for the treatment of lunatics, but are only bound to remove them
to an asylum and pay for them there. The treatment rests with the district boards
of lunacy, subject to the control of the General Board in Edinburgh. He further
showed that the county council constituency is the same as the parish council con¬
stituency, which is really representative of all classes of the ratepayers, and depre¬
cated any great increase in the numbers of the district lunacy boards. Referring
to Inverness, eighty-three parishes would require representation. As to the plea
that payments and representation should go together, Lord Balfour pointed out
that where parish councils manage their own asylums ( e.g . Edinburgh) the town
councils suffer the same injustice, being requisitioned for the money to build, yet
without representation. The town councils would naturally make the same request
as the parish councils if the question is touched, and he doubted if the parish
council of Dundee would care for that. He recognised that if parish councils were
represented on district boards having no asylums of their own they would be
parties to the making of contracts for the maintenance of their insane patients, but
did not think that would carry them far, as the General Board has power to fix the
cost. Lord Balfour suggested that the county councils should elect those of their
number who are also parish councillors, in so far as possible, to the district lunacy
boards, and thus gain much without legislation. With regard to the royal asylums
he saw grave difficulties. Although they have privileges which should not be con¬
tinued, they were built by charitable donations, and not by public rating. The in¬
timate connection in these institutions between private and state-paid patients would
have to be considered, and in view of the difficulties it would be necessary to con¬
sult the General Lunacy Board and the Local Government Board. Lord Balfour
guarded himself against any promise of immediate legislation.

TYPHOID FEVER CAUSED BY CELERY.

In a report published by the Springfield Republican of December 14th, 1899, on
an outbreak of typhoid fever which occurred recently in the Insane Asylum,
Northampton, Massachusetts, U.S.A., the disease appears to have been originated
and spread by means of celery. It seems that up to September 9th, 1899, the
institution had been singularly free from typhoid fever, there having been only
four cases in ten years. But on and after that date cases occurred with alarming
frequency, so much so that in about two weeks forty inmates were stricken with
the malady, which, moreover, exhibited no signs of abating. Accordingly the
services of Dr. Morse, of the Massachusetts State Board of Health, were requisi¬
tioned, and he was requested to make an investigation. The fact was then dis¬
closed that patients, nurses, farm help, and kitchen help were affected, and further,
that the only patients attacked were those who paid for their care at the institu¬
tion. Therefore it seemed probable that the cause of the epidemic was due to some
article of food of which the patients, nurses, and servants partook, and in which
the non-paying patients had no share. The discovery was made that the paying
patients were sometimes supplied with extra articles of food, such as fruit and
vegetables. At the time of the epidemic they received celery raised on the farm.

Digitized by VjOOQle

NOTES AND NEWS.

6lJ

1900.]

This vegetable was ultimately decided to be the cause of the disease, and investi¬
gations were set on foot thoroughly to probe this theory. It happened that the
sewage after being filtered was on the celery beds, and owing to the methods used
in cultivating celery, by banking the stalks of the plant with earth, the vegetable
provided a very favourable medium for the transmission of the disease. Celery
was first used at the Massachusetts Asylum in August, and became quite a common
article of diet for the paying patients, the nurses, the house help, and the farm
help. The most significant fact of all, however, is that one of the farm servants,
not realising the danger of eating celery, and disregarding the injunctions for¬
bidding its use, ate some, and quickly contracted typhoid fever. After orders had
been given to stop the further consumption of celery the epidemic immediately
subsided.

RETIREMENT OF THE REV. HENRY HAWKINS.

Mr. Hawkins, who is, we believe, the senior chaplain of the English asylums,
retires after thirty-two years’ service at Colney Hatch, with a previous service of
eight years at Haywards Heath.

This long period of service has been distinguished not only by the faithful dili¬
gence with which Mr. Hawkins has performed the daily round of duty, but by
unbounded sympathy with the suffering poor to whom he has ministered.

His unremitting industry and kindly charity have also led him to take an active
part in general movements for the welfare of the insane. The After Care Associa¬
tion was entirely due to his initiative, and to his steady persistence it owed its sur¬
vival in the earlier stages of its existence. He has been active, too, in promoting
other societies for the weal of the insane and asylum workers.

Literary contributions, of value both to physicians, attendants, and chaplains,
have also formed another outlet of his never-resting desire to do good.

That he may long enjoy the leisure for other forms of activity, which his retire¬
ment will give him, is the sincere wish of the large number of friends with whom
he has worked for so many years.

OBITUARY,

Dr. William Marcet.

Dr. William Marcet, who recently died at Luxur, was the grandson of Dr.
Alexander Marcet, of Guy’s Hospital. His principal scientific inquiries were in
regard to respired air, ana he also wrote on climatology. To alienists his most
interesting work is that on Chronic Alcoholic Intoxication, published in i860. In
this he followed on Huss’ work, from whom he differed in laying stress on causes
and treatment.

Miss Matilda Robins Giddings.

Miss Giddings died on 20th March, 1900, and the event claims mention in this
Journal, as possibly marking the severance of the last tie of this generation of
asylum workers with the great Conolly. Miss Giddings went to Hanwell in 1850
as an Assistant Matron, having been attracted by the fame of Dr. Conolly. There
she had charge of The Bazaar , the female work-room, and played the organ in
chapel and the piano at dances. Only female patients took part in the dances at
that time, and it is a note of interest that the late Dr. Parsey, of Warwick County
Asylum, claimed to have been the first to associate the sexes at these entertain¬
ments, an innovation which then involved a very great deal of consideration.

Miss Giddings spent three years at Hanwell, and was thereafter appointed Matron at
the Perth Royal Asylum in 1853, when Dr. Sherlock undertook the duties of Resident
Physician. On his appointment to the Worcester County Asylum in the following
year, her sister, Miss Eliza Giddings, who had also served in Hanwell, was asked
to become Matron at Powick. Both sisters retired on pensions about eleven years

Digitized by LjOOQle

6 i8

NOTES AND NEWS.

[July.

ago, but Miss Eliza did not long survive her severance from public life. The
changes which have occurred during the half-century which has elapsed since these
honoured ladies went to Hanwell have been enormous, yet Miss Matilda Giddings
maintained her interest in the asylum world up to the very last. She served the
insane with a whole-hearted desire for their good, she was keenly alive to their
wants, and she loyally co-operated in what sometimes seemed to her to have been
revolutionary experiments.

Miss Giddings long and valued services are kindly remembered not only by her
fellow officials, but by many grateful patients. She was a typical matron of the old
school, an English lady, and one of the best.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

Five hundred and twenty-one candidates applied for admission to the May exami¬
nation for this certificate. Of this number 59 failed to satisfy the examiners, 24
withdrew, and the following were successful:

England.

Berks County Asylum, Wallingford .— Males: James Forbes.

Bucks County Asylum t Aylesbury. — Males: Richard Watson, George Turnham,
Richard J. Washington, George Jones, Henry Woodbridge. Females: Alice
Scott, Ada Harrison, Fanny Arnett.

Counties Asylum, Garlands , Carlisle. — Males: John Scott, William H. Metcalfe,
Tom Glaister, John Howe. Females: Sarah Elizabeth Carrick, Mary Kenny,
Elizabeth Christie, Elizabeth Dowding.

County Asylum, Fulbourn, Cambridge.—Female : Rose Cumming.

Devon County Asylum, Exminster.—Males : Frederick Tohn Bunker, Jeremiah
Endicott, William Field Lowe, James Adams, Charles Alford, William El worthy,
Charles Trenchard. Females: Mary Baker, Florence Penrose Lacy, Beatrice
Mary Fry.

Glamorgan County Asylum , Bridgend.—Males: Frederick William Watts,
William Williams, Lewis Jenkin Thomas, John Thomas, William Richard Mor¬
gans, Henry March, Roger Jones, William Ewart John, Henry John, William
Isaac, Joseph Harrison, William David Harries, Thomas Harry, Seth Francis,
William Henry Evans, David David. Females: Amelia Morgan, Jane Lewis,
Annie Matthews, Mary Ann Hughes, Annie Higton, Rosina Griffiths, Miriam
Andrews.

Hants County Asylum , Knovole, Fareham.—Males : Frank Moss, Thomas Wells,
Francis Percy Hunter, Edward Cook, Edward John Gray. Females: Gertrude
Holburn, Maria Edmunds, Alice Maud Dawkins, Susan Ann Neal, Mabel Ellis.

Kent County Asylum , Chartham. — Females: Eliza Jane Neary, Margaret Mac-
master, Edith Grace Croucher, Mary Ellen Walch, Emily Louise Keating.

Lancashire County Asylum , Rainhill. — Males: Abraham Pitchford, William
Sutton, William Lock, Alexander Gunn, Thomas Bryant, Richard Wilson, Frank
Lyttelton Harris, John Hodgson, John Stanton Sherlock. Females: Mary Boyd
Sharpe, Jeanette Shimmin, Annie Kate Weller, Grace M. M. Mackenzie, Minnie
Lokier, Daisy M. W. Volume, Ethel Bence.

London County Asylum , Banstead.—Females : Sophia Webb, Joanna Smart, Eva
Gazzer, Edith Hughes, Agnes Kelleher, Margarite Matilda Holden, Gertrude Win-
terton, Nellie Mary Sharpe, Marie Elizabeth Ham, Emily Lynds, Elizabeth Harriet
Marshall, Emilie E. Menage, Minnie Bruce, Clara Rea.

London County Asylum , Clay bury. —Males : William Cail, John Gordon, Arthur
Robert Church, Walter John Smallbone, Ernest Edward Bailey, Denis Hayes,
William Owen. Females .- Psyche E. Cronchley, Mary Jane Taylor, Mary Louisa
Price, Catherine Gray, Florence Puffett, Margaret Jane Price, Ada Whymark,
Annie Mary S. Welchman, Mary Walsh, Emma Best, Mary Llewellyn, Jessie
Eliza Seabrook, Sarah Edgar, Maria Elizabeth Thomas, Cassie Evans, Alice Bessie
Hopwood, Ethel Marie Skinner, Elizabeth C. Turner, Hetty Lloyd, Frances Haw¬
kins, Edith Allwork, Ellen Griffiths, Lucy Sugden, Caroline Beck.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

6 19

London County Asylum, Hanwell.—Males: James Richard Walker, Edward
Bridgman, George Weeds, Frederick William Cox, Arthur Bowdery, George
Barnes, William John Stanton, William Evans, David Callam, Thomas Walter
Farrance, Tames Smith, Alfred Green, Alfred Gill, George Branton, George
Baker, William Hedge, Frederick Martin, Thomas Whiteley, John W. Gray.
Females: Minnie Wiggins, Ellen Ketcher, Emily Edith Scott, Agnes Wilkinson,
Emily Williams, Elizabeth Scales, Jane Frances Meen, Flora Baker, Alice Leman,
Edith Payne, Kate Creed, Elizabeth Robert, Emma Bird, Annie Goldsmith, Julia
Raynham, Helene Whitehouse, Mary Willett, Rose Carr, Sarah A. Meadows,
Georgina Hedge, Emily Earle, Emily Drewett, Bertha Mitchener, Charlotte Earle,
Harriett Perrin, Alice Bird, Ellen Swait, Martha Spratley, Jessie Betts, Mary Rose,
Lily Mahoney, Rosine J. Stanford, Jessie Pitt, Ada Grove, Annie B. Edington,
Julia Ann Harding.

Monmouthshire Asylum , Abergavenny. — Males: John Davies, William John
Lewis, Robert Wilson Wall, William Allen Thomas, John Worthing. Females:
Marie Preece, Annie Morgan, Jenny M. Rogers, Maud L. George, Grace Sloley,
Elizabeth Williams, Martha Jane Edwards.

Middlesex County Asylum , Tooting. — Females: Edith Kate Lewis, Margaret
Jane Wilcox, Margarida Portugal, Jessie Johnson, Alice Dawson, Lilian Agnes
Hodge, Caroline Barber.

Nottingham County Asylum, Nottingham. — Female : Nellie Lever.

Northumberland County Asylum, Morpeth. — Females: Kate McAllister, Janet
Mather, Kate Kelly, Mary McGonnigal, Susan Forster, Martha Johnson, Annie
Liddell.

Stafford County Asylum, Burntwood, Lichfield .— Males : Joseph Clarke, Thomas
Elkin, Thomas Jones, Silas Perks, James Stewart.

South Yorkshire Asylum, Wadsley, Sheffield.—Females: Agnes Harrison, Eliza¬
beth Woodfield, Beatrice Mary West.

Somerset and Bath Asylum, Wells. — Males: Herbert Charles Francis, Walter
Bedford, Isaac Gould, Jacob Cook. Females: Florence Louisa Redstone, Lucy
Bishop, Harriett Gill, Eva Louisa Caswell, Eva Nicholls, Edith Maud Tovey.

Suffolk County Asylum , Melton.—Male: Tom Newbould Scaife. Females:
Johanna Prout, Annie Honor Roberts, Mary Ellen Banner, Ada Frost.

Surrey County Asylum , Brookwood.—Males : Thomas Anthony Bullock, Chris¬
topher William Crondace, James George Fagan, Frederick Sinclair. Females:
Winifred Mary Brooker, Lillie Agnes Northwood, Mary Jane Waller.

Warwick County Asylum, Hatton .— Males: Samuel James Clarke, William
George Sewell, Edwin E. Smith, George Lock. Females: Patience Mary Donagh,
Minnie Dore Altree, Elizabeth Mary Jones.

West Sussex Asylum , Chichester. — Males: William George Spooner, Archibald
John Robertson. Females: Annie Perrett, Harriett Hyett, Emily Louisa Cane, Emily
Sarah Ridley.

West Riding Asylum, near Leeds. — Males: John Hardisty, William Moody,
Fred Ryder. Females: Hannah Baldwin, Annie Simpson, Carrie Watnough,
Adelaide Stephenson, Emily Bradley, Hannah Brookes, Delia Mary Holmes.

West Riding Asylum, Wakefield.—Male : John Henry Just. Females: Bertha
Pidcock, Mabel Berry, Isabella Patterson, Harriett Stead, Amy Welby, Edith
Eccles.

Wilts County Asylum, Devises. — Males: Fred Spiller, Edward Thomas Davis,
George Walter Fennell, William Staples. Females: Annie Louisa Ludlow, Agnes
Lucy Jane Andrews, Ellen Davis, Sarah Maud Spiller, Jane Annie Smith Williams,
Aline Lagnaz, Miriam Catherine Gover.

Birmingham City Asylum, Winson Green. — Males: John Palmer, John Ellsmore,
Harry Cluley. Females: Ellen Taylor, Minnie Ada Bullock, Annie Beatrice
Collins, Mary Hodgetts, Maud Williams.

Bristol City Asylum, Fishponds. — Male: Robert Henry White. Female: Jane
Williams.

Exeter City Asylum, near Exeter. — Females: Rose Woolf, Lucy Spry, Florence
Ada Spry, Emily Pyle, Ada Crosswell.

London City Asylum, near Dartford. — Males: George Yeates, David Lewis
Evans. Females: Beatrice Read, Kate Oswald, Mabel Giawdys Williams.

Nottingham City Asylum , Nottingham. — Males: Henry Dickinson, William

XLVI. 42

Digitized by VjOOQle

NOTES AND NEWS.

620

[July,

George Knight, Samuel Bentley, William Arthur Drake, Arthur Spivey, William
Hallam. Female: Mary A. M. Higton.

Newcastle-on-Tyne, City Asylum, Gosforth. — Males: Robert Elliott, Robert
Riddle, James Sims. Females: Isabella Priest, Phyllis Melvin, Margaret Kirk¬
patrick, Jessie Millicent Jackson.

Portsmouth Borough Asylum.—Females: Florence Blyth, Julia Langridge, Helen
Mortimer, Louise Crooks.

Bethlem Royal Hospital, London. — Males •• George Francis Oulds, Thomas Warr,
Philip Thomas Herbert Crow, Tames Waters, Francis Frederick Howe. Females:
Ethel Eyre Haynes, Susan Mills.

Darenth Asylum , near Dartford. — Females: Christina MacPherson, Alice
Haynes, Rose Francis, Annie Macarthur, Edith Day.

Heigham Hall, Norwich. — Females: Margaret Harmer, Ellen Hurren, Emma
Pitcher, Martha Mary Hubbard.

Holloway Sanatorium, Virginia Water.—Females: Alice Jane Gubbins, Laura
Woodman, Mabel Cordelia Woolmer, Florinda Waterhouse, Marie Barrett, Ethel
Beatrice Marie Koek.

The Retreat, York. — Males: Ernest John Coulter, Henry Clack, Samuel Yeates.
Females: Minnie Miller, Frances Pick.

Redlands, Tonbridge, Kent.—Male: Edwin D. Baker.

Scotland.

District Asylum, Inverness.—Females : Agnes Malcolm Reid, Margaret Shirley,
Martha Knox, Cecilia Smith Drummond, Lizzie Cranston L. Carruthers.

Royal Asylum, Dundee .— Male: Peter Innes. Females: Johan Shepherd,
Nellie Wardhaugh, Isabella Peter Suttie.

Royal Asylum , Gartnavel , Glasgow.—Females: Emily Miller, Jessie Cameron
Reid, Jane Ewen, Agnes Lindsay, Clementina Stewart, Isabella Graham Lear-
month, Elsie Macdonald, Annie Bremner.

u James Murray's ” Royal Asylum , Edinburgh.— Female: Helen Jane Pattillo.

Lanark District Asylum, Hartwood, Shotts.—Males : John Lind, Samuel Gamble
Dunnachie, Thomas Monat. Females: Lottie MacLaren, Annie Dyer, Kate
Rogers, Margaret Rae, Elizabeth T. Fullarton, Bessie Davidson.

Perth District Asylum, Murthley.—Males: Peter Mitchell, Duncan Ferrier,
Alexander Scott, James Thomson, John Rattray. Female : Minnie Ogilvie.

Royal Asylum, Edinburgh. — Males: Gordon Stewart, John Allan. Females:
Margaret Cowie, Agnes Henderson, Mary Feeney, Julia Jamieson, Elizabeth H.
Ferry, Mary E. Macdonald, Margaret B. Simpson, Margaret D. Rutherford.

Roxburgh District Asylum, Melrose.—Females: Jane Hebenton, Rubina Clubb,
Mary Anderson.

Stirling District Asylum, Larbert.—Males : George Macdonald, Robert Mitchell,
John Mackie. Females: Annie Gambley, Rachel Hendrie, Margaret Rankin,
Elizabeth Hobson.

Ireland.

District Asylum, Clonmel.—Males: William Brett, James Cummins, Patrick
Brett, Patrick Griffin, Mark O’Brien, Matthew Foley. Females: Annie O’Connell,
Mary Anne Mooney.

District Asylum, Londonderry.—Male : Robert John Davis. Female: Elizabeth
Jane Buchanan.

District Asylum , Kilkenny. — Male: Patrick Hennessy. Female: Bridget
O’Meara.

St. Patrick's Hospital, Dublin.—Female: Johanna Brophey.

Stewart Institution , Chapeliaod, Dublin.—Females : Ellen Carter, Kate Duffey,
Julia Branigan.

Richmond Asylum, Dublin. — Males: James O’Neill, Robert Kavanagh, James
J. Cunningham, Michael Ryan, Patrick Curley, John Sheehan, Thomas Keating,
Archibald McCollum, Patrick Behan. Females: Eva Barry, Annie Behan, Kate
Drew, Anne Clindenning, Mary McEntyre, Mary Anne Duffy, Ellen A. Scully,
Annie Burrows, Rebecca Camp, Annie Farrelly, Mary Anne Wisely, Jane Murphy.

Sligo District Asylum, Sligo.—Male : James Devins.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

62 I

The following is a list of the questions which appeared on the paper:

1. Describe the mechanism of respiration. 2. Name the glands of the skin, and
give their uses. 3. Describe the stages of an epileptic fit. State how you would
manage a patient during, and immediately after, a fit. 4. Name the principal
arteries of the arm, and describe generally the situation of each. 5. What
symptoms are specially noticeable in diseases of the respiratory system ? 6. Give
examples of reflex action. 7. What are the causes of suffocation ? What is the
correct treatment P 8. Give directions for the preparation of good beef tea. 9.
What is a sprain P Give an example, and describe the appearances. 10. What
rules are to be observed in bathing insane patients ?

Next Examination for Nursing Certificate .

The next examination will be held on Monday, November 5th, 1900, and candi¬
dates are earnestly requested to send in their schedules, duly filled up, to the
Registrar of the Association not later than Monday, October 8th, 1900, as that will
be the last day upon which under the rules applications for examination can be
received.

Note.

As the names of some of the persons to whom the nursing certificate has been
granted by the Association have been removed from the register, employers are
requested to refer to the Registrar in order to ascertain if a particular name is still
on the roll of the Association. In all inquiries the number of the certificate should
be given.

Examination.

The examination for the Certificate in Psychological Medicine will be held on
Thursday, July 19th, 1900, at 10 o’clock a.m. in London, at Bethlem Hospital; in
Edinburgh at the Royal Asylum, Morningside; in Glasgow at the Royal Asylum,
Gartnavel; in Aberdeen at the Royal Asylum ; in Dublin at the Richmond Asylum
and in Cork at the District Asylum.

Gaskell Prise.

The examination for the Gaskell Prize will be held at Bethlem Hospital, London,
on Friday, July 20th, 1900, at 10 o’clock a.m. Candidates for this examination
must give fourteen days’ notice of their intention to sit at the examination to the
Registrar.

NOTICES OF MEETINGS.

Medico-Psychological Association.

Annual Meeting. —The Fifty-ninth Annual Meeting of the Association will be
held in London on Thursday and Friday, July 26th and 27th, 1900, at the Rooms
of the Association, 11, Chandos Street, Cavendish Square, W , under the Presidency
of Dr. Fletcher Beach. There will be a meeting of Committees as follows, on
Thursday, July 26th, before the Annual Meeting :—Educational Committee, 9 a.m.;
Parliamentary Committee, 9.30 a.m.; Tuberculosis Committee, probably 10 a.m.,
but further notices of this will be announced ; Council Meeting, 10.30 a.m.

The Annual Meeting commences at 11 a.m. on Thursday. In addition to the
usual business, the following resolution will be placed before the meeting with a
recommendation that a copy thereof be sent to the Local Government Board in the
three Kingdoms :—“ It is the unanimous recommendation of the Medico-Psycholo¬
gical Association of Great Britain and Ireland, that in Union Workhouses in
which insane persons are detained, a properly qualified and trained mental nurse
should be employed in the insane wards.”

2 p.m.—The President’s address, after which William Wynn Westcott, M.B.

Digitized by LjOOQle

622

NOTES AND NEWS.

[July, 1900

Lond., H.M. Coroner for North-East London, and President of the Society for the
Study of Inebriety, will read a paper entitled “ Inebriety: its Causes, Results, and
Treatment; " and Dr. Elliot Daunt will afterwards speak upon " The desirability
of all medical men (other than the medical officers of public and private asylums
or licensed houses) who undertake the care and treatment of persons who are
mentally affected, or so-called * borderland ’ cases, being brought into direct touch
with the Council of the Medico-Psychological Association under an organised
system."

Friday, 27th July.—10 a.m. The plans of the new East Sussex Asylum will be
exhibited and described by Dr. H. Hayes Newington (member of the Sussex
County Council and of the Asylum Committee). W. Ford Robertson, M.B.,
Pathologist, Scottish Asylums Laboratory, Edinburgh, “ A Microscopic Demon¬
stration of the Normal and Pathological Histology of Mesoglia Cells." David
Orr, M.B., Pathologist, Prestwich Asylum, “ A Contribution to the Morbid
Anatomy of General Paralysis of the Insane;" and Thomas Phillips Cowen,
M.B.Lond., microscopic and lantern demonstration. J. O. Wakelin Barratt,
M.D.Lond., Pathologist, West Riding Asylum, "Two Cases of Lepto-meningitis
—a microscopic and lantern demonstration.” John Turner, M.B., " Some Altera¬
tions produced by Disease in the Giant Nerve-cells of the Cortex—microscopical
and lantern demonstrations." Lewis C. Bruce, M.D., Physician Superintendent,
and H. de Maine Alexander, M.B., Assistant Physician, Perth District Asylum,
Murthly, " Observations upon the various Physical Changes in the Acute and Sub¬
acute Stages of Melancholia."

2 p.m.—Cecil F. Beadles, "The Insane Jew." W. C. Sullivan, M.D., "Alco¬
holic Homicide." David Blair, M.A., M.B., " Non-diabetic Glycosuria." A. F.
Shoyer, M.B.Cantab., " An Angeioma of Broca’s Convolution in a Lunatic." F.
W. Edridge-Green, M.D.Lond., " Psycho-physical Perception.”

Saturday, July 28th.—The President, Dr. Fletcher Beach, and Mrs. Fletcher
Beach, will be " At Home " to members and their friends on Saturday, July 28th,
four to seven o’clock, at Winchester House, Kingston Hill, Surrey.

The Annual Dinner will take place at the Whitehall Rooms, H6tel Mltropole,
on Thursday, July 26th, at 8 p.m. Tickets £1 is. each.

Northern Division .—The Autumn Meeting will be held at the Newcastle City
Asylum on Wednesday, 3rd October, 1900.

APPOINTMENTS.

Gow, W. B., M.D., appointed Medical Superintendent of the Lunatic Asylum at
Wellington, New Zealand.

Macdonald, J. A., M.B., B.Ch.Glasg., appointed Assistant Medical Officer
(Pathologist) to the Glasgow District Asylum, Woodilee, Lenzie.

Morton, Gavin, M.B.Syd., appointed Senior Medical Officer to the Hospital for
the Insane, Gladesville, New South Wales.

Roseby, Edmund Rupert, M.B., Ch.M., appointed Assistant Resident Medical
Officer at the Parkside Lunatic Asylum, and Medical Officer to the Adelaide Gaol.

Smith, Henry B., M.B., appointed Junior Assistant Medical Officer to the County
Asylum, Bicton Heath, near Shrewsbury.

Wood, J. M. S., M.B., Ch.B., appointed Assistant Medical Officer to James
Murray's Royal Asylum, Perth.

Digitized by VjOOQle

THE

JOURNAL OF MENTAL SCIENCE

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

No. 195 [To."T] OCTOBER, 1900. Vol. XLVL

Part I.—Original Articles.

The Presidential Address delivered at the Fifty-ninth
Annual Meeting of the Medico-Psychological Associa¬
tion , held in London on the 26th July , 1900. By
Fletcher Beach, M.B., F.R.C.P.

First let me thank you very heartily for the high honour you
have done me by electing me to the Presidential chair. When
one looks over the names that have preceded me, from the time
of Conolly downwards, one finds that it has been occupied by
men of high talent, well known as workers in psychiatry, not
only in this country, but abroad. To emulate them will be
my endeavour, and I shall certainly do everything in my power
to uphold the dignity and welfare of this Association.

It is usual in addresses of this kind to refer to the losses
which the Association has suffered during the past year. We
have a very good precedent for it, for it is the custom of the
President of the College of Physicians of London, when de¬
livering his annual address, to give an account of the lives of
Fellows who have died during the year. The time at my
disposal will only allow me to do so briefly, but I think it is
only right and proper that their names should be placed on
record.

The first name to which I wish to refer is that of Dr.
Godding, who had been an honorary member of the Association
for fourteen years. Early in life he determined to devote

XLVi. 43

Digitized by VjOOQle

624

PRESIDENTIAL ADDRESS,

[Oct.,

himself to the study of mental diseases, and after being assist¬
ant physician for four years at the New Hampshire Asylum,
he was appointed to a similar position at the Government
Hospital for the Insane at Washington. Seven years after¬
wards he became superintendent of the asylum at Taunton,
Massachusetts, where he remained for the same period of time,
and then returned as superintendent to his old asylum at
Washington. When he died he had been superintendent for
twenty-two years, and had managed the affairs of the hospital
with wisdom and conscientiousness. He was a man of high
intellectual culture, and was much beloved by his colleagues.

Professor Ludwig Meyer was also an honorary member for
thirteen years. He was the founder of the non-restraint system
in Germany, and though his proposal to do away with restraint
was considered impracticable, time has shown the method to
be a complete success. He studied architecture, and turned
his attention to land surveying for a time, but fortunately these
pursuits did not content him, and he became a student of
medicine at Bonn University, From there he moved to
Wurzburg, and afterwards to Berlin, and after passing his
examinations and becoming qualified, he was appointed as¬
sistant in the Psychiatric Department of the Charitd Hospital.
For a short time he became second physician to Schwetz, but
was recalled to the Charitd as head physician. He only re¬
mained there a year, when he was elected re-organiser of the
Hamburg Lunatic Asylum, and chief physician of the Psy¬
chiatric Division of the General Hospital. Here he made a
sale of the strait jackets which had formerly been in use, and
allowed visitors to see the patients on Sundays. He built a
new hospital for the patients at Friedrichsburg, and moved
there with them at the end of eight years, but two years later
he was appointed Professor of Mental Diseases in the University,
and Director of the Lunatic Asylum at Gottingen, and here he
remained for the rest of his life. He was a voluminous writer,
and not only published articles in Virchow's Archives and the
Chariti Annals, but established, in conjunction with Griesinger,
the Archives of Psychiatry.

Serafino Biffi, although not a member of our Association, is
worthy of notice, as he may be considered as one of the founders
of Italian psychiatry. Whilst still a student, he engaged in
•experimental work, and published his researches on the function

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

625

of the lingual nerve and the innervation of the iris. After
taking his degree, he became an assistant at the University of
Pavia, but in 1848 was appointed to the post of assistant at
the Casa Privata dei Pazzi at San Celso, in Milan, and hence¬
forth devoted himself entirely to the study of mental diseases.
Five years later he became Director of San Celso, and a leading
man in everything connected with the progress of psychiatry.
In association with Verza, he formed the Societa Freniatrica,
and lent his aid to the establishment of Italian journals devoted
to psychiatry. He was an authority on criminological and
penal matters, and a well-known medico-legal expert. He was
much loved by his colleagues and patients.

Reginald Southey was not a member of the Association, but
he was so closely connected with our specialty that his name
must not be omitted. In i860 he was elected Radcliffe
Travelling Fellow, and became a member of the Royal College
of Physicians, London. He took his degree of M.B. at Oxford
during the following year, and went abroad to continue his
studies. On his return, after being connected for twelve
months as physician to the City of London Hospital for
Diseases of the Chest, and the Royal General Dispensary in
the City, he was elected assistant physician to St. Bartholomew’s
Hospital. Next year he took his degree of M.D., became a
Fellow of the Royal College of Physicians of London, and
delivered the Gulstonian Lectures on the “ Nature and Affinities
of Tubercle.” At the end of five years he became full phy¬
sician to, and teacher of clinical medicine at, St. Bartholomew’s
Hospital, and delivered annually a course of lectures on public
health and medical jurisprudence in the medical school. He
held this appointment for fourteen years, and up to the end of
his life his interest in the progress of hygiene never diminished.
In 1881 he gave the Lumleian lectures on Bright’s disease,
but in 1883 he resigned his appointments at St. Bartholomew’s
Hospital on being appointed Commissioner in Lunacy. He
held this post for fifteen years, and then resigned on account
of the failure of his health. He did not live long to enjoy
his well-deserved leisure, as he died somewhat suddenly last
November. He was a vigorous writer, and in addition to
contributing articles to the various London medical societies,
he wrote the article on “ Personal Health ” in Quain’s Dictionary
of Medicine . He was a hard worker, and not only acknowledged,

Digitized by VjOOQle

626

PRESIDENTIAL ADDRESS,

[Oct.,

but did his best to support the conscientious work of others,
and in this way gained the good opinion of those with whom
his work brought him in contact

Louis Gustave Bouchereau was also not a member of our
Association, but his work in Paris renders his name worthy of
notice. He graduated M.D. in 1866, and was elected, together
with Dr. Magnan, during the same year M^decin de Service de
Repartition at St Anne Asylum. After holding this post for
thirteen years, he was appointed superintendent of the female
wards. In 1866 he was elected Secretary to the Association
Mutuelle des M&decins Altenistes de France, an association
whose object is to help the members or their widows or orphans
who might be in want of assistance. We have no such society
in this country, but this, perhaps, may be due to the better pay
and pension of alienists here. In 1881 he became President
of the Paris Medico-Psychological Association. He was a
modest man, but was much beloved by all who came in contact
with him, his patients being much attached to him^ 1 )

With regard to the subject of my address, I have thought I
might profitably employ the time at my disposal, by tracing
the progress which has been made in the treatment of certain
defective classes of society, such as idiots, imbeciles, the feeble¬
minded, the epileptic, and juvenile delinquents, during the last
sixty years. At the commencement of that period two schools
for idiots had been established in Paris, one by M. Ferrus at
the Bic£tre, the other by M. Falret at the Salp£tri&re. Both
of these, no doubt, were the result of the teaching by Itard of
the savage boy of Aveyron. Dr. S^guin, to whom belongs the
honour of having created the true method of teaching idiots
and imbeciles, had three years previously, on the advice of
Itard and Esquirol, undertaken the treatment of an idiot boy,
and his first publication on the subject, published in 1838,
gives the results that he had obtained.( 8 ) About 1840 he
was given the care of ten idiots, who were inmates of the Hos¬
pital for Incurables, Paris, and in 1841 he published under the
title, Thlorie et Pratique de CEducation des Idiots , an account
of the intellectual, moral, and physical characteristics of each
idiot, and the means he adopted in training and teaching them.
The contents of this book led Orfila to make a report to the
General Council of the Hospitals of Paris. The Council con¬
sidered the report, and decided that “ M. S^guin should be in-

Digitized by VjOOQle

1900 .] BY FLETCHER BEACH, M.B. 627

structed to apply his method to the numerous idiots of the
BicStre Hospital, with whom should be united those whose
education had been commenced at the Hospital for Incurables,
and that this new trial should be carried on for a year, in order
that the merit of the measures employed by M. Sdguin might
be recognised with certainty.” ( 8 ) The Prefect of the Seine
approved the decision of the Council of Hospitals, and author¬
ised S^guin to continue his work at the BicStre up to the end
of the year 1843, and charged the physicians there to follow
the progress and results of this new method. S^guin com¬
menced his work at the end of November, 1842, but difficulties
were put in his way, false accusations were made against him,
and at the end of December, 1843, he was obliged to retire.
He then started a small school of his own and continued to
carry on his work. “ After seven years of this patient labour,
and the publication of two or three pamphlets on the subject,
a Commission from the Academy of Sciences of Paris, consist¬
ing of Messrs. Serres, Flourens, and Pariset, in 1844 exa¬
mined, critically and thoroughly, his method of training and
educating idiot children, and reported to the Academy, giving
it the highest commendation, and declaring that up to the
time when he commenced his labours (1837) idiots could not
be educated or cured by any means previously known or
practised, but that he had solved the problem. His work
thus approved by the highest scientific authority, Dr. S£guin
continued his philanthropic labours in Paris for some years,
his school being almost constantly visited by teachers and
philanthropists of his own and other nations, and his methods
bearing the test of experience, schools for idiots were esta¬
blished very soon, based upon these methods, in England and
several countries of the Continent.” ( 4 ) Ini 846, nine years
after the commencement of his work, S£guin published his
admirable book Traitement Morale Hygiene et Education des
Idiots , et des Autres Enfants Arrieres , which still continues to
be the manual for all those who are interested in the education
of idiots. I have related the history of this remarkable man
at some length, because his indomitable spirit overcame all the
difficulties placed in his way, and to him we owe what we
know of the training and education of idiot children. Of
course as time has gone on improvements or additions have
been made to our knowledge, but the fact remains that he was

Digitized by VjOOQle

628

PRESIDENTIAL ADDRESS,

[Oct.,

the first to put the methods he advocated into practice. I had
the honour of his acquaintance, and found him full of enthu¬
siasm, as, indeed, a man must be to accomplish the work he
had done.

In 1842 a part of the Deaf and Dumb Institution at Berlin,
of which M. Saegart was the head, was permanently put
aside as a hospital for idiots, and M. Saegert, assisted by
one male and two female teachers, instructed twelve pupils
with encouraging results. About the same period Dr. Gug-
genbuhl established on the Abendberg, Switzerland, 3600
feet above the level of the sea, a hospital for the cure of
Cretin children. He commenced with eleven children, whom
he taught himself, but in 1845 there were twenty-five under
instruction by Guggenbuhl and an assistant, and two Sisters of
Charity came from the Protestant establishment at Lausanne to
attend them. In a pamphlet by Dr. Guggenbuhl,( 5 ) a full
account is given of six cases who had much improved under
treatment. Two years previously Dr. Twining had published
an account of Cretinism and the Institution on the Abendberg,
and solicited money to allow Dr. Guggenbuhl to carry on his
work. Probably as the result of this a small school for imbe¬
ciles was opened in 1846, at Bath, under the management of
the Misses White.

Up to this time there had been little interest in the subject
in Great Britain, but in 1847 Dr. Scott, Principal of the West
of England Institution for the Education of the Deaf and Dumb,
published some remarks on the education of idiots and children
of weak intellect, in which he gave an account of the work that
had been done by S£guin and Saegert, and appealed to Lord
Ashley, afterwards Lord Shaftesbury, to erect an institution
for idiots in England. In the same year an article on the
subject by Dr. Conolly appeared in the British and Foreign
Medico-Chirurgical Review , and two articles in Chambers'
Edinburgh Journal by Mr. Gaskell, afterwards a Commissioner
in Lunacy, in both of which a reference was made to the good
work which Sdguin was doing at the Bic£tre. These articles
attracted the attention of Dr. Andrew Reed, a noted philan¬
thropist, who, with the assistance of Conolly and others, opened
an asylum in 1848 at Park House, Highgate. This building
soon became too small for the numerous applicants, and it was
necessary to have a branch, until one large asylum could be

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

629

erected. Essex Hall, Colchester, was obtained, and some of the
pupils at Highgate were transferred there. In 1853 the Prince
Consort laid the foundation stone of the asylum at Earlswood,
near Redhill, and it was opened in 1855. The inmates at
Essex Hall were removed to Earlswood, and the former place
became a separate institution, and is now known as the Eastern
Counties Asylum for Idiots and Imbeciles, Colchester. The
Asylum for the Western Counties was founded in 1864, and that
for the Midland Counties in 1868. In 1870 the Royal Albert
Asylum for Idiots and Imbeciles of the Northern Counties was
opened, and in 1875 the first pauper school for imbecile
children, the patients being for a time located at a building at
Clapton, and four years afterwards at the institution specially
built for them at Darenth, near Dartford, Kent. At this
institution an important change is now being made. As time
has gone on a large number of ineducable patients have accu¬
mulated, and some of the educable ones are being removed to
an institution at Ealing, so that their education and training
may be carried on in a more efficient manner, and it is to be
hoped that eventually all the educable cases will be kept
together in one establishment.

In 1886 the Idiots Act was passed, in order to free the
charitable institutions above mentioned, and certain licensed
houses, such as Normansfield, Hampton Wick, and Downside
Lodge, Chilcompton, Bath, from provisions of the Lunacy Acts,
which formerly applied to them, and which sometimes interfered
with the reception of cases. In fact, whereas formerly patients
were required to be certified as lunatics before they could be
admitted, the machinery required under this Act was much
simplified.

A medical certificate to the effect that the patient, who may
be an infant or of full age, is an idiot, or has been imbecile
from birth, or for years past, or from an early age, is capable
of receiving benefit from an institution, the name of which is
given, registered under the Idiots Act, has since the passing of
this Act been all that has been necessary. These charitable
institutions became registered under the Act, the admission of
cases was much simplified, and the annual inspection of the
establishments by the Commissioners in Lunacy being con¬
tinued was a proof that the patients and arrangements were
managed in a satisfactory manner.

Digitized by VjOOQle

630

PRESIDENTIAL ADDRESS,

[Oct.,

Coming now to more recent times, we find that no more
separate institutions have been erected, but a block for fifty
imbecile children has been set apart at the Northampton County
Asylum, and an annexe for 200 imbeciles has been built at the
Middlesex County Asylum. In addition, there are also special
wards for idiots at the Hants, Kent, Durham, and Rubery Hill
Asylums, and Winwick Hall has been fitted up by the
Lancashire Asylums Committee for the treatment of fifty idiots
of the male sex.

In Scotland there are two public institutions. One is at
Baldovan, Dundee, and has been erected by Sir John and Lady
Jane Ogilvy; it was opened in 1854, and accommodates forty
patients. The other at Larbert, near Falkirk, owes its origin
to the liberality of Dr. David Brodie; it was opened in 1855
in Gayfield Square, Edinburgh, where it remained for four years,
and was then removed to better premises at Colinton Bank, in
the suburbs of that city. Soon after the committee acquired
nine acres of land at Larbert, and they commenced in 1861
the erection of an institution in which they proposed to accom¬
modate 200 idiots and imbecile children.

In Ireland there is only one public establishment, which
was founded by Dr. Stewart in 1869, and contains sixty-two
children. It is called the Stewart Institution for Imbecile
Children, and is situated at Palmerston, near Dublin.

Meanwhile our American cousins had not been idle. In
1847, a Commission, of which Dr. Howe was appointed
president, was appointed by the State of Massachusetts to
inquire into the condition of idiots in the Commonwealth, to
ascertain their number, and whether anything could be done
for their relief. Shortly afterwards they made a report, in
which was enclosed a letter from Mr. Sumner, who had seen
S^guin’s work, which he highly eulogised and approved. In
1848 the Commission made a complete report, in which statis¬
tical tables and minute details were given, and recommended
the opening of an experimental school. As a result the
Legislature made an annual appropriation of twenty-five
hundred dollars for three years, to be devoted to such a school,
for the purpose of testing the capacity of idiots for improve¬
ment. The school was opened on the istof October, 1848,
and Dr. Howe was appointed superintendent. Three years
later the Joint Committee on Charitable Institutions visited the

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

631

school, and were highly gratified with what they saw. They
therefore recommended that the school should be made per¬
manent under the name of the Massachusetts School for Teach¬
ing and Training Idiotic and Feeble-Minded Youth, and that
five thousand dollars should be annually devoted to its support.
This recommendation was adopted, and the school has ever
since been doing good work. Two months afterwards a private
school was opened at Barre, in the same State, by Dr. Wilbur.
In 1846, Dr. Backus, Senator of the New York State, endea¬
voured to bring in a law for providing training and education
for the idiot children of that state ; this was adopted by the
Senate, but thrown out by the other Assembly. Another
attempt was made in 1847, which also proved unsuccessful,
and it was not until 1851 that a law was passed voting an
amount necessary for carrying on an experimental school for
two years. It was situated at Albany, and was opened in
October, 1851, under the direction of Dr. Wilbur, who left his
private school at Barre, being succeeded by Dr. G. Brown. The
work at Albany attracted considerable attention ; educational¬
ists, members of the Legislature, and other bodies visited the
school, and in September, 1854, the corner stone was laid for a
building expressly erected for the care and education of idiot
children. Dr. Wilbur remained as superintendent until his
death in 1883. The example set by the States of Massachu¬
setts and New York was soon followed by other States,
Pennsylvania, Ohio, Connecticut, Kentucky, and Illinois being
amongst the first to establish State Institutions for their idiot
and imbecile children. In 1873 the Association of Medical
Officers of American Institutions for Idiotic and Feeble-Minded
Persons was founded, and no doubt owing to the influence it
exerts, more state institutions have been opened, so that,
according to a report published by Dr. Powell in the Proceed¬
ings of the National Conference of Charities and Correction , 1898,
there are now nineteen States which maintain twenty-four
public institutions, and care is provided for 8492 idiot and
imbecile persons. New York has a custodial asylum for adult
idiots and imbeciles at Rome, and many of the other institu¬
tions have custodial as well as educational departments, the
most complete being that provided at Elwyn for Eastern
Pennsylvania. This is a most important arrangement, and is
much wanted in this country, where patients from the charitable

Digitized by VjOOQle

632

PRESIDENTIAL ADDRESS,

[Oct.,

institutions have to be sent back to their homes after a period
of residence to make room for the admission of other patients.

If we compare the provision made in Great Britain and
Ireland for this defective class with that in the United States,
we shall find that both provide for about six per cent., but it
must be remembered that the institutions here are chiefly
supported by voluntary contributions, while the majority of
those in the United States are maintained by funds supplied by
the different States. It will be thus seen that much remains to
be done in this country for this class of children, especially by
Poor Law Authorities, if we are to provide asylums supported
by the rates only up to the standard of State-aided institutions
now at work in America.

Returning now to France, we find that there are now five
institutions in the department of the Seine which receive idiot
and imbecile and epileptic children, viz. the Bicetre, the
Vaucluse Colony, the Salpetri£re, the Valine and the Villejuif,
the whole of these accommodating 980, or including the institu¬
tion of Dr. Boumeville at Vitry, 1000 patients.( # ) There are
some scattered cases in some of the provincial asylums, and in
the John Bost Institution, which consists of nine houses, four
have been put aside for idiots and imbeciles, as well as for blind
and infirm cases, and 217 patients here find a home.

In Germany there are twenty-nine establishments, which
accommodate 3070 idiot and epileptic children, and 1831 adult
cases of the same class, so that the work first begun by Saegert
has been followed up successfully in that country. In Austria
there are five institutions, in Belgium four, in Holland four, in
Italy two, in Switzerland five (since increased to fourteen), in
Denmark three, in Norway three, in Sweden sixteen, in Russia
five, and in Finland one. All these are public institutions, but
there are some private ones as well. It is worth noting that
in the school for idiots at the Hague there are thirty-eight
scholars who live at their homes and attend school daily, and
that one of their employments is cigar-making. It should also
be pointed out that although only three institutions have been
assigned to Denmark, one of them, the Keller Institution, has
five buildings set apart for the teaching and training of idiot
children.

As regards our Colonies, Canada has an establishment at
Orillia, Ontario, which contains 61 o patients ; and there are

Digitized by

Google

1900.] BY FLETCHER BEACH, M.B. 633

branch establishments in connection with two asylums in
Australia and one in South Africa.

In the Argentine Republic the idiots occupy a separate
quarter of Los Mercedes Hospital for the Insane, and pro¬
vision is there made for eighteen children and ten adults.
The authorities are about to erect a separate building for
them, which will contain baths, workshops, and a gymnasium.
In the hospital for demented women the accommodation is
not so good, but there are separate wards for seven children
and twenty-three adults. Altogether the provision here made
puts to shame many European countries which are supposed
to be more enlightened.

As regards moral imbeciles, they were kept in prison sixty
years ago, and on the Continent are there still; but in England
and America they find their way into the institutions for idiots
and imbeciles. They are a difficult class to deal with, for they
are often intellectually sharp and clever, but morally they are
thieves, liars, full of cunning, and sometimes criminal in their
tendencies. If remonstrated with they will promise amend¬
ment, but their promises are soon forgotten, and a slight cause
produces a fresh outbreak. In some cases they possess good
manual skill, and use it for bad purposes. The late Dr.
Kerlin, who was Superintendent of the Pennsylvanian Institu¬
tion for Feeble-Minded Children, was of opinion that they
should not be educated, as it increased their power for evil,
but that they should live in buildings apart from other chil¬
dren, in order not to infect them with their bad tendencies.
Dr. Jules Morel is of opinion that they should be received into
institutions set apart for their treatment, as they are not fit
subjects for lunatic asylums, reformatories, or prisons ; and in
this opinion I concur. If they are not kept under control
they will be sure to commit some act which will result in their
being sent to prison, and this, as Dr. Morel says, is not the
place for them.

At a meeting of the British Medical Association, held at
Glasgow, in 1888, Dr. Warner read a paper in the Psychology
Section on “ Methods of Examining Children in School as to
their Development and Condition of Brain/* and a resolution
was passed “That a committee be appointed to conduct an
investigation as to the average development and condition of
brain function in primary schools, and that their report be sent

Digitized by VjOOQle

«34

PRESIDENTIAL ADDRESS,

[Oct.,

to the Editor of the Journal; and further, that the Com¬
mittee should have power to add to its number, and to apply
to the Council for a grant ” ( 7 ). A Committee was appointed,
and a grant of money was made to assist the investigation.
In 1889 a report on the investigation of children in fourteen
schools was made to the Council of the Association by Drs.
Hack Tuke, Warner, Shuttleworth, and myself; 5334 children
had been seen, and 809 cases were examined and the results
tabulated. In the same year (1889) a Royal Commission on
the blind, deaf, and other classes requiring exceptional modes
of education was held, and the evidence already obtained was
laid before the Commission by Dr. Warner. After collecting
a considerable amount of evidence on the subject, they issued
a report in which, among other recommendations, was one in
favour of county or town councils providing for educable im¬
beciles, and another “ that with regard to feeble-minded chil¬
dren, they should be separated from ordinary scholars in public
elementary schools, in order that they may receive special
instruction, and that the attention of school authorities be
particularly directed towards this object ” ( 8 ). At the meeting
of the British Medical Association at Leeds, in 1889, the
report above alluded to was read ; the Committee was re¬
appointed, and a further grant of money was made. In 1890
the Charity Organisation Society appointed a Special Com¬
mittee to “ consider and report upon the public and charitable
provision made for the care and training of feeble-minded,
epileptic, deformed, and crippled persons ” ( 9 ), and the Com¬
mittee was instructed to promote a scientific inquiry into the
number and condition of feeble-minded children and adults, to
raise a fund for carrying on the inquiry, and “ to prepare for
publication a statement endorsed by leading men and others
who may be specially qualified to form an opinion on the
subject.” ( 10 ) In 1891 the investigation with regard to the
number and condition of feeble-minded children was proceeded
with, and in July of that year an interim report, containing
elaborate tables and particulars respecting this investigation,
was published. In the same year (1891) the Congress of
Hygiene and Demography met in London, and it was decided
that the results of the investigations made by the British
Medical Association, which was still going on with the work,
and the Charity Organisation Society, should be put before

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

635

the Congress. It was also resolved that the Congress should
be asked to appoint a Commission, whose duty should be to
inquire into the condition of children in schools and elsewhere,
and that they should have power to add to their number, and
to appeal to authorities for assistance if necessary. The
Congress acceded to this recommendation, and a Committee
was soon appointed to carry on the work. Up to this time
50,000 school children had been seen, and 9186 had been
examined; and in 1893 the Charity Organisation Society
published a report, containing statistical tables, in which the
results of the investigation of the physical conditions of these
50,000 children were given, and suggestions were made for
the better education and care of feeble-minded children and
adults. It was considered advisable that the results obtained
by the investigation of 50,000 children should be checked by
an investigation of another 50,000, and this was carried out
by the Committee appointed by the Congress of Hygiene and
Demography. Funds were collected from private sources, and
grants were made by the Congress and by the British Associa¬
tion for the Advancement of Science. Finally, in 1895, a
“ Report on the Scientific Study of the Mental and Physical
Conditions of Childhood, with particular reference to children
of defective constitution, and with recommendations as to
Education and Training,” was issued by the Committee. Of
the 100,000 children who were seen by the examiner (the
greater part of the work was done by Dr. Warner) 18,127
were particularly noted, and observations were made as to
defects in development, abnormal nerve signs, low nutrition*
and mental dulness. The report contained tables showing the
coincidence and co-relation of various classes of defects, and it
was decided that i*6 of the first 50,000 and o # 88 of the
second 50,000 required special care and training. The Com¬
mittee, having concluded its labours, was dissolved, and a new
Society, called the “Childhoqd Society,” was formed in 1896
to still further carry on the investigation. This Society has
been in operation for three years, and annual reports are issued
giving an account of the work done during the year. It has
higher aims than those of the preceding societies, for besides
promoting “the study of educational methods, and of the
environment of children during school life best suited to ensure
their physical and mental development,” it desires “ to supply

Digitized by VjOOQle

6 3 6

PRESIDENTIAL ADDRESS,

[Oct.,

information and diffuse knowledge on points connected with
the mental and physical status of children, by means of publi¬
cations, lectures, etc., and to promote the special training of
teachers to qualify them to deal with abnormal children ; and
to assist by legislation, philanthropic efforts, or otherwise, in
the provision necessary for them ” (“). In pursuance of this
work six courses of lectures have been given at the offices of the
Society, Parkes Museum, Margaret Street, London. At the
meeting of the British Association at Dover last year, a report
was read by a Committee appointed by that body, some of
whom are members of the Childhood Society, on the mental
and physical deviations from the normal among 1120 children
in public, elementary, and other schools, and a very complete
table was given, which showed the conditions of those children
who required special care and training.

No doubt as the result of the investigations I have already
mentioned, and the fact that there were a number of children
who could not be instructed in the ordinary way, the Lord
President of Council appointed in December, 1896, a Depart¬
mental Committee, in order that they might inquire into the
systems then in force for the education of feeble-minded and de¬
fective children. The Committee, on which Drs. W. Smith and
Shuttleworth served, held several meetings, and examined both
medical and lay witnesses who were interested in the subject,
and afterwards drew up a report, in which they estimated that
1 per cent, of the school population belonged to the feeble¬
minded class. They recommended that there should be legis¬
lation for the education of feeble-minded children under con¬
ditions similar to those provided in the Blind and Deaf Act;
that “ school authorities should be required to appoint medical
officers to advise them as to the discrimination of defective and
epileptic children,” and that the Education Department should
“ consider whether a medical adviser should be appointed, whose
duty it should be to advise the Department on all matters
arising out of the education of defective and epileptic children,
and to inspect homes and classes for such children when
required.” ( 19 ) In 1899 the Elementary Education (Defective
and Epileptic Children) Act was passed, and although it is
permissive only, yet it contains many provisions which will be
found useful for those who have to deal with the instruction of
defective and epileptic children. Thus a school authority may

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

637

make arrangements for ascertaining “ ( a ) what children in their
district not being imbeciles, and not being merely dull or
backward, are defective, that is to say, what children by reason
of mental or physical defect are incapable of receiving proper
benefit from the instruction in the ordinary public elementary
schools, but are not incapable by reason of such defect of
receiving benefit from instruction in such special classes or
schools as are in this Act mentioned ; and ( 6 ) what children in
their district are epileptic children, that is to say, what children,
not being idiots and imbeciles, are unfit by reason of severe
epilepsy to attend the ordinary public elementary schools.”
In order to ascertain whether a child is defective or epileptic
within the meaning of this section of the Act, “ a certificate to
that effect by a duly qualified practitioner approved by the
Education Department shall be required in each case.” This
is a very proper provision, for medical men alone are able to
ascertain whether children are defective, or epileptic, or not.
When a school authority has ascertained that there are defective
children in their district, they may make provision for them by
means of “ classes in public elementary schools certified by the
Education Department as special classes ; or by boarding out,
subject to the regulations of the Education Department, any
such child in a house conveniently near to a certified special
class or school; or by establishing schools, certified by the
Education Department, for defective children.” The provision
that the Education Department shall not certify any establish¬
ment after the commencement of the Act for boarding and
lodging more than fifteen defective or epileptic children in one
building is, in my opinion, a mistake which requires to be
rectified. Twenty-four children would be a much better
number, as there would be more chance of classification, and
twenty-four could be as easily managed as fifteen. There are
two good provisions ; one giving a school authority to provide
guides or conveyances for children, who, on account of any
physical or mental defect, are unable to attend school without
them ; and the other, the extending of the period of education,
so that a defective boy or girl is deemed to be a child until the
age of sixteen years. We all know that deficient children
require a longer period of education than normal children, and
for my part I should like to have seen the age limit extended
to eighteen years. The Act gives power to the Education

Digitized by

Google

638

PRESIDENTIAL ADDRESS,

[Oct.,

Department to give grants from public money towards the
education of defective and epileptic children, makes the parent
liable to contribute towards the expenses of the child, and
allows Boards of Guardians to contribute towards the expenses
of providing, enlarging, or maintaining a certified special class
or school, in respect of scholars taught at the class or school
who are either resident in a workhouse, or in an institution to
which they have been sent by the Guardians from a workhouse,
or boarded out by the Guardians.

We in Great Britain and Ireland have been late in taking up
the practical instruction of feeble-minded children. As long
ago as 1863 there was established at Halle, in Germany, an
auxiliary class for children “ who could not be taught the
ordinary school curriculum,” and in 1867 a similar class was
established at Dresden. Leipsig and Brunswick followed, and
gradually auxiliary schools grew out of the classes. Herr
Kulhorn .... gave an account in 1894 of thirty-two auxiliary
schools, consisting of 110 classes, with a teaching staff of 11 5,
established in various parts of Germany, and Herr Wintermann,
of Bremen, was able to supplement this statement in 1898 by
the information that at that date auxiliary schools existed in
fifty-two German towns, consisting of 202 classes, and con¬
taining 4281 children under instruction by 225 teachers. A
later estimate states that there are probably not less than 6000
children receiving instruction within the limits of the German
Empire.( 18 ) This is a splendid record, and we may be quite
sure that a practical nation, such as the Germans, would not
have established all these schools unless they had already seen
good results. Conferences of teachers of auxiliary schools are
held annually, and matters of interest are then discussed. In
Norway classes for the instruction of abnormal children have
been established for at least twenty years, and are under the
management of Herr Karl Lippestad and Herr Soethre, the
former being director of an imbecile institution at Christiania,
the latter at Bergen. Separate classes have also been organised
for backward children in connection with two of the largest
elementary schools at Bergen. In Copenhagen there are a
number of institutions, some of which contain feeble-minded
children, which have been organised by Dr. Keller, and Dr.
Shuttleworth and myself had the opportunity of seeing the
good work which he is doing on visiting these establishments

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

639

in 1897. The classes we found usually consisted of from eight
to ten pupils, so that the ratio of teachers to children was high.
Great stress is laid upon physical and manual work ; one of the
teachers gave us an exhibition of gymnastic exercises in a well-
fitted up gymnasium by some of these feeble-minded boys
which would have done credit to normal children ; and in one
of the classes was a miniature garden, in which the boys were
educated in cultivating with tools specially made for the
purpose.

It was not until 1892 that special classes for these children
were established in England, the first of the kind being opened
at Leicester in connection with the School Board. Later on
in the same year the London School Board established
“Schools of Special Instruction,” for children who could not
be taught by the ordinary method, and Mrs. Burgwin, who
had been for some years a teacher under the Board, was
appointed Superintendent. Under her direction fifty-three
schools have been opened, and there are now between 2000
and 3000 children who are being specially instructed. The
Metropolitan Asylums Board has opened a home for twenty
children, and others are in contemplation. The children
attend the special classes, and there is, therefore, more indivi¬
dual care and better training than they could have in Poor
Law Schools. In the provinces, too, special classes have been
opened, for, besides the one at Leicester just alluded to, classes
are in operation at Birmingham, Bolton, Bradford, Brighton,
Bristol, Burnley, Bury, Nottingham, and Plymouth. Some
private educational homes have also been instituted during the
last few years, for patients belonging to a higher social class,
who also require special methods of education.

On the Continent, Belgium and Switzerland have set apart
schools for the instruction of feeble-minded children, and
Austria is in favour of the movement. Dr. Bourneville has
advocated, in his last volume of the Clinical and Therapeutical
Researches , the creation of special classes attached to primary
schools in Paris and France, and details the results of the
classes which have been in operation in Switzerland, England
and Belgium, in support of his appeal. In Italy “colonies
have been formed for backward children, where sea-bathing
and summer outings are enjoyed .... and there is an excel¬
lent institution for mentally backward children of good circum-

XLVI. 44

Digitized by VjOOQle

640

PRESIDENTIAL ADDRESS,

[Oct.,

stances at Nervi, near Genoa .... it should be mentioned
that there is also another institution at Vercurago, in the
province of Bergamo ” ( u ). Quite recently a “ National League
for the Protection of Feeble-minded Children ” has been organ¬
ised in Italy, under the presidency of Professor Bacilli, Min¬
ister of Public Instruction. “ His chief aim is the creation of
an institution in each province for the training of these unfor¬
tunates ” ( 1B ). One of the results of this National League
has been the opening in Rome of a day school for these
children. A private institution has been established for their
training at Melbourne, and Dr. Stawell, in January of this year,
read a paper on “ The State Education of Mentally-feeble
Children ” before the Australian Association for the Advance¬
ment of Science, in which he advocated the establishment of
a school at Victoria ( 16 ). Finally, Mr. R. Osuga has opened a
small institution for ten feeble-minded orphan children at
Tokyo, Japan, and a good notice of his work has been pub¬
lished in the Church in Japan y for November and December,
1898 ( 17 ).

For some years past small homes have been established
by philanthropic ladies for the reception of feeble-minded
girls, in different parts of the country, and the Metropolitan
Association for Befriending Young Servants has opened one
at Hitchin. From statistics which had been prepared it was
found that many girls, on leaving public elementary schools
at the age of fourteen, or poor law schools at sixteen, were
apt to go wrong, not because they were vicious, but, being
simple-hearted and mentally feeble, they were taken advantage
of by evil-doers, and at last came into the workhouse to be
delivered of a child. In some cases the same girl would come
into the workhouse again and again for the same purpose,
there being no power to detain her. Many ladies, becoming
acquainted with this state of affairs, opened homes into
which these girls have been received, and trained in laundry,
domestic, and other industrial work. There is no power of
detention ; but there is no necessity for it, for their lives are
rendered so happy that they do not attempt to escape. In
1896 the National Association for Promoting the Welfare of
the Feeble-minded was formed, under the presidency of the
Duchess of Sutherland, and the chairmanship of Mr. Dickinson,
Chairman of the London County Council, in order to co-

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

64I

ordinate these scattered institutions, and to endeavour to arouse
public interest in these cases. Since its formation this Asso¬
ciation has opened four homes near London, two of these being
for adult girls, one for grown-up boys, and one for children
who are trained in the same method as those who attend the
special classes. Including these homes, there are now no less
than fifteen which carry on this useful work, and as they are cer¬
tified by the Local Government Board, and visited by their
inspectors, and in the case of the four houses just mentioned
by consulting physicians, specially appointed for the purpose,
we may be quite sure that the arrangements made for the
comfort and welfare of the inmates are as perfect as possible.

Epilepsy was recognised as far back as the time of Hippo¬
crates, who wrote about it under the name of the “ sacred
disease,” though he was enlightened enough to consider it not
more divine nor more sacred than other diseases, but that it
had a natural cause, from which it originated in the same
way as other affections. In fact, he stated that the disease
was connected with the brain, and he gave a description of the
blood-vessels which connect it with the trunk, a remarkable
discovery on his part considering the time at which he lived.
Later Latin writers, such as Gabucinus, wrote concerning it
under the name of “ comitialis morbus,” so called, according
to Festus, because its occurrence was considered ominous, and
put a stop to business for the day. In the book of Gabucinus,
which was published in 1561, reference is made to the ancient
Greek, Arab, and Latin authors who have written on the
subject, and Homer, it appears, had mentioned it in his works.
Various authors succeeded Gabucinus, and in 1827 Portel wrote
his Observations sur le Nature et le Traitement de Flipilepsie , in
which he fixed the seat of epilepsy in the brain, and principally
in its medullary substance, and described the observations he
had made in an examination of the body after death. In
1851 Marshall Hall delivered the Croonian lectures before the
Royal College of Physicians of London, “ On the Threatenings
of Apoplexy and Paralysis ; Inorganic Epilepsy ; Spinal Syn¬
cope ; Hidden Seizures ; the Resultant Mania ; etc.,” in which
he described the principles on which prevention of the seizures
depend. In all the affections treated of in these lectures,
certain causes, emotions, and irritations, act directly on the
muscles of the neck, inducing what he calls Trachelismus,

Digitized by VjOOQle

642 PRESIDENTIAL ADDRESS, [Oct,

and treatment should be directed to remove this Trache-
lismus, because on it epilepsy depends. Other writers, such
as Delasiauve, Brown-Sequard, Sieveking, Russell Reynolds,
Bourneville, Hughlings Jackson, and Gowers, have since written
on the subject, and the well-known views of Hughlings Jackson
are now accepted by nearly all medical men who have studied
the subject.

With regard to the provision for insane epileptics, sixty years
ago they were mixed together with the other patients in the
asylums. The first movement for improving their condition
was to provide special wards for them, so that they might be
separated from the other cases. As long ago as 1874, Mr.
Ley, in his annual report, advocated that the epileptic patients
at that time in the various Lancashire Asylums should be
placed in a separate institution ; but apparently nothing was
done. In 1892 Dr. Ewart read a paper before this Associa¬
tion, in which he advocated the establishment of colonies, not
only for the epileptic insane,, but for adults and children who
were epileptic only and not insane. Public opinion had
evidently been ripening on the subject, for in 1897 Dr. Rhodes
and Alderman McDougall were appointed by the Chorlton and
Manchester Joint Asylum Committee to visit institutions for
the treatment of imbeciles and epileptics in Germany, France,
and Belgium, and on their return they issued a report in which
they recommended : “ (I) that of the epileptics and imbeciles, the
mental and bodily sick—say 20 per cent.—should be provided
for in pavilions similar to the Wilhelmina Augusta Pavilions at
Alt-Scherbitz ; (2) that the epileptics and imbeciles who are not
physically incapable—say 80 per cent.—should be provided
for in homes on the colony plan, and that not more than thirty
persons should be placed in the same home; and (3) that
provision should be made for those able to pay a proportionate
sum towards their maintenance ” ( 18 ). These recommendations,
viz. the colony system, they say have been approved by the
International Congress on Public Assistance, held at Paris in
1889, and the Congres International de M^decine Mentale.
As a result of this report the Manchester and Chorlton Unions
decided to establish a colony for imbeciles and epileptics. A
site was decided upon, and was about to be purchased, when,
at the last moment, Dr. Rhodes informs me the Liverpool
authorities intervened and bought the land themselves, so the

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

643

Manchester and Chorlton Unions now have to search for
another site. It is proposed to accommodate the imbecile and
insane epileptics on one part of the estate, and the sane
epileptics on another part. This good example has been
followed by the Leicester Board of Guardians, who are about
to acquire a large area of land for the treatment, on the
colony system, of the imbeciles and epileptics in the Leicester
workhouse. The London County Council is about to build
on the Horton Manor Estate, and I am informed by Mr.
Charles Clifford Smith, Asylums Engineer, that the colony will
accommodate 300 male patients, 127 acres of the estate being
allocated to it, the buildings forming it occupying an area of
twenty-seven acres. The buildings comprise an administrative
block, with which is included staff quarters and an infirmary
for patients, a separate block containing the stores and kitchen
departments, with the recreation hall adjoining, and eight villas
for patients. These villas are single-floor buildings, and each
will accommodate thirty-six patients and staff in proportion.
A house for the medical superintendent is placed within
convenient distance of the administrative centre. This scheme
has not yet been adopted, but it is the latest information I
have on the subject. Finally the Lancashire Asylums Board
are about to provide a colony for the insane epileptics in
Lancashire.

Turning now to the provision for sane epileptics, John Bost,
to whom I before referred, opened his first home for epileptics
at La Force in 1862, and since then he has opened others, the
last being founded in 1881. The houses clustered round a
centre, and were built on the family system, as a family of
homes. The Bielefield Colony in Germany, also, consists of a
number of homes, and accommodates 1400 epileptic inmates,
and, according to the reports, is :—(1) a sanatorium, a medical
investigation being made in every case ; (2) an institution for
the education and instruction of epileptic children ; (3) an
institution for the employment of epileptics ; and (4) an asylum
for imbecile epileptics. The last seem to have become imbecile
as the result of long-continued epilepsy, but of late years
30 per cent, of those admitted have been epileptic imbeciles.
There are besides some weak-minded epileptic children, so that
it is not purely a colony for sane epileptics. The homes which
have been built more recently are smaller in size, and contain

Digitized by

Google

644

PRESIDENTIAL ADDRESS,

[Oct.,

from fourteen or sixteen to forty or sixty inmates. In this, as
in all well-conducted colonies, all the colonists are employed
as much as possible. There are tailors, smiths, joiners, shoe¬
makers, basket-makers, brickmakers, toy-makers, and others
who work on the farm and garden, while the women are
employed in the laundry, kitchen, housework, and sewing room.
They are divided into three classes, according to the amount of
money they pay. A good many of the epileptics, Dr. Rhodes
informs me, are in asylums, and although Bielefield seems to
be the only one known as the colony, its methods are followed
in most of the other institutions. Apparently in Germany
more than in any other country attention has been given to
the special treatment of epileptics, and from the report of the
Charity Organisation Society, which inquired into the subject
in 1891, and from Dr. Rhodes’s report, there appear to be in
that country no less than forty institutions which deal with
epileptics. A number of epileptics are in the State Asylum
for Chronic Lunatics at Dalldorf, near Berlin, which I visited
when the Congress was held in Berlin, but the largest number
are included in the Asylum for Epileptics and Imbeciles,
Wahlgarten, near Berlin. As regards other countries, there are
in Austria-Hungary three, in Russia three, in Denmark two, in
Holland one, in Switzerland three, in Italy five, and in France
five. Besides the five in France, epileptics are accommodated
in the Bicetre and the Salpetri&re. In America there are six.
The first institution was built at Ohio,.and since then colonies
have been established at Massachusetts, New Jersey, California,
Pennsylvania, and New York. One of the most important of
these is the last, which is known as the Craig Colony, at
Somyea. This institution was opened in 1896, and is intended
to accommodate about 1000 inmates.

The first home that was established in England was the one
at Maghull, near Liverpool, in 1889 by Dr. Alexander and
others, and the colonists are there well classified ; but as the
number of cases increases new houses will have to be built—
one has already been built for male epileptics—for the patients,
who will have to be still further subdivided and classified.
From a letter which I have received from Dr. Alexander, I
learn that the number of colonists at present in residence are
123. In 1893 a Home of Comfort for epileptic women and
girls from the ages of two to thirty-five, from all parts of the

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

645

kingdom, was founded by Lady Meath, at Godalming, Surrey.
The inmates must be able to engage in some occupation, such
as needlework, bead-work, basket-making, or laundry work.
Here about fifty female epileptics are accommodated, members
of the “ Girls’ Friendly Society ” being admitted on payment
of 10s. 6 d. per week, non-members at 12 s. 6 d. f and children at
8 s. The charge for ladies is from one guinea to two guineas
per week. In 1894 the first colony in England for sane epi¬
leptics was opened at Chalfont, in Buckinghamshire, by the
National Society for the Employment of Epileptics. The
object of the Society is “to establish homes where persons
suffering from epilepsy, yet capable of some occupation, may
enjoy the advantages of regular life, with healthy surroundings,
and where, under the necessary supervision, they may, accord¬
ing to their age, sex, and condition, be educated, industrially
trained, or suitably employed.” ( 19 ) Alcohol is not allowed,
and the bromides are sparingly used, being only given when
absolutely necessary. The houses have been gradually in¬
creased, and there are now seven, three for men, one for women,
one for boys, one for girls, and one for colonists requiring
special care and treatment, and accommodating altogether 134
inmates. Mr. Passmore Edwards, who not only purchased the
135 acres of land on which the houses are erected, but has
himself built some of them, is about to commence the building
of an administrative block, which has been found urgently
necessary An anonymous donor has provided funds for the
erection of another home for women ; and a gentleman who will
not allow his name to be disclosed has undertaken to build a
home for convalescent cases. It is well known that convales¬
cent institutions will not admit cases liable to epileptic fits, so
that this will be a very welcome addition to the colony. An
important change which was made in the law last year, by the
passing of the Elementary Education (Defective and Epileptic
Children) Bill, before referred to, has interfered with the open¬
ing of the boys’ and girls’ homes, since by that bill the number
in a home is limited to fifteen, whereas the homes for boys and
girls at Chalfont were erected for twenty-four. The National
Society has sent a memorial to the Education Department
praying them to alter the number to twenty-four, but in the
meanwhile the boys’ home will be used for epileptic youths of
fourteen and upwards, and the home for girls for grown-up

Digitized by VjOOQle

646 PRESIDENTIAL ADDRESS, [Oct.,

girls and women. It is to be hoped that this grievous obstacle
to the erection of homes for children will soon be removed, for
at present there is no place where the children of the poor can
be educated and trained. The London School Board is, I
believe, making an inquiry into the number of children under
their jurisdiction, and there are no doubt many epileptics in
the Poor Law Schools for whom provision should be made ; but
at present apparently nothing can be done until this limitation
of fifteen children for a home is altered. The colony, how¬
ever, is doing good work, for, besides employment in the farm
and garden, there are also a few carpenters, plumbers, painters,
bricklayers, and smiths, while the women are employed in the
laundry, or in house work, and needlework. The result has
been that marked improvement has taken place in most cases ;
the general health has improved, and the number of fits has
diminished. Another colony for sane epileptics is to be opened
at Chelford, in Lancashire, where the Lewis trustees have
bought an estate of 460 acres. Dr. Rhodes, who induced the
trustees to take up the subject, informs me that it is proposed
to accommodate 200 cases, and they will be divided into first,
second, and third classes, according to payment, as in the
German institutions.

Notwithstanding what has been done, many more colonies
will require to be erected to meet the demand for them. It is
calculated that there are 40,000 epileptics in the United
Kingdom, and of these a large number are no doubt accom¬
modated in workhouses, which is not at all the place for them.
Many of the best cases at the Chalfont Colony have been
colonists, who had been in the workhouse for only a short time,
and who have drifted into pauperism from no fault of their
own, but simply from their inability to obtain work. It is to
be hoped that the unions not only in England and Wales, but
in Scotland and Ireland, where no special provision has yet
been made for them, will copy the example of the Chorlton and
Manchester, and Leicester unions, and provide colonies for these
afflicted persons. In places where the numbers are small the
counties should combine and build a colony for their epileptics.
For the class above paupers voluntary effort is much required.

Finally, I should like to say a few words about juvenile
delinquents. There is no doubt that sixty years ago they were
badly treated, for with the exception of the Reformatory Farm

Digitized by VjOOQle

1900.]

BY FLETCHER BEACH, M.B.

647

School at Redhill, Surrey ; the Houses of Refuge and the Dalston
Refuge ; the County of Warwick Juvenile Criminal Asylum ; the
Children’s Friend Society ; and some others, nothing was done for
them in England but to send them to gaol. On the Continent
they were in a worse condition, though efforts for their rescue
by means of schools of industry and reformation had for a long
time been put forth, the most notable case being that of John
Falk, of Weimar, in Prussia, who was a pioneer in this work.
His compassion was excited by seeing the orphan children
after the battles of Jena, Liitzen, and Leipsic, who wandered
like wild beasts of the forest in the neighbourhood of these
places. “Falk gathered 300 of them into his house, to give
them food, education, and an honest calling, and he gave
himself wholly to this rescue work, and succeeded in it.” (^)
This simple experiment induced practical men in England to
try and give it effect on a larger scale. It was seen that a
gaol could not be converted into a school, and that a true
reformatory school should always be an industrial training
asylum. Various parliamentary inquiries into the matter had
been instituted, and judges and magistrates were endeavouring
to deal kindly with the children, who were often quite small,
so that their heads could hardly be seen in the dock in which
they had to stand. At length, in 1852, schools were established
for them, of which three may be mentioned : one, at Hardwicke,
in Gloucestershire ; another at Kingswood, near Bristol ; and
the third in Birmingham. All yielded good results, but the
one at Birmingham was such a remarkable success that, encou¬
raged by the liberality and work of Lord Norton and some
others, the Birmingham Reformatory Institution was founded.
This society established the Saltley Reformatory in order to
endeavour to rescue, educate and reclaim youthful criminals,
provide for them a home, and train them to habits of regular
industry. Those who had founded these schools, and others
which soon came into existence, were much encouraged by the
efforts which had long been in operation at the Warwickshire
County Asylum and the Redhill Reformatory Farm School, before
mentioned, in the former of which 65 per cent., and in the
latter 75 per cent, were permanently reformed. At Mettray,
in France, 85 per cent, turned out irreproachable ; at the Rauhe
house, at Hamburg, only 9 per cent, gave cause of complaint;
and at institutions at Wurtemberg and other places more than

Digitized by VjOOQle

648

PRESIDENTIAL ADDRESS,

[Oct,

half the children turned out well; while at the old established
schools in the United States, including the House of Refuge at
New York, and the State Reform School at Massachusetts, the
success was so complete that the practicability of criminal
children being reclaimed by this method was considered as a
settled question. From this period the idea of the modem
reformatory may be considered as naturalised, not only in
Europe and America, but also in England, Scotland, and
Ireland ; but still there was a general feeling that the question
of dealing with this class was not completely solved, for in
1849 there were 12,508 young persons under seventeen years of
age under detention in gaols. In order to enlighten the public
mind and to obtain legislative powers, an organisation was
brought into existence as the results of two conferences held at
Birmingham in 1851 and 1853, when “such an impetus was
given to the whole question that this period has ever since
been looked upon as forming an epoch in the progress of
reformatory science.” ( 21 ) The result of the first conference was
that a committee of the House of Commons was appointed in

1852 to take the whole matter into consideration, and after
having sat during two sessions of Parliament, they presented in

1853 a report in which the reformatory system was strongly
advocated. The conclusions arrived at received great support
from the second conference, held at Birmingham, in December,
1853, at which there were many influential speakers, who
supported the doctrine that reformatory treatment of criminals
ought to be substituted for retributive punishment. The public
mind and the Government were so much impressed by these
meetings that in 1854 this principle, so far as it applies to the
young, was embodied in the Youthful Offenders Act. This
Act was amended in 1854, 1855, 1856, and 1857, and all
were consolidated in the Act of 1866.

This act established some new and important principles, and
the main lines on which the original Act and its subsequent
amendments proceeded are similar to those which have been
followed in America, France, and other countries. These are
“ the detention of the offender for a long period of correction
and industrial training, the introduction of the family system
and domestic feelings and habits into the schools, and the
keeping the offender under supervision after leaving the school
by placing him out in employment, on probation, under

Digitized by VjOOQle

1900 .] BY FLETCHER BEACH, M.B. 649

license, previous to his final discharge/’ (* 2 ) By the introduc¬
tion of the first of these principles remedial was substituted for
punitive punishment of children, it being recognised that their
moral responsibility differed from that of adults, and thus
judges and magistrates were enabled to send youthful offenders
to reformatory schools established by voluntary contributions,
where they were detained for instruction and training for a
term not exceeding five years. Though these schools are
assisted and superintended by the State, they are conducted
by voluntary management, and have thus retained an inde¬
pendent, partially charitable character. Another important
principle was the entrusting of these outcasts of society, with a
view to their being able again to take their place as members
of the public community, to the benevolence of earnest people
who were willing to assume the charge. The aim of this
principle was to make an entire change in the character of the
offender, and to develop habits and conduct which could not
flourish under the rigour of life in prison. Four distinct
advantages have been obtained by the adoption of these
principles ; first, the inmates of these schools have obtained
opportunities of employment, and openings for gaining a liveli¬
hood on their discharge from detention, which no establish¬
ment under official management could have given them ; and
secondly, private individuals have become interested in these
children, who have been allowed to enter life without any
drawback from the character of the place from which they
have come. Thirdly, the offender was committed to prison
for a short period previous to his corrective training and de¬
tention in the reformatory school. This was thought to be
necessary, in order that the public community should not feel
that vicious and mischievous children were rewarded and placed
in a better position than children of respectable and honest
parents. Fourthly, the criminal or neglectful parent was com¬
pelled to pay something towards the reformation of his child.
The effect of this law has been to stimulate parents to perform
their duties, and to diminish the number of young criminals.
There is no doubt that the diminution of juvenile delinquents
has been accomplished ; for in 1856 no less than 13,981 chil¬
dren under seventeen years of age were committed to prison,
while in 1866 the number was reduced to 9356, in 1876 to
7138, and in 1893 to 2924. This Act of 1866 is still law,

Digitized by VjOOQle

PRESIDENTIAL ADDRESS,

[Oct.,

650

but a few changes were made by Lord Leigh's Act of 1893,
as a result of which preliminary imprisonment was no longer
obligatory; the minimum age for admission to reformatories
was raised to twelve, unless the child had been previously con¬
victed ; the limit of age up to which an inmate may be de¬
tained was reduced from twenty-one to nineteen ; and three
years, instead of five years, was prescribed as the minimum
period of detention to be fixed by the sentence. In 1896
there were fifty reformatory schools, all under voluntary man¬
agement, containing 4800 inmates, generally between thirteen
and nineteen years of age, and no child was admitted except
on conviction and sentence.

The Reformatory Schools were not the only result of the
Birmingham conference, and the parliamentary inquiry. The
Ragged School Movement had begun some years before, and
in Scotland schools for disorderly and vagrant children who
were outside the criminal class were established in most of the
large towns ; but in 1854, the same year as the Reformatory
Schools Acts was enacted, the first Industrial Schools Act was
passed and applied to Scotland exclusively. Amendments
were made in 1855 and 1856, and in 1861 these acts were
repealed and a consolidating statute was passed, by which not
only mendicant and destitute children were admissible, but
children under twelve charged with an offence, and refractory
children under fourteen. The parent was bound to pay for his
child, and if he was unable to do so, the expense was to be
recovered from the parochial board of the parish to which the
child was chargeable. Meanwhile, in 1857, the Industrial
Schools (England) Act was passed. Under this Act the chil¬
dren admitted were to be above seven, and under fourteen, at
the date of their detention, and they could not be detained
above the age of fifteen. In all cases conviction of vagrancy
was the first step, and power was given to the justices to dis¬
charge the child to the parents or managers, if they were satis¬
fied that employment was to be provided for him, or that due
security was given for his good behaviour. The parent was
made liable for the support of his child, but no liability was
imposed on the guardians ; they were, however, empowered
to contract with the managers for the education of any pauper
child. In i860 this Act was amended, and in 1861 (the
same year in which the consolidating Act as to Scotch Indus-

Digitized by VjOOQle

1900.] BY FLETCHER BEACH, M.B. 651

trial Schools was passed) these Acts were repealed by a con¬
solidating enactment. The two chief changes were that power
was given to the Treasury to contribute towards the mainten¬
ance of the children, and that the contribution of parents might
be as much as five shillings per week, and if the child was
refractory they were required to pay the full expense. Con¬
viction was not rendered necessary, and besides destitute and
mendicant children, those who were charged with an offence,
and refractory children, were admissible. In 1866 the English
and Scotch Acts were consolidated by an Act which is still in
force, and by it the industrial schools of both countries are
placed on the same footing. According to this Act children
cannot be sent to an Industrial School, if they have been pre¬
viously convicted in England of felony, or in Scotland of theft;
and power was given to send refractory children from work-
houses and pauper schools. In 1880 the scope of industrial
schools was much enlarged, and authority was given to send
to the school any child under fourteen years of age, who was
found to be lodging or residing with common prostitutes, or
who was frequently in the company of prostitutes. There are
now 141 industrial schools, all but sixteen of which are under
voluntary management, and they accommodate between 17,000
and 18,000 children between the ages of six and sixteen.
The children are not admitted on conviction.

In some cases, and especially in the case of first offenders,
a child who is guilty of larceny, of obtaining money under
false pretences, and of setting fire maliciously to a wood,
heath, etc., may, with his consent, be dealt with under the
Summary Jurisdiction Act, 1899. This Act is an amend¬
ment of the Summary Jurisdiction Act of 1879, an d includes
certain offences not mentioned in that Act. The punishment
is the same however ; the court may, either in addition to, or
instead of, any other punishment, cause the child to be privately
birched by a constable. This is a good arrangement, for the
child is punished as a consequence of his act, but at the same
time is kept out of prison.

Want of time prevents me from giving you an account of
the Certified Day Industrial Schools and Truant Schools in
England, and of the treatment of Juvenile delinquents in
foreign countries, including the Continent of Europe, the United
States of America, Japan, and the Colonies of Australasia,

Digitized by VjOOQle

652

PRESIDENTIAL ADDRESS.

[Oct.,

Canada, and the Cape; but in each country arrangements have
been made to remove children from prison, and to place them
in colonies, reformatory or industrial schools. Public opinion
has decided, and rightly so, that children should not be
treated in the same way as adult criminals who prefer a life
of crime to that of honest labour.

Dr. Conolly Norman : I rise to propose a vote of thanks
to our President for his admirable address. The subject is one
of very great interest to all of us. The kindly treatment and
care, the improvement and education of the feeble-minded class,
is one of the most benevolent works to which humanity can
devote itself. These unfortunate persons, to whom mother
Nature is only as it were a step-mother, are deserving of our
very particular sympathy and care, and it is a great honour and
credit to our profession that so much has been done by
physicians for a class who used to be considered, so lately as
sixty years ago, hopeless outcasts.

Dr. Mickle : It gives me much pleasure to second the vote
of thanks proposed by Dr. Conolly Norman. Our President
has been so intimately associated with the treatment and care
of persons of feeble mind, that there are few, if any, better able
to lay down with accuracy and authority the history of the
subject, in which he has taken a large part, for much of it has
occurred in his own time. I was particularly interested in the
latter part of the address, where the young criminal was spoken
of, and from a public point of view that is extremely important.
Criminals to a large extent are, as a rule, a feeble-minded race.
At all events, although many of them may be clever in some
particular direction, still they are in my opinion specimens of
deterioration. The importance of dealing with the criminal
young is a matter which will be urged upon the public
authorities. In fact, to deal successfully with your criminal,
you must catch him young and keep control over him, other¬
wise he will give rise to much trouble. The whole subject of
criminality is so intimately interwoven with that of feeble¬
mindedness that I was extremely glad to hear our President
dwell upon it.

The vote was passed with hearty applause, and Dr. Beach
in acknowledgment said—

I am exceedingly indebted to you for the kind manner in

Digitized by VjOOQle

1900.] INEBRIETY, ITS CAUSES AND CURE.

653

which you have received my address, and especially for the
kind words which have fallen from my two friends. I thank
you very heartily.

Since the delivery of this address, I have been informed that
a third institution for idiots has been erected in Scotland, and
besides the colonies for sane epileptics which I have mentioned
there are two small institutions for them in England which
have been recently opened.

( l ) For the information I have been able to give regarding the lives of these
distinguished men I am indebted to the Journal of Mental Science. — (*) Resumt
de ce que nous avons fait pendant quatorze mois, Esquirol et Seguin, 1838.—
( 3 ) Rapport sur VAssistance des enfants, idiots, et degintrls, par Bourneville,
Lyons, 1894.—( 4 ) In memory of Edouard Seguin, M.D., being remarks made by
some of his friends at the lay funeral service held October 31st, 1880.— (*) Ex -
tracts from the First Report of the Institution on the Abend berg, near Interlachen,
Switzerland, for the Cure of Cretins, by Dr. Guggenbuhl, translated by W. Twining,
M.D., 1845.—(*) For the information here given, and for that which follows as
regards the provision made in Europe for this defective class, I am indebted to the
report published by Bourneville in the Assistance, Traitement, et Education des
Enfants, Idiots, et Deg&itres, 1895.—( 7 ) Brit. Med.Journ., August 18th, 1888.—
(*) Report of the Royal Commission on the Blind, the Deaf and Dumb , etc., of the
United Kingdom, 1889.—( 9 ) The Feeble-minded Child and Adult, London: Swan,
Sonnenschein & Co., 1893.—( 10 ) Ibid. —( u ) Prospectus of the Childhood Society. —
( 1S ) Report of the Departmental Committee of Defective and Epileptic Children,
London: Eyre and Spottiswoode, 1898.—( ia ) Mentally-Deficient Children; their
treatment and training, by G. E. Shuttleworth, B.A., M.D., 2nd edit., London :
H. K. Lewis, 1901.—( 14 ) Article by Lombroso, published in the second number of
the Kinderfehlen for 1896; quoted in the Journal of Psycho-Asthenics for
December, 1897.—( 15 ) Journal of Psycho-Asthenics for June, 1899.—( 16 ) Inter¬
colonial Medical Journal, February 20th, 1900.—( 17 ) Journal of Psycho-Asthenics
for March, 1899.—( 18 ) Treatment of Imbeciles and Epileptics, by Dr. I. M. Rhodes,
C.C., and Alderman McDougall, J.P., Manchester, 1897.—( 19 ) Leaflet issued by
the National Society for the Employment of Epileptics.—(") “ Reformatory
Enterprise: its Pioneers and Principles,” a paper read by William Morgan at the
Fourth Conference of the National Association of Certified and Industrial Schools,
held in London, in 1888, and published in a Report of the Congress.—( M ) Ibid.—
(**) Report to the Secretary of State for the Home Department of the Departmental
Committee on Reformatory and Industrial Schools, vol. i, 1896.

Inebriety , its Causes and Cure . By William Wynn
Westcott, Her Majesty's Coroner for North-East London,
M.B.Lond., D.P.H. ; President of the Society for the
Study of Inebriety.

We are all prepared to grant that alcohol is a poison in a
general sense, and that any use of it for the pleasurable
sensations it produces may lead to discomfort, to folly and to

Digitized by

Google

654

INEBRIETY, ITS CAUSES AND CURE,

[Oct.,

disease, and yet the majority of our adults persist in its
habitual use, and readily take the risks of future suffering for
the sake of present daily enjoyment.

The total abstainer, with whom alone is absolute safety, is
still a member of a minority in this country ; he rejoices in his
safety from the evils of alcoholic poisoning, and is generally
somewhat self-assertive and jubilant on the subject. It is to
me still a moot point whether his self-contentment is an
enticement to the ordinary drinker to follow in his path. His
self-sufficiency is apt to ruffle the feelings of the common man,
rather than to convert him.

On the other hand, I am not prepared to say that the truly
moderate drinker succeeds in transforming many inebriates
into sober members of society.

Habits of drinking on social grounds are so interwoven with
our national life that a man needs much determination to
separate himself from his fellows, and so to forfeit many social
amenities, only to avoid what may seem a small risk of being
seduced into intemperate habits. A man can look around him
and see crowds of his fellows who have not fallen under the
seduction of intemperance, although they have joined in the
common festivities of life. Yet he knows in his inmost heart
that some of his ancestors, and some of his friends as high-
minded as himself have fallen, and have wrecked themselves
and their families to satisfy their craving for alcoholic indul¬
gence.

What are the true reasons why inebriety exists, and is
common among us ? Are the causes capable of being removed ?
and is an inebriate a patient who can be cured ? Such are the
considerations which are referred to in this essay, which is
offered to members who cannot but be familiar with the results
of alcoholic intemperance in the origin of insanity.

In 1838 Father Mathew’s crusade against excessive whisky
drinking among the Irish caused a universal awakening of the
public conscience, and from that date onward Teetotalism
became a bye-word, and Total Abstinence.a public virtue.
National and local societies designed to make our people
abstainers have obtained much success. Even yet, however,
there is a terrible amount of drunkenness constantly before
our notice.

Digitized by VjOOQle

i goo.]

BY WILLIAM WYNN WESTCOTT, M.B.

655

Temperance reformers, largely successful in their efforts,
turned their attention to medical treatment, and declared that
all disease could be equally well cured without alcoholic
preparations, and a few eminent physicians have subscribed to
this opinion.

These reformers then called public attention to the assertion
that, beyond the needlessness of alcohol as a medicine, there
was a further mischief done by doctors, in advising the use of
alcoholic drinks as means of hastening recovery from illness,
and thus creating many inebriates. The medical profession as
a whole repelled the assertion, and Dr. Norman Kerr denied
the prevalence of the evil, and stated that the charge was
exaggerated, and in his large experience only accountable for
one half per cent, among 4000 recorded cases.

The existence of inebriety is a factor of such immense
importance to life assurance companies that it is possibly of
even more notable value than a discovery of hereditary ten¬
dencies to gout or tuberculosis. Sir Dyce Duckworth has
lately drawn special notice to this question. Sir Andrew Clark
also, by thorough investigation into candidates usual drinking
habits, showed that many “ moderate drinkers ” had to confess
to morning, afternoon, dinner, and evening tippling, which,
represented in total quantities, fairly astonished them.

Causation .—Inebriety shows itself in many forms, and is
perhaps as varied in its manifestations as insanity itself: these
forms are partly related to the causation and partly to the age,
sex, and nature of the sufferer. Inebriety is, no doubt, often
an hereditary failing ; yet it seems in some cases to be entirely
a personal acquirement. We all know some drunkards in
whose family history there is no record of intemperance, and
their ancestors may have all been sober men and women. We
must, however, remember that drinking habits are often con¬
cealed, and that two or three generations back total abstainers
were few in number, and that general social opinion did not
concern itself with the drinking of individuals, except in the
way of joke, or in the way of pride at a man’s drinking
powers. These considerations will, I think, tend to make us
favour an hereditary causation, rather than postulate an evil
acquirement in the individual. That an hereditary predisposi¬
tion to the drink crave is common few doctors will deny, and
that it passes on through many generations is accepted.
xlvi. 45

Digitized by VjOOQle

656 INEBRIETY, ITS CAUSES AND CURE, [Oct.,

Medical opinion is, however, now hopelessly divided over the
question whether an “ acquired inebriety ” can be transmitted
from father to son, any more than other somatic acquirements
which we never see transmitted, We all have seen drunken
parents have drunken children, but the question arises whether
the inebriety of the child was due to the father’s giving way
to drink, or to his inherited tendency to do so.

If a sober man has three children, and they are healthy,
and then he becomes a chronic drunkard,—are the children
subsequently bom more likely to become drunkards than the
first three children ?—no hereditary tendency to drink being
present in the father.

Teetotalers almost invariably say “ yes,” and warn every
one that his drinking habit will be reproduced in his children.
We may note here one peculiar source of inebriety, some wives
during a pregnancy by a very drunken husband are affected by
the drink crave throughout their pregnancy.

Biologists say that no acquirement has been shown to have
been inherited, and that there is no proof whatever that an
acquired inebriety is reproduced in the children, although this
is often surmised. The biologists are prepared to grant that
intemperate habits enfeeble the parent, and may in some way
produce a germ which, when fecundated, may grow up into
an individual who is feeble and imperfect; but they deny that
there is any proof that the special peculiarity of the “ drink
crave? when parentally acquired\ can be so transmitted by a
sperm or germ cell. Again, if a man has an hereditary
tendency to drink and does drink to excess, and does have
children, have they the father’s hereditary tendency plus an
added increment from the father’s excesses ? Dr. Archibald
Reid urges that if this were so, each generation getting more
and more drunken, the race should be poisoned and die out
by alcohol early and surely; but it is the men of races who
have had no previous experience of alcohol who die most
certainly and rapidly of alcoholic poisoning, while races like
the Italian and the Spanish, who have had access to alcoholic
drink for a thousand years, are much more sober, and have a
low alcoholic death rate. Dr. Reid’s contention is that it is
in vain to argue that because alcohol is almost constantly cir¬
culating through a certain person’s body—the totality of
somatic cells—therefore, the single sperm or germ cell which

Digitized by VjOOQle

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

657

chances to produce a new being must develop into a man or
woman with a special drink craving ; and that no proof of
this has ever been adduced.

Race is a factor in the proportion of inebriety, because
it involves the question of how long alcohol has been in free
use among the people ; for history leads us to recognise that
the excessive indulgence in alcohol is in inverse proportion
to the ancestral experience ; prolonged use and abuse of
alcohol tends to eliminate the alcoholic diathesis of drink
craving, and tends to render a race more and more sober.

“ Nearly all races which have had no experience of strong
alcoholic drinks are excessively drunken when introduced to
them—so drunken that, given the opportunity, they drink to
extinction ” (A. Reid).

So there is an evolution of sobriety.

The question of climate is nearly related to that of
race, and need not be separately considered here, except as
regards the effect of a change of climate upon a traveller or
colonist.

The man accustomed to a temperate climate, on being
removed to the tropics, suffers much from heat and thirst,
and if he drinks largely of alcohol he rapidly suffers from
liver disease, and early death follows ; yet each debauch of
drink produces less obvious appearance of drunkenness, because
the alcohol is more quickly evaporated and excreted.

In the arctic regions, on the contrary, alcoholic excess causes
a rapid onset of drunkenness, and an exposure to the open
air when drunk is very fatal; yet internal organic alcoholic
disease is not very notable. This effect of cold can be seen,
in a modified form, in our English winters when frosty, for
a man may drink heavily in a hot room, and leave it with
the appearance only of jollity ; but let him essay to walk
home in the frosty night air, and before many minutes are
over he will be staggering and helpless.

Dr. Norman Kerr said that southern warm climates do not
show so much chronic inebriety or so many dipsomaniacs as
cold northern lands, yet temperate Italians emigrating to
London often become drunkards.

Another consideration occurs here, that each climate pro¬
duces its own form of drink, and that the special drink of the
country does much less harm to the native, and even to the

Digitized by VjOOQle

65 8 INEBRIETY, ITS CAUSES AND CURE, [Oct.,

visitor, than does imported wine or spirit—for example, many
a Londoner has found he can drink freely of Scotch whisky
when visiting Scottish highlands, but that the same quantity
makes him ill at home.

Then comes the question of adulteration. It is certain
that very much disease and inebriety are caused by impurities
in cheap and common drinks, the adulterations being more
poisonous than the alcohol itself. This is especially true of
fusel oil and derivatives of amylic alcohol, and of acetone
from the methylic series.

When the source of the alcoholic drink is from grapes, the
alcohol is purer than from other sources—from corn is next
best ; very offensive impurities may arise from unskilled
manufacture of alcohol from beetroot ; and potatoes produce
the most dangerous forms of distilled liquor, which require
excessive purification.

There are in this country many inebriates who consume
methylated spirit from choice or for its cheapness, and there
are, as is well known, many ether drinkers, especially in
Ireland.

The environments of work and social life have much in¬
fluence in the causation of inebriety, both from a physical
and a moral point of view. Many occupations have a great
tendency to make men drink, and so foster inebriety, such
as those involving exposure to great heat and great changes
of temperature, as is seen among gas stokers and iron
founders ; those exposing the workers to much dust, as grind¬
ing works ; those carried on late at night in low, gas-lit badly-
ventilated rooms, as compositors; occupations also which call
for heavy work with intervals of idleness, as occurs among
dock labourers. Exposure to inclement weather, with occa¬
sional periods of no occupation, makes cabmen tend to become
drunkards.

On the other hand, there is much protection against the
risk of becoming an inebriate if a man be a cleric or a lawyer,
and many men with an inherited tendency to inebriety have
been saved by such professions.

The fear of disgrace is a very powerful deterrent from
drunkenness.

This last consideration is a great safeguard for all women,
who know that men have generally considered them more

Digitized by VjOOQle

1900.] BY WILLIAM WYNN WESTCOTT, M.B. 659

moral than themselves, and they shrink from the disgrace of
equalling man in his vices.

When, however, a woman has at last become a drunkard, she
tends to become utterly lost to all sense of propriety, and falls
lower than the average man does.

Motherhood, implying an urgent need for constant watch¬
fulness over children, is a great protector of womankind from
inebriety; and in my experience the majority of female
drunkards who kill themselves by excesses, or by suicide after
inebriety, are childless wives.

As to the general influence of Sex , the Retreats of America
show a proportion of patients of five males to one female. In
England there are certainly many more homes for female
inebriates than for males, but the male inebriates are vastly
more numerous than the female. Female inebriety, unfor¬
tunately, is certainly on the increase in this country.

It is alleged, and with much truth, that the introduction of
the grocer's licence to sell wines and spirits by the single
bottle has been a chief factor in encouraging women, and
especially well-to-do ladies, in habits of secret drinking.
Among the rich it used to be a difficulty for ladies to buy
wines and spirits by the cask or the dozen for private consump¬
tion.

In regard to Age , the largest number of serious cases of
inebriety occurs between the ages of 30 and 40 years.

In the matter of Religion , Dr. Norman Kerr arrived at
the conclusion that drunkenness was increasing at a greater
rate among Roman Catholics than among Protestants, and
especially among the women, and he adds that the sobriety
of Jews puts to open shame the habits of Christians.

Inebriety as a disease is indebted to the cultivated classes
for a large proportion of its subjects. As to Smoking , the
glass precedes the cigar quite as often as the cigar leads to
drinking ; neither, he thinks, has any appreciable effect upon
the other, as regards immoderate use.

Companionship and the standard of family life are most
potent factors in deciding the future of an individual who has
an inborn tendency to drunkenness.

Incidents and accidents of life are commonly called exciting
causes of inebriety. One man will take to drinking on his

Digitized by VjOOQle

66o

INEBRIETY, ITS CAUSES AND CURE,

[Oct.,.

marriage, from a fancied strain on his nervous system, another
will drink because he is disappointed in love. One man will
drink more and more as his financial position becomes easier,
another will take to drink when he fails in business.

A shock, mental or physical, to the nervous system is a
cause which frequently starts a man or woman on a course of
excessive drinking.

People cannot be made temperate by argument alone, but
by education and by legal pressure. Our principal object
must be the consideration of the best modes of regulations
limiting opportunities of free drinking. We must teach the
cultivation of habits of personal cleanly life. Judging by
analogy, the moderate drinker cannot be exterminated. Let
us devote our energies to the restraint of the moderate
drinker within limits to be defined by the medical profession,
and to the absolute cure of those who have passed the border¬
land, and are ruining their lives and the lives of those depen¬
dent upon them. These must be deprived of their personal
liberty until they have survived the craving which ruins them'
body and soul.

Treatment .—The medical treatment of inebriety can hardly
be carried out with success unless the patient be under control*
Two considerations present themselves : Firstly , the relief of
the acute effects of alcoholic excess; how to relieve the
dyspepsia and the debility due to chronic excess ; and how to
check the progress of organic alcoholic disease. Secondly , is
there any medical treatment, if any, which can control the drink
craving, the disordered mind, the sleeplessness, the state of
humiliation, and the tendency to repetition of debauches. The
physician has a large pharmacopoeia of drugs suitable to re¬
lieve disorders of the first class.

The serious problem is, what remedies are there that have
power over the second class ? Is there, indeed, any remedy,
other than seclusion and absolute prohibition from alcohol ?

The advertising quack generally professes to cure the dis¬
orders of class two, by the remedies for class one, as will be
referred to later on. The first practical point for decision is
that of the stoppage of the supply of alcohol ; shall it be
done at once, and entirely ? or shall the amount be gradually
decreased ? It has been widely contended that as the heart is

Digitized by VjOOQle

1900.] BY WILLIAM WYNN WESTCOTT, M.B. 66 1

weakened by alcoholic excess, and is often rendered fatty by it,
there must be a risk of a fatal syncope if it be suddenly with¬
drawn ; and no doubt many patients have died after the stop¬
page of alcohol in delirium tremens.

On the other hand, it has been argued that the person is ill
and dying of a poison gradually administered, so that no further
dose of the poison can possibly be allowed. From my own
observation I am inclined to say, stop the whole of the alcohol
at once, as a rule ; but a few cases of cardiac weakness may be
saved from immediately fatal syncope by one or more small
doses of wine or brandy, before the entire cessation of alcohol.

Hot baths should be used as soon as possible. Calomel
with saline purgatives seems to hasten the excretion of waste
products which have accumulated in the system.

Bromide of sodium in drachm doses is probably the safest
remedy for the insomnia, but it is not a powerful remedy.
Chloral often succeeds, but it may cause fatal syncope, although
I have never met with that unfortunate experience. Formerly
opium, and then morphine were prescribed ; but of late years it
has been objected that they tend to constipate and check ex¬
cretion. Chloralamide, paraldehyde, hyoscyamine, and hyos-
cine are more powerful sedatives, and have what has been called
a power of chemical restraint. Sulphonal may certainly be used
in many cases with advantage. Da Costa has obtained valu¬
able results from cocaine, in doses of iV of a grain, given by the
stomach ; calming its irritability, and soothing the nervous
system towards sleep.

It is to be observed that there is a possibility of a drunkard
falling a victim to the sedative which has thus been prescribed.

The stage following on the acute symptoms is that most
commonly treated by quack remedies chosen from the prescrip¬
tions of the physician.

The effects of drugs in this stage are largely dependent upon
the integrity of the vital organs, for if there be serious degenera¬
tion of vital organs, very little improvement can be anticipated.
In this stage the use of strychnine is universally recommended.
It improves the state of the nervous system, gives tone to the
muscles, improves the appetite, and relieves the tendency to
feel the stomachal craving for drink, which is distinct from the
mental craving.

In many cases the preparations of iron do good. There is a

Digitized by VjOOQle

662 INEBRIETY, ITS CAUSES AND CUR^, [Oct.,

tendency to prefer the Galenical preparations of cinchona to
quinine. During a course of tonic treatment it is advisable to
change the drugs frequently ; phosphorus and arsenic and the
mineral acids may thus be alternately given with those above
named. Other drugs have gained a reputation in curing ine¬
briety, such as atropine, the salts of manganese, and the chloride
of gold and sodium. As to the last remedy, it should be noted
that an irritating red rash often occurs more or less all over the
body, and a diminished dose must then be administered.

The tincture of hydrastis is considered as almost a specific by
many physicians in Canada. Dr. Mac Nutt of California re¬
commends the mixed tinctures of hyoscyamus and cinchona.
Preparations of capsicum certainly relieve the stomachal craving
which is so irritating and tedious in many patients. Digitalis
is in frequent use, seeming to slow and strengthen the action of
the poisoned and weakened heart.

Tartrate of antimony, recommended by many American
physicians, on the ground that it produced a distaste for
whisky, is a doubtful remedy, for it creates, pari passu , a dis¬
like for food and wholesome drinks. Dr. Crothers, of Hartford,
has had similar results with apomorphia.

A series of hot baths, or, better still, the use of Turkish or
Russian baths, are extremely valuable remedies. Massage
encourages a free blood-circulation through the muscles, and
does much to assist excretion, and is therefore appropriately used
with baths.

The use of electricity, constant and induced, hastens the pro¬
cesses of repair in nerve and muscle, and so to a greater and
general bodily energy.

Whatever may be the medicinal treatment, it is not by medi¬
cines alone that we shall cure inebriates. Restraint combined
with exercise, fresh air, and hopeful, useful employment must
be added, and must be continued not for days or weeks, but for
months. The disuse of alcohol, however, often reveals disorders
previously masked by drunken habits, and diseases are certainly
often rapidly fatal under these conditions. Thus an unsuspected
rapid phthisis may occur; general neuritis is common ; and
forms of chronic rheumatism and gout come into painful notice.
Melancholia may gradually develop, and paralysis, especially of
spinal origin, frequently appears. Renal diseases come pro-

Digitized by VjOOQle

66 3

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

minently into notice, and soon lead to death. Dementia is
often found.

As has been indicated, the cure of inebriety has been con¬
stantly attempted by the advertising quack, notably in the
United States of America.

Speculators have introduced vaunted nostrums, and commer¬
cial companies have been formed for the cure of the drunkard.
Needless to say no real mode of cure has evolved from the
strife of these contending professors.

The so-called cures have been mostly culled from medical
remedies. Thus while strychnine, iron and the salts of gold
have been specified by physicians as promising drugs for certain
stages and forms of alcoholic poisoning, some quacks have chosen
these as unfailing remedies of the disorder as an entity.
Necessarily their methods have been failures. The salts of
gold have a small curative power in certain cases of alcoholism,
and this limited value has been exploited as universal.

The “ Dwight Cure ” was alleged to be gold in medicinal form ;
the “ Golden Specific,” according to Dr. Usher a preparation
of cinchona with a small percentage of tartar emetic ; the
“ Boston Drug” and the “ Fisk Gold Cure” are all more or
less familiar.

Lastly, there has been in France a resort to “ Anti-ethyline,”
as was noticed in the Journal of Mental Science in April, and in
Australia similar experiments of doubtful value.

The recent claims made for hypnotism are well known. Dr.
Milne Bramwell recommends hypnotic suggestion for dipso¬
maniacs—those who are not habitually drunken, but are subject
to crises. The bout of drinking passes off and leaves the
patient more or less ill. Recovery follows, characterised by a
period of sane conduct.

An hereditary neurotic predisposition may often be traced in
those persons who are the least susceptible of complete cure.

There are certain difficulties which restrict the frequency
with which this mode of relief can be applied. Hypnotism and
suggestion are very dangerous experiments unless their per¬
formance is restricted to the medical practitioner, and I do not
feel at all sure that he may not do more harm than good in an
unwitting manner.

Then, only comparatively few doctors can produce hypnosis
simply by reading a tract on the subject; and, again, only a

Digitized by VjOOQle

664 INEBRIETY, ITS CAUSES AND CURE, [Oct.,

certain percentage of patients can be hypnotised by anyone.
Dr. Milne Bramwell confesses that the art is useless unless the
patient himself wills to be cured.

The production of hypnosis is often a long and tedious pro¬
cess, and even if its use checked the drink crave, its value would
depend upon how long the control lasted, as such a process
could seldom be conveniently repeated at short intervals.

The hypnotic method has not yet had a full trial, and per¬
haps need not be condemned offhand, yet the assumed cures by
the process should be carefully watched for years to come.
Doubtless, like other means of cure, it may succeed in a few
cases, and will fail in many more ; but even if any dipsomaniacs
are cured by it that will be a distinct gain. It is still a moot
point whether the inebriate is more or less susceptible to
hypnotism ; on that account opinions differ, for some think that
the alcohol having enfeebled the will renders a patient more
prone to succumb to suggestion ; on the other hand, as the will
must consent to a successful, useful hypnosis, and as hypnosis
in its onset is much assisted by a determined calm concentra¬
tion of mind, so the weakened will and mind should be less
easily hypnotised.

I have known many non-medical observers in this field, and
have been informed of their successes, and of their many failures,
but I am entirely of opinion that the employment of hypnotism
upon any sick, or inebriate, or insane person should be restricted
to the duly qualified medical man.

I have known inebriates who shrank from cure for fear that
it would mean for them a continual desire for drink, combined
with the loss of power to take it.

Neither Tit-Bits nor the Society for the Study of Inebriety
in England has obtained any information of value in regard to
the drink cures vaunted by their owners.

It cannot be doubted that the present view of the medical
profession is incontrovertible. It may be stated thus :—That
the relief of the sufferer from alcoholic excess is a purely
medical question of medicinal treatment on ordinary therapeutic
lines, and that the tendency to inebriety can only be overcome
by a period of hygienic restraint in an institution regulated by
law and managed by medical men who have had experience in
the treatment of mental degeneracy and physical incapacity.

Total abstention from alcoholic liquors is the only safe pro-

Digitized by VjOOQle

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

665

cedure for the dipsomaniac and the inebriate, and for all those
who have shown any morbid, if even temporary, craving for
alcoholic excess. Yet for the ordinary man in good health, in
regular work, or with sufficient exercise, who has shown no
warning signs of inherited or acquired craving, there is much
reason for allowing him a moderate amount of alcoholic drink,
taken with the principal meals of the day. He should not look
upon this as a necessity, nor should the practice become so
habitual as to produce discomfort if the amount be omitted.
With moderation thus understood, an occasional glass on days
of public or private rejoicing will do no harm, nor would there
be any craving to make the glass into a debauch. It is the
man who is regularly drinking up to, if not above, the tolerable
quantity, who on festive occasions gets splendidly drunk, and
has to pay the necessary penalty of sickness and headache, even
if he be fortunate enough to avoid an apoplexy, an inflammation,
and an accident.

Let us now consider the question of the relief of the inebriate
by enforced abstinence , combined with seclusion in a home or
institute under medical care.

There have been for long asylums and homes of various kinds
to which an inebriate could voluntarily retire for treatment, but
until recent years there has been no legal means of compulsory
cure, unless a person of inebriate habits were also definitely
insane.

By the Habitual Drunkards Acts of 1879 an habitual
drunkard could be admitted to a retreat licensed by a local
authority, and placed under medical care, upon the statutory
declaration of two persons that he was an habitual drunkard ;
and on his own application, attested before two local justices,
he might be then detained for a period not exceeding twelve
months.

This Act was only to remain in force for ten years, and so
in 1888 an Act to amend the Habitual Drunkards Act of
1879 was passed, and it was ordered to remain in force until
varied by Parliament. This Act enabled the licensee of a
retreat to appoint a deputy, and ordered that any two justices
might act, instead of two justices having only local jurisdiction.

Lastly, in 1898, there was passed the Inebriates Act, a
second Amending Act, which came into force on January 1st,

Digitized by

Google

666 INEBRIETY, ITS CAUSES AND CURE, [Oct.,

1899. Section 1 provides that where any person is convicted
of an offence punishable by imprisonment or penal servitude,
and if the court is satisfied that drunkenness contributed to
the offence, and the offender admits that he is, or the jury find
that he is, an habitual drunkard, the court may order his
detention in a State, or a local licensed reformatory for any
period not exceeding three years.

Any offender who has been three times convicted within a
year may, on a fourth conviction, if he be an habitual
drunkard, be also detained three years in a reformatory, the
managers of which are willing to receive him. Section 3
authorises the Secretary of State to establish reformatories ;
and by Section 4 the Secretary of State may issue a certificate
or licence to any approved reformatory, established by any
county council, borough, or other persons.

By Section 16, the signature of one justice is required,
instead of the signatures of two justices, in the voluntary
seclusion of an habitual drunkard, and the period of time is
extended from twelve months to two years for his detention.

By many persons it is considered that still further legisla¬
tion is necessary, on the one hand for the confinement of the
wealthy drunkard, and on the other hand for the gratuitous
care of the poor inebriate. Possibly, also, an extension of the
meaning of the word " inebriate ” to include other forms of
drug intoxication, such as morphinism, would be advantageous.

This Act has been in force for a year and a half, but it
cannot be said that very great results have yet been achieved.
The Home Secretary declined to build a State reformatory for
the nation, or any part of it; he also declined to set aside any
special prison for the purpose.

The boroughs and county councils, fearing the original out¬
lay and subsequent expenses, have in many cases declined to
undertake the work, alleging that the foundation of such
reformatories is a national duty.

In many other cases councils are still conferring with neigh¬
bouring councils as to a joint establishment.

In still other cases boroughs and councils have made
arrangements with privately owned licensed houses to admit
inebriates from their districts. The home at Brentry, near
Bristol, has made arrangements with twenty-two local
authorities, borough, and county councils, to receive and treat

Digitized by

Google

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

667

both male and female cases. Lady Somerset’s Home at
Duxhurst, near Reigate, has also taken many cases of female
inebriates. St. Joseph’s Reformatory for Roman Catholics at
Ashford is well supplied with patients. Lancashire has
obtained a special Act of Parliament to create an Inebriates
Board representing twenty-five boroughs, in addition to the
County Council.

In all, four institutions for female inebriates, and one for
males, have been licensed under these Acts ; while two other
reformatories for men, and one for women, are expected to
receive certificates at an early date.

During the first year’s working of the new Act, only eighty-
two patients were received, five under Section 1, upon con¬
viction for an offence punishable by imprisonment or penal
servitude ; and seventy-two under Section 2, on a new con¬
viction, after three previous convictions within a year, of an
habitual drunkard. Of these London has supplied sixty-one
cases.

The London County Council has appointed a Special Com¬
mittee to deal with all matters relating to the Inebriates Act.
It has also made temporary arrangements with existing
institutions for the care of its inebriates. The Council has
also purchased a large estate of 364 acres at Chari wood, near
Horley, Surrey, and is in process of modifying some existing
buildings there to serve as a reformatory for the restraint and
treatment of additional cases, which are sure to be committed
from the judicial courts within the area of its control, for, of
course, the present sixty-one certified drunkards do not form
even a small proportion of the offenders who are also
habitual drunkards in London. This institution will be opened
in August of this year.

There may be delay, and there will be doubtless many diffi¬
culties to be surmounted before the County of London will
be fully supplied with all the desirable accommodation for
inebriates, but that the arrangements made will be well con¬
sidered and skilfully executed, under the guidance of the
present chairman of the Inebriates Committee, Dr. Job
Collins, no one who has long known that councillor can
have any doubt.

Inebriate reformatories may in the future well be of
various characters, some for the criminal, some for the mis-

Digitized by VjOOQle

668 INEBRIETY, ITS CAUSES AND CURE, [Oct,

demeanant, and others for the treatment of the sick inebriate,
and the semi-insane dipsomaniac.

It will be difficult also to combine under one roof suitable
treatment for rich and for poor sufferers.

In all cases we think the superintendent of the institu¬
tion should be a physician and not a civilian, and he should
be a doctor who has an enthusiasm for the work of curing
inebriety. He should be an abstainer, and so should all his
officers. The home should be in the country as far as possible
from towns, to avoid the risks of drinking by the straying
away of patients, and so as to provide ample agricultural and
gardening work. Regular and suitable labour, and regular but
varied amusements should be provided. The system of pre¬
serving good order by the bestowal of rewards is to be pre¬
ferred to that of punishment for errors. The culture of the
patients by a well-considered moral code will be a necessary
feature of the successful mode of cure.

The separation of the sexes will be necessary, but there
might well be two adjacent homes, one for each sex, by which
means the agricultural work of one might supplement the
laundry and clothing work of the other. Small dormitories
should be preferred to large wards. The mental and moral
standing of the nurses and attendants should be a matter of
careful selection. Lastly, these homes should be self-support¬
ing colonies devoted to self-improvement by means of pure air,
exercise, regular work, sufficient play, good food, and healthy
dwellings.

Placed under these conditions, the chronic drunkard may
soon regain health, and lay a basis for future good conduct.
The difficult cases will be those of patients who remain
reasonable for long periods, but who occasionally break out
into maniacal drink craving and violence ; such cases are to be
-controlled by drugs.

The members of the Medico-Psychological Association will,
I am sure, take a keen interest in the foundation, equipment,
and management of these coming reformatories, because they
are so fully aware of the importance of the treatment and cure
of the inebriate, and also because so many of them are
experienced in the practical working of asylums for the insane,
to which the new inebriate reformatories must have a close
relation in regulation and work.

Digitized by

Google

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

669

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

Dr. Beach. —1 am sure that you will agree with me in according a very hearty
vote of thanks to Dr. Wynn Westcott for the excellent and exhaustive way in
which he has treated this subject, in which we are all interested. At the British
Medical Association Meeting at Portsmouth last year, a resolution was passed and
referred to the Inebriates Legislation Committee. The result is that a Bill has
been drafted to provide not only for the well-to-do inebriate, but for inebriates
generally.

Dr. Forman (L.C.C.).—1 am sorry that I arrived rather late, and therefore did
not profit, as I otherwise should have done, by the very instructive paper that has
just been read. I came here to learn, and not to teach ; to pick up a few hints as
to how we were to manage our new Inebriate Reformatory. The subject has
interested me for a good many years while I was in private practice, and since I
have been a member of the London County Council I have been a member of the
Asylums’ Committee for more than ten years, and of sub-committees of various
asylums, and have been struck with the immense number of drunkards brought
under our notice. But the question has often occurred to me whether these
persons have been driven into the asylums by means of drink, whether drink has
made them mad or insanity led them to drink. It has seemed to me that, in a
large number of cases, the latter is the true explanation. As a Justice of the
Peace, I have been struck, during the last few days, with the very large number of
those who have drunk themselves into an insane condition through thirst caused
by the great heat. There is a large number of persons who, drink however much
they may, do not drink themselves into a condition of delirium tremens, in the
production of which a certain peculiarity of nervous system is necessary.
Drunkards, therefore, divide themselves into two big classes. There are diseases
caused by alcohol irrespective of mental influences. For instance we find cases of
cirrhosis, etc., in general hospitals, while in asylums we find drunkards who are
rarely affected with these maladies. I do not mean to say that there are no excep¬
tions, but that is, speaking generally, the fact. Therefore, although there may be but
few who are in a condition of irresponsibility solely through drink, there is some
antecedent factor which has caused them to be more susceptible to the influence
of alcohol than their more fortunate neighbours. Of course these cases are more
frequently met with in the female sex than in the male sex. These women fall
into the hands of the relieving officer, then go to the workhouse, and most fre¬
quently pass on to the asylum, while their husbands, brothers, and sons are able to
carry their liquor without becoming responsible before the law. If they do go to
the workhouse, the majority never pass on to the asylum. We remand them for
fourteen days, and, generally speaking, before that time is completed the men are
well enough to be discharged. It is not so with the sister or wife. The fourteen
days that the law allows are not sufficient for them, and they have to be sent on to
the asylum. It is then discovered that there is some nervous instability, either
epilepsy or hereditary insanity. I think that we may get rid of the phrase
“ hereditary tendency to drink,” by substituting for it a “ hereditary tendency to
nervous instability,” and regard these neuropaths, as Dr. Mott calls them, as sub¬
ject to an insanity that is unquestionably often brought on by alcohol. There are
cases, no doubt, that are often erroneously thought to be purely alcoholic. The
majority of these are cases of commencing general paralysis.

I pass on to cases of inebriety such as we now have to treat. I think that the
Council and London generally are very fortunate in having secured for the
committee so able a chairman as Dr. Collins. I happen to be the Vice-Chairman,
and we work together as amicably as two medical men should do in this great
work, which we hope to carry through with success. We have purchased a Targe
farm, a beautiful estate of 364 acres on which are two houses. These we are
fitting up in the best way we can. No doubt it would have been better if we
had pulled them down and rebuilt them, but there has been such a persistent
outcrv that we were doing nothing, when we have really been industrious, that
we thought it was on the whole better to secure what premises we could and
to adapt them as best we could. The London County Council has really done
more in this matter than any other county council. No county except Lancaster

Digitized by tjOOQle

670

INEBRIETY, ITS CAUSES AND CURE,

[Oct.,

has done so much to carry out the Inebriates Act. We have placed some of
these persons in Lady Henry Somerset’s Reformatory, and others at Ashford,
and if we found any male drunkards we should have accommodation for them.
It is extraordinary that there has been little call on the part of the male sex for
accommodation. It has been entirely females that have required to be dealt with.

We hope to be able to receive inebriates by the first week in August, and thus
to show London that we have not been so dilatory as has been stated. I am sorry
that a coroner in the Times of to-day has thought fit to censure the London
County Council on account of the accidental death of a lady who was an
habitual drunkard. Her husband said that his wife would not go into an inebriates
home, and before she could be placed there by the law she must have been con¬
victed three times in one year, but she was not in that position, indeed she had
never been convicted at all. The husband did the best he could for her, and this
misfortune has come to him without his having been able to prevent it. Certainly,
no blame could be attached to the London County Council.

We have tried to get information as to the best way of dealing with these
people on all sides. We have conferred with Mr. Paton, who is at the head of one
of the male inebriate reformatories. He seems to think very much, and so do I,
of the careful selection of attendants—of those he calls Christian brothers. We
have taken a leaf out of his book, and have secured an admirable matron, who has
been matron at St. Bartholomew’s and at Bath. We have temporarily appointed
one of the medical men residing in the neighbourhood, and are carefully watching
the working of the system, while deputing a good deal to the matron. Seeing that
the farm is some fifty miles distant from London, it goes without saying that we
shall have the advantage of abundant fresh air. There are some people who de¬
plore that there is no reformatory in the County of London, but we thought that
the farther it was out of London the better, and the site fixed is also a long way
from a public-house. We have been acting in concert with the Home Office, and
have had to put up bolts and bars, and walls, and so on, but we have done as
little of that as possible. We have sought to regard inebriety not so much as a
crime as a disease, and have thought that anything that made the place resemble
a gaol would be ineffective. On the other hand, these persons are sent to us by
the stipendiary magistrates, and there are certain things enforced by law that we
cannot escape. With Dr. Collins I have visited Duxhurst, Ashford Reformatory,
and Holloway Jail, and have gained information from all three places. From Dr.
Scott, of Holloway, we gained the information that there were very few, if any,
male inebriates. The number committed by the magistrates, according to him,
was almost nil. He also told us that the crimes of inebriates are of the most
trivial character, and such as would arise from the drink. He impressed me
greatly in stating that the great criminal never drinks. We hope to do these
people good by interesting them. We shall have the ordinary business of the
farm, and shall have to employ men accustomed to agricultural operations; but
in addition we propose to keep bees, to grow fruit, to make jam, to grow tomatoes,
to do anything possible to provide work such as these women are able to do,
and such as will be suggested by their ordinary occupations. In the case of the
London woman it is not likely that she will know much about floriculture, and
therefore we do not expect that she will be able to do much in the tending of
flowers, but it does seem an important point that we should find her something to
do. What is wanted is to raise her self-respect, to make her less ashamed of
herself, and that means that she must be kept there for a long time. My own
view is that Lady Henry Somerset’s successes may possibly turn out to be failures,
as time will show. We shall have to keep these inebriates longer than she does,
and may not meet with her remarkable results. So far as at present advised,
we shall not attempt any of those cures which have been alluded to by Dr.
Westcott. It has seemed to me, as a medical man of a good many years’ ex¬
perience, whether they are inside or outside a reformatory, a necessity to look
upon them as poor, weak creatures, and not to impose such tasks upon them as
they are unable to complete, however easy those tasks may seem to those in
good health. If a man says he must go to a particular customer and get an
order, but that he cannot face that customer before he has had a “ go of whisky,”
I think it obvious that he should be placed where facing a customer is not his
occupation, and where the “go of whisky” will not be required. At any rate, we

Digitized by VjOOQle

1900.] BY WILLIAM WYNN WESTCOTT, M.B.

671

shall be able to prevent their bringing into the world children with like proclivi¬
ties, and in that way, at least, good will be done. Dr. Collins and 1 , when we
visited gaols and inebriate institutions, have been struck by the fact that certain
of our asylum patients have been constantly brought under our notice. Jane
Cakebread, who had been more than 100 times in gaol, died in Claybury Asylum.
There is undoubtedly a close connection between what the law considers as a
criminal condition, and what we, as medical men, regard as the best means of
treating inebriety, namely, placing it under restraint.

Dr. Morton. — 1 can only express my agreement with what has fallen from Dr.
Forman. There has certainly been an impression in the temperance world
that the London County Council were not moving as fast as they might have
done in providing the machinery to deal with these cases, and it is very gratify¬
ing to hear that there are two such men as he and Dr. Collins charged with the
work. 1 have no doubt that in their hands it will prosper. There is a great deal
in what Dr. Forman says as to the connection between a predisposition to insanity,
and a predisposition to suffer from the effects of drink in the nervous system
rather than in the other organs of the body. We should all keep that very
steadily before us in our studies of inebriety.

Dr. Heywood Smith.—1 am in agreement with what Dr. Forman and Dr.
Morton have said. We ought to insist upon the Government passing a law for
the detention of all inebriates. It seems a thousand pities that, after all these
years, a person should have committed some criminal act before he can be treated.

Dr. James Stewart. —The general opinion among those experienced in this
subject is that it is utterly out of the question to expect any Government would
last for any length of time who banished from their mind the bugbear of the free¬
dom of the subject. That is the barrier in the way of any such legislation. I
think it is very important that we, as medical men, should be prepared to give
some answer as to the possibilities of a permanent cure, where treatment is
adopted of such a kind as may be at present undertaken. My answer is that no
permanent cure may be hoped for unless the patient is kept absolutely and
entirely free from the risks of alcohol for at least eighteen months. The cir¬
cumstances by which the patients are surrounded in homes where they cannot
get alcohol, are very different to the circumstances which surround such patients
when they go out, and six or seven months is not long enough. It requires
a period of at least five years to elapse from the time the patient leaves such a
home before one can say with any confidence that a cure has been effected.
I have found a number of cases restored, and able to fight the battle of life
after being under treatment, but they are invariably those who have remained
in homes for eighteen months. The larger number of permanent cures are
amongst ladies. They are generally regarded as absolutely incurable, but it so
happens that I have had a proportion of five ladies to eight gentlemen through¬
out my twenty-four years’ experience, and I can state that the proportion of cures
is something like twenty percent, greater amongst ladies than amongst gentlemen.
I account for that because the former can be more easily spared from home
duties, and therefore she remains longer under treatment. The Home Secretary
was quite within bounds when, in his circular letter, published in the Times in
January, 1899, he said that the consensus of medical opinion with regard to this
question was decidedly that a period of from eighteen months to two years was
absolutely necessary; because if for years and years a person has been diminish¬
ing his will power by taking alcohol, that period is a comparatively trifling length
of time to be under treatment. I have had under my care persons of consider¬
able position in the literary world, with marked powers of writing, etc., and yet at
the end of eighteen months have considered them perfectly unfit to go about the
world. It is not the case that the intellectual faculties are disturbed by the effect
of long-continued drinking to the extent that the public generally suppose. At
least 70 per cent, of those who came under treatment, at all events amongst the
educated classes, are those whose condition of inebriety, whose physical deteriora¬
tion, whose weakened condition of the will power, has been caused by their feeling
unequal to doing their work. They are born with a neurosis, are unable to do a
normal amount of work without a stimulant. We should be in the van of those
medical associations who are educating the public and the medical profession, to
understand that inebriates are, as a rule, more to be pitied than blamed. It has
XLVI. 46

Digitized by VjOOQle

67 2 INEBRIETY, ITS CAUSES AND CURE. [Oct.,

been stated to-day that successes are due to the attendants. I have had successes
because I have had no attendants.

Dr. Archdall Reid. — I have given a good deal of time to ascertain the effect
of drink, not upon the individual but upon the race. I think that a number of
medical men share the opinion that drunkenness in the child is due in great
degree to the drinking of the parent; that because the parent was a drunkard, the
child is more prone to drink than he or she would otherwise be. I think that
there is also another impression which most people hold, namely, that it is found
that the parents’ drinking so affects the subsequent offspring that they are more
feeble. Such an affection would come through the germ, and when a germ has
been affected, then the organism which springs from the germ shows certain
peculiarities, and the germs which spring from that second organism continue the
peculiarity; so that generation after generation would have the drink tendency
increased in the race, until at last the race became extinct. It has been found
necessary to forbid the use of opium in Burmah, and alcohol has been prohibited
in Australia. The temperance problem is by no means so simple as temperance
reformers ordinarily suppose. It is next to impossible that, with an increasing
craving for drink, we can combat intemperance; and therefore I think that tem¬
perance reform should include not only a scheme for saving the individual
drunkard, but also one which, by legislative or individual action, shall discourage
the procreation of children by him.

Dr. Briscoe said that the scandal of permitting inebriates to go about un¬
restrained at home was greater than the alleged hospital scandals in South Africa.
He instanced the case of a clergyman whom he had lately seen in a state of in¬
toxication at a railway station. On his appealing to the police, the officer said it
was not a case for him if there were no misbehaviour other than drunkenness.
Dr. Briscoe would have a detention room for the care of drunkards attached to
•every public-house, for his opinion was that a man when drunk was really
mad.

Dr. Clouston. —If there is a difficult position in which a medical man can be
placed, it is when the wife or the husband of a drunkard comes and states his or
her pitiable case, and asks what is to be done, and when your reply is that nothing
can be done. The law, as it at presents stands, allows every Englishman to drink
himself to death if he likes. There is no doubt that nine tenths of the medical
opinion of this country is absolutely solid for effective legislation in regard to
habitual drunkards. I consider that the Act of 1899 is one of the most futile
legislative efforts ever passed by the British Parliament. All that trouble had
been taken for the relief of a few absolutely incurable drunkards! It really pained
me to hear of the splendid efforts of the London County Council to benefit per¬
sons who are not worth doing anything of the kind for. If they are not going to
cure them, they are wasting money in purchasing that estate and fitting it as they
are doing. The Act applied to Scotland, and no medical man was appointed on
the Departmental Committee. The College of Physicians brought this business
under the notice of the Secretary of State for Scotland, and I was elected to serve.
We sat for a week, went down to Lady Henry Somerset’s Home, made many
rules, brought out a blue-book. The whole affair was an absolute waste of human
energy. The only exception I make is this, that if the county councils of London
and Lancashire set up their institutions for criminal inebriates, and if they make
•them successful, then I think we shall get our lawyers and politicians to rid them¬
selves of the monomania of fear and suspicion that at present possesses them, and
they will then perhaps consent to give us a Bill of real service to curable persons.
What do we care about women who have been convicted 100 times ? Why buy
an estate for those who are not worth it P What we want is an island where whisky
is unknown, where drunkards may be detained, where they will have plenty of
work, and adequate supervision. There is one other point to which I would
-direct the attention of this Association, namely, to the purely scientific aspect of
the study of inebriety, and in supplement to Dr. Westcott’s paper I would mention
the German studies at present going on in regard to the action of alcohol on the
brain cortex. The results are exceedingly striking. They appear to prove that in
regard to intellectual effort alcohol absolutely does harm ; inhibition is destroyed,
while the feeling of well-being is remarkably increased. Certain molecular changes
take place as a result of taking alcohol, and they are to a large extent permanent.

Digitized by VjOOQle

1900 .] PLANS OF A NEW ASYLUM FOR EAST SUSSEX. 673

It is well worth while to study the effects of alcohol on different kinds of brain.
I am quite sure that Dr. Reid is right in what he says as regards the preven¬
tion of drunkenness.

The Plans of a New Asylum for East Sussex. By H.
Hayes Newington, F.R.C.P. Edin.

When East Sussex determined a year or two back to build
an asylum for its sole use, a Visiting Committee, appointed
for the purpose, was fortunate enough to find in the centre of
the county a suitable estate which the County Council
purchased. It is situated at Hellingly, a village about nine
miles north of Eastbourne. The area is four hundred acres,
compact, as you will see on the plan, having within 400 yards
of its western boundary a railway station which we propose
to connect with the main asylum by a full gauge tramway. It
slopes gently upwards from the south towards the north, where
it attains its highest level of about 130 feet above the sea.
The subsoil is most favourable, being, with the exception of
two patches of clay, of a sandy or gravelly nature. The water
supply is adequate, and the general contour lends itself readily
to an efficient system of drainage, which will be bacterial. The
views are excellent, extending to the sea and the south downs.
It would be difficult to find a more suitable site for an asylum.
A sub-committee was authorised to travel about the country to
inspect other asylums, I being appointed its chairman. We
visited the Hartwood, Lenzie, Gartloch, Hawkhead, Cheddleton,
Bumtwood, Glamorgan, Dorchester, Isle of Wight, and Chi¬
chester Asylums. I extract from the full report which we
drew up on our return the following passage:

“We cannot refrain from expressing, also, the intense interest
and admiration that we felt in seeing the progressive steps
which have been taken, and are being taken, in the recognition
of the just claims of the insane poor to be treated in a reason¬
able and liberal manner. It has been especially interesting to
us to note the success with which each medical superintendent
has impressed his individual aims on the establishment under
his control, and how, even in the older asylums, by skilful and
kindly attention to the personal surroundings of patients,

Digitized by VjOOQle

674 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct,

comfort, often of a homely nature, has been attained to an
extent not to be exceeded in the newer. On some points of
structure and management we found wide divergence of
opinion; however, where we have found it impossible to
harmonise such differences, we have been content to follow
positive experiences rather than fears of failure.”

Our report being received, the services of Mr. Hine were
retained, and we were further commissioned to obtain plans
from him. The report being handed to him, the plans nqjv
before you are, after much consultation, the result, Mr. Hine
having truly and very skilfully reproduced our leading ideas.

The County Council has seen fit to adopt without hesitation
the plans as they left the committee, and the work is so far
forward that the foundations are in, while the tenders for the
superstructure will be before the Council next Tuesday.

Since the time when there were sufficient county asylums to
offer ground for comparison it has been a custom, which
continues to this day, to classify and label them according to
the various features they present It is a matter for satisfac¬
tion that our new asylum cannot be relegated to any particular
class. We claim, with one or two exceptions perhaps, no
particular novelty in ideas; but we can, I think, claim as novel
the arrangement of some ideas already in existence.

The leading principle has been to divide patients into two
groups, and to provide dissimilar accommodation for them.
The first group includes the dangerous, suicidal, and trouble¬
some chronic cases, who must be made safe at any cost; the
sick and infirm who need special care and nursing; and lastly,
the residuum, if I may so call it, of advanced mental mischief,
—that considerable mass of patients who cannot appreciate
anything more than warmth, good food, and adequate personal
attention. For all these we have provided a large main asylum.
The second group contains those whom more extended and more
segregated accommodation may justifiably be supposed to
benefit. To contain these two groups the asylum has been
planned for 1275 patients, but the accommodation now to be
built is for 111 5.

I will begin then with remarks on the main asylum, which
contains 840 beds. As you will see, it is of the strung-bow
design now commonly adopted. The main entrance, committee
rooms, office, and receiving-rooms are on the north side, thus

Digitized by VjOOQle

1900 .] BY H. HAYES NEWINGTON, F.R.C.P.ED.

675

allowing all the south aspect to be apportioned to the patients’
quarters. The latter are allotted to females on the east, and to
males on the west side. The two sides are similarly arranged,
the only difference being in point of accommodation, which is,
as usual, greater for the females. The first floor and ground
floor are also identical in arrangement. The only part in
which a second floor has been planned is that set apart for the
chronics. The dormitories for these patients are above their
own day-rooms and those of the epileptics.

The component wards of this building, though administra¬
tively detached, are structurally continuous, an arrangement
which in our opinion allows of greater ease and convenience in
working, and greater safety in case of fire, than are found where
the wards are separated buildings attached to the main corridor
by a pedicle. It is possible for a medical officer to travel
through the whole of the first floor without having recourse to
the stairs between the wards. The arrangement permits also
of the freest ventilation, and of all the many day-rooms only
one on each floor is without a direct south or west aspect.

As it is my intention, having regard to time, to describe
principles more than details, I will pass lightly over this
building.

The chronics of each sex are at the outside tips, next come
the epileptics, and after these are the troublesome, dangerous,
and suicidal cases, forty in each ward. I point out what we
consider to be a good arrangement here of the day-rooms,
which are three in number in each ward. The three together
form a right angle about a central lobby, and are separated
by glazed partitions. Thus both outside rooms can be com¬
manded from the central one, while the former do not overlook
each other. This should permit of convenient separation of
the cases where necessary.

Then we come to the wards for infirm patients, and inside
them, again, those for the sick. The latter are separated as
between the male and female sides by passages only. The
object of this arrangement is that thereby it will be possible to
work all the wards for sick and infirm of both sexes, containing
300 beds, as one large infirmary for the purposes of nursing
and supervision. It is the avowed intention to have this done
by female nurses under one responsible head, as far as circum¬
stances will permit. Such a head obviously will be a person

Digitized by VjOOQle

676 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct.,

with large experience of hospital nursing. We quite recognise
the fact that there are male cases which cannot or should not
be attended to by females, and our arrangements are such that
one quarter, one half, three quarters, or the whole of the male
beds can be left to male nursing. But on the supposition that
not more than a half or quarter will be thus cut away, we have
provided accommodation for married attendants.

Our views on this great question of the best form of nursing
for sick and infirm patients were thus expressed in our report:

“ It may be said at once that in advising that the whole of
the nursing in the infirmary should be doije by females, no
reflection on the capacity of male nurses is implied ; for we
know that the latter do their work admirably. We trust, how¬
ever, that in recommending the arrangements which are uni¬
versal in general hospitals, and are, indeed, partially admitted
into military hospitals, we are simply furthering the wishes
which would arise in each one of us in case of illness. Further,
we consider that the influence of the female nurse may in many
cases have good results in the control of language and habits.”

But whether in course of time our views are carried out or
not, we consider that this aggregation of feeble folk in the
sunniest portion of the building, with medical assistance close
at hand, and in close touch with the recreation hall, forms a
distinct feature in the general disposition of the accommoda¬
tion. In some instances the partitions between dormitories
and day-rooms are glazed, the Committee having been struck
with the appearance of light and cheerfulness which resulted
from this arrangement, as seen in Dr. Spence’s new infirmary
wards at Lichfield.

Two suitable rooms have been provided for pathological
work, in addition to the space to be found in the mortuary.

With regard to the administrative portions of the main
asylum I have but little to say beyond that they appear to be
convenient and economical. You will see that on each side we
have provided independent blocks for the attendants, to which
they can retire when their services are not required in the
wards. The tramway head is worth noticing. Here coals can
be delivered straight from the railway trucks. This is a matter
of importance to us, for we are but twenty-five miles from the
harbour of Newhaven, to which we are joined by the rails of
one company only. Thus we can purchase sea-borne coal by

Digitized by

Google

1900 .] BY H. HAYES NEWINGTON, F.R.C.P.ED.

677

the shipload, and have it conveyed direct into our sheds with¬
out further handling. Then, also, heavy goods can be delivered
into the yards on either side, while flour can be swung from the
truck by a crane into the store. Other goods can be trollied
into the main stores by an underground passage. Besides this,
a small passenger platform is provided opening into a main
corridor. Probably some sort of tramcar will be provided for
use between the station and the asylum, and, as suggested by
one of my colleagues to meet a point officially raised, it will be
serviceable for the conveyance of patients to the recreation hall
from the hospital, to be presently described.

Leaving now the main asylum, I point out the other
detached houses provided for the various types of patients which
compose the second group. Here is the separate house for
idiots, which follows with certain variations the general idea of
the excellent house at Fareham. I need hardly give the reasons
for separating these patients from adults. The accommodation
is provided for sixty, which is beyond our immediate wants,
but we are persuaded that we can fill it from other sources,
possibly receiving non-pauper patients of small means, for
whom there is such scanty accommodation in the country.
We have added accommodation for fifteen adult female
chronics, whose services will be required for ward cleaning ;
and it is to be hoped that we shall find some motherly bodies
in the asylum who will take an interest in the children, to their
own benefit. A schoolroom at first sight seems to be supereroga¬
tory, but one could see at Fareham that even if the children sat
at the desks with their books upside down they were learning
important lessons in sitting still and general discipline. Then
there are four villas, two for males, and two for females, each
having thirty beds. One will be set aside for the laundry
workers, and another for male patients working in the shops,
and possibly for some of those patients who do odd jobs about
the place as orderlies. These two villas will be supplied with
meals from the main kitchen in specially prepared trolleys, such
as we saw in effective use at Glamorgan. The other two villas
are for well-conducted females who can use the needle well,
and for farm patients respectively. Both of these will have
their own kitchens, materials being supplied from the stores.
The women’s house is supplied with a large sewing room, and
it is justifiable to believe that, if a sufficiently business-like air

Digitized by VjOOQle

678 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct,

is given to its conduct, much profitable work may be turned
out, not only for the asylum itself, but for other county
purposes.

The particular amount of accommodation in each villa was
decided by the view that it can be worked by two attendants,
or, as we expect, by one attendant and a tradesman, farm hand,
laundry woman, or sewing mistress, as the case may be. We
are encouraged in this hope by the experience of other asylums
where patients are supervised by members of the outside staff
without any regular attendant. Such an arrangement would
obviously be economical, and to the probable comfort of the
patients, although difficulty may be found in finding just the
right person for the duty.

We regard the following as some of the advantages of these
detached sections. More variety of food and more elasticity of
rtgitne can be allowed. These will make the houses more
comfortable and less institutional, thus affording an inducement
to patients to get to and remain in them. And such a system
does afford an opportunity of rewarding to some extent, by
small indulgencies of trifling cost, those who do work often of
considerable value for the asylum. Such a contrast in treat¬
ment between workers and drones is demanded by justice, if
not by business interests, and it can be carried out in the villas
to an extent which would be unattainable, or at least difficult,
in an asylum compressed into one building.

I may point out that the total accommodation, if and when
required, can be extended almost indefinitely by the erection
of further villas, without causing appreciable inconvenience to
the management of the asylum.

The chapel and medical superintendent’s house are detached
altogether. Without entering into the thorny question of this
treatment, we can say, at least with regard to the chapel, that
it is a relief to get rid of it in planning the main asylum. It
is difficult to work it in so as to do justice both to it and the
building to which it is attached.

The last and most important of the detached buildings is
the hospital for the treatment of cases which present any pros¬
pect of ultimate recovery. The idea of separating such cases
from the mass of incurable patients is by no means a new one.
When I had the honour of sitting where you now sit, Mr.
President, some eleven years ago, the hospital treatment of the

Digitized by VjOOQle

1900 .] BY H. HAYES NEWINGTON, F.R.C.P.ED.

679

insane was under warm discussion, and on it I founded my
official address. I sketched out what I ventured to term a
county hospital, much on the same lines as those which by
the most fortuitous of circumstances it has devolved on my
colleagues and myself to suggest and carry out. I then pointed
out that as far back as 1845 an Act was passed, sister to the
one which now forms the foundation of lunacy law. This
Act provided for special independent buildings for chronic
patients being erected, so as to leave the chief asylum more
free to exercise its curative functions. It was repealed in
1853, having never been acted on. Within the last few months
I have come across the following opinion, expressed before a
Select Committee which inquired into lunacy abuses in 1815.

Being asked to give his opinion of the plan of the Stafford
Asylum, then building, a witness roundly stated that he thought
it an extremely bad one. Asked why, he said, “ Because I
think there should be a discrimination between new cases, or
those who can be called curable, and those that are incurable ;
and it is my firm belief that a large public asylum in which
all descriptions of lunatics are admitted is a great deal more
calculated to prevent recovery than to promote it, under the
best regulations possible.” “ I think that the mind should be
entirely divested of the idea of incurable lunacy ; close con¬
finement is necessary and the company of incurable lunatics.”
“ I would recommend that the curative system should be
entirely separate from the system of keeping incurables ; I
think that nothing in the world can reconcile them together,”
etc.

This statement came from a layman ; eighty-five years ago
few but laymen had any experience in treating the insane.
But in spite of its source, and after making all allowances for
the great advance in treatment, can any one deny the exist¬
ence in this opinion of at least a germ of solid sound sense,
applicable to present circumstances ?

Again, some five or six years ago, when the question of
extending Hayward's Heath was under consideration, such an
institution was one of the recommendations which were made
by the Visiting Committee in a report drawn up for it by Dr.
Saunders.

When, therefore, our Committee set out on its travels the
idea was not unknown to it. I studiously forbore, however, to

Digitized by VjOOQle

680 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct.,

bring forward my personal, I may say expert, opinions, feeling
sure that an inspection of the admirable arrangements at Gart-
loch and Hawkhead would have a strong influence on my
colleagues. Thus it happened, and the foundation stone of our
project was a hospital for curable cases. But the idea is
carried out on different lines to those of the above or any other
asylum, and the building you now see before you is, I believe,
the first in this kingdom which is to be devoted solely to re¬
coverable patients. As you know, medical and administrative
convenience have suggested the combination of bodily and
mental sickness as at the above-named asylums, or, as found
elsewhere, the treatment of such a detached building as a general
reception-house, the hopeless cases being moved on after obser¬
vation has shown that there is no prospect of cure. But we
thought that the trouble and extra cost of such a detached
house should be incurred only for the curable, and that most of
the objects for which it has been proposed would be imperilled
by any mixture of chronic and acute patients.

The plans which are now before you show accommodation
for thirty-two male and forty-eight female patients, a total of
eighty beds. Apart from difference in numbers the general
disposition of the two wings is identical. The dormitories are
above, and the day-rooms on the ground floor. Each wing is-
divided into three sections, the outer being for the more excited
cases, the middle for patients of the quieter and depressed type,
while inside will be found the convalescent. You will see that
each of the two former sections have two day-rooms, while in
addition to the day-room space on the female side are three,
and on the male side two, single sitting-rooms, which I must
claim as an idea, or perhaps a fad, of my own. Experience
leads us to know that separation of highly excitable cases has
a beneficial influence on excitement, and I venture to say that
if judiciously continued it must tend to a shortening of that
period when either recovery or non-recovery is practically
determined. On the other hand, there are quiet, shrinking
patients, who for their ultimate good, if not for their present
comfort, should be protected, if possible, from the troubles and
alarms of an average ward containing recent cases. The
single sleeping, and specially prepared rooms, are provided
according to accepted scale, and we have not arranged for
any excess of these, or for any very special sick ward, on the

Digitized by VjOOQle

1900.] BY H. HAYES NEWINGTON, F.R.C.P.ED. 681

general ground that if a case should be so turbulent and
noisy as to be a bar to the comfort of others, or become so
sick as to require more than an ordinary sick room, it should
go to the main asylum, where ample provision has been made.
Indeed, a temporary removal there, or a threat thereof, may
have a salutary disciplinary effect. I am aware that some
may think that our principle is trenched on by such a removal.
So it may be, but the comfort and progress of the great
majority are the chief considerations, and we set out with the
idea that no rigid rule in any direction should imperil them.

As to the working of this hospital, you will see that it has
its own kitchen and administrative centre. This may appear
to be a source of undue expense ; but I am not sure that when
all is considered it will be found to be so. As we know, the
diet of acute cases is necessarily expensive, as no class of sick
people require a more liberal and varied supply. Every extra
penny that is judiciously expended in this direction will
probably be amply repaid by speedier and more thorough
recovery. This being so, it will be more convenient to have
the special food prepared apart from the bustle of the main
kitchen, and the extra supply can be more readily followed, and
if necessary checked.

Accommodation is provided for the residence of one of the
medical officers in the hospital. In addition to an office he will
have the advantage of a complete set of reception-rooms for
each sex. The idea was borrowed from Hartwood, where we
found a suite of examination, dressing, and bath rooms, which
afford every convenience for carrying out the important duties
of reception. There are also quarters for chief attendants and
an ample staff of attendants and nurses. The idea is that each
side, though it is in three sections, will be worked as one ward.
This arrangement would seem best to provide for meeting
emergencies arising from an undue proportion of one type of
new case, from sickness, or absence on leave of the staff, and
it will avoid the necessity of having charge attendants for each
section, none of which are large.

The cross passages connecting the centre with the outside
sections have been made roomy, so as to serve for visiting
when required, and to allow of indoor exercise in wet weather.

One more provision I have to describe, and this we consider
to be of the utmost value. In a central position, where it can

Digitized by VjOOQle

€82 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct,

be readily reached from either wing, is a recreation room forty
by twenty-four feet in size. It is proposed that this shall be
comfortably and domestically furnished, and that it should be
used constantly—even most evenings—by those of either sex
who are well enough to be admitted there. We all know what
benefits arise from the dances and other entertainments for
which the large recreation-room is provided in every asylum ;
but, considerable as such benefits are, I do not think that for the
class of cases now under consideration, they will equal those to
be derived from the quieter and more social use of a meeting-
place such as this, where songs and games and books, and
•even now and then a little dance, can be enjoyed night after
night without troublesome preparations, and with but the
supervision of a chief attendant. When a patient has got on
his or her road far enough to be allowed admission, he or she
will have reached a point where social influences will have the
best effect in confirming self-control and a natural habit of
thought. So, too, with those who have not got so far, there
will be some inducement to try and join their more fortunate
companions.

I must say a few words as to the number of beds here
provided. When I was preparing the address to which I have
alluded before, I endeavoured to work out the proportion of
such accommodation of this nature which might reasonably be
provided to the total accommodation of an asylum. The re¬
sult was that one bed should be provided for every fifteen of
the total patients. I have recently worked out the question
again in greater detail from the statistics of Hayward’s Heath
and some other asylums over a space of seven consecutive
years, and I find that the above proportion is justifiable. At
Hayward’s Heath in those seven years of the admissions,
when considered in classes, no less than 35 per cent, were
obviously hopeless, being congenitals, epileptics, chronics, and
dements, etc.

Then Dr. Saunders gives year by year a valuable table
showing his forecast of the admissions considered individually.
On collating these tables I found that 50 per cent, presented
to him a bad or hopeless prognosis.

Yet again I collated the returns in the Commissioners’ Re¬
ports as to the number of patients deemed curable on
December 31st of each year, and naturally found the propor-

Digitized by VjOOQle

1900.] BY H. HAYES NEWINGTON, F.R.C.P.ED. 68J

tion of hopefulness much decreased, a fact further confirmed
by the actual number of ascertained recoveries.

We may take it, then, that on the average 50 per cent, may
claim admission to the hospital.

I found that those patients who did recover within twelve
months were discharged after a mean residence of five months.
A few recover later, and on the whole, we may consider the
average of all cases to be six months. The control figures of
other asylums, as far as they could be applied, presented a very
similar conclusion. This would mean a turnover of beds twice
a year. In practice it would occur oftener, for some die, and
with us some will soon show the hopeless nature of the case
and would then be removed to the main asylum.

On the average, the rate of admission into county asylums
is one to every four of the average number resident in the year.

The sum works thus, then : In an asylum of 1000 patients
about 250 will be admitted each year, of whom 125 will pro¬
bably recover after an average residence of half a year.
Assuming that there is no very great departure from average
admissions, hopefulness, and residence, sixty-three beds will
accommodate these hopeful cases—and 63 to 1000 is not
quite 1 to 16.

Of course one knows that, however much averages prevail in
the long run, they do not hold constantly, and under unfavour¬
able circumstances this proportion may occasionally be found
insufficient. We are not likely in East Sussex to suffer from
such vagaries for some years to come, since we are building for
many more than our present number of patients, proposing to
fill up with out-county chronic cases, who will obviously have
no claim on the hospital. When a time of strain should come
it will be easy to extend our provision for curable cases.

Another point on which question has arisen is how on
admission a distinction can be drawn between hopeless and
hopeful cases. I confess that difficulties may and will arise^
and that possibly cases may be missent either to the hospital
or the asylum. Even if this should be the case, the main
principle will not be killed, and steps can be taken to correct
such mistakes as do occur at the earliest possible moment. A
great deal of assistance may be rendered by union medical
and relieving officers when once the importance of such assist¬
ance is recognised. In some localities there probably is a want

Digitized by VjOOQle

684 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct,

of helpfulness on the part of these officers. But after all,
asylum and union officers are the servants of the ratepayers,
even though they carry out their duties under different sets of
the ratepayers* delegates. It is not too much to hope that as
county councillors and guardians are often the same persons,
and as a liberal interest in the insane is spreading to all autho¬
rities, pressure may be brought to bear, in the interest of the
county as a whole, to ensure that at least some intimation of the
nature of the case to be admitted will be forwarded, if necessary
by the telegraph. Even if only the congenitals and dements
were so announced some trouble would be saved, and for this
no very extraordinary powers of diagnosis would be required.

As to the objects of the hospital, we have no exaggerated
views of the results to be expected. We simply wish to pro¬
vide a place where patients shall have a better chance of re¬
covery, a shorter and happier sojourn under control, and a less
distressful memory after recovery. We think all these can be
promoted by the withdrawal of the ordinary experiences and
rtgirne of an asylum. What, for instance, can be more pre¬
judicial to recovery than the one set hour of getting up for
those who have good sleep, and those who perhaps are just
closing their eyes after none ? What more irritating to those
who are improving than to have to get to bed at an hour fixed
by the requirements of the sick and by the general convenience
of the whole asylum ? We have in our county asylums, besides
peasants who lie down and get up almost with the sun, people
of superior positions and other habits of life. A rigid rule in
many such social matters must press hard on some, and one
great purpose of this part of the institution is to allow of
reasonable departure from the rigidity which is essential in the
general asylum. As medical men, also, we have a well-founded
belief in the value of treatment, whether medical or moral, in
the earlier days of the disease, and nowhere is such treatment
more certainly and conveniently applied than in a place which
contains only active and moving cases, bespeaking continuous
attention, and supplying the motive as well as the name of a
hospital. Again, we are persuaded that the existence of such
a half-way house, founded on the idea of active hospital treat¬
ment, will overcome to a considerable extent the reluctance on
the part of friends to send patients in the earlier days of the
•disease.

Digitized by

Google

.1900.] BY H. HAYES NEWINGTON. F.R.C.P.ED. 685

Going back again to the general consideration of our scheme,
three questions arise : first, what will be the capital cost ? An
-exact answer to this cannot be given, as some portion of the
work has not been submitted to tender. But, taking as a
guide the tender which we accepted ten days ago for the super¬
structure, it is reckoned that for the initial accommodation for
1115 patients the cost per head for the buildings will be ^275,
and the total cost, inclusive of land and equipment and all
other matters, will be about ^325 per head. When the further
accommodation for 160 is added, it is estimated that the total
cost will be reduced to £ 300.

About three years ago we reported to the County Council
that the total cost per head of a good modern asylum was
about ^250. Since then, in addition to the fact that we have
had cast on us considerable expenditure not usually included
in estimates, the cost of building has without question most
materially advanced, so much so that it is fair to assume that
if the prices of three years ago obtained now we should have
not exceeded the original estimate. In any case we think that
a comparison with the cost of other asylums recently erected
goes to show that our variations in general disposition and
design have not led to any material increase in expenditure.

Secondly, will the current cost of carrying on the asylum
be greater than is usual ? Apart from the hospital, I do not
think that it will be. The chief item of extra expenditure, if
any, will be in respect of salaries and wages. There is no
reason why a staff of one attendant by day to every ten
patients over the whole institution should not be amply suffi¬
cient. Any extra amount of staff, after making allowance for
savings elsewhere, will be called for by the hospital, and the
cost of this, with the cost of food, will probably be repaid by
more frequent and more speedy discharge on recovery. A
missed recovery is equivalent to burying, for the time being,
some hundreds of pounds, the interest on which would be re¬
presented by the cost of boarding and lodging the patient.
Therefore, if by reason of extra expenditure for a restricted
time the county is relieved of the life-long charge of even a
few patients, the balance may well be found to be in its favour.

The last question is, will an institution planned as this is
entail more trouble and anxiety than the average present day
asylum ? It certainly may at first until practice and routine

Digitized by VjOOQle

686 PLANS OF A NEW ASYLUM FOR EAST SUSSEX, [Oct.,

have been settled, but there is this about lunacy—it tends to
speedily follow up and justify any advance in liberality of treat¬
ment. We have but to look back to the sudden and deter¬
mined abolition of restraint at Hanwell, to the disappearance of
brick walls, and to the gradual disuse of the key, for a confir¬
mation of this proposition. It is so true that no authority
can conscientiously afford to build an asylum on the lines
considered to be advanced thirty or even less years ago. In
our proposals we have borne this fully in mind, and believe
that while we have provided sufficient accommodation of a
fixed nature for those classes of patients where no variation in
the effects of disease is to be looked for, there is ample scope
for introducing yet further improvements for the benefit of
other classes.

But whether there be undue difficulties or not, there is no
question about there being plenty of men fit to successfully
cope with them. The management of asylums in former days
was an art, dependent for its success almost entirely on the
personality of the manager; now it has become a science, and
he who is called to the position of medical superintendent can
start with a large stock of organised knowledge, whereas his
predecessor often had to create a system for himself. We may
claim the credit of this for our Association, and the opportuni¬
ties its meetings and journals create for criticism, comparison,
and record of experience. Certainly I, for one, do not hesitate
to own my debt to it for much of whatever I may know of this
subject.

In conclusion, we will fain hope that even if there be a heavy
load placed on the shoulders of our superintendent, whoever he
may be, he will not be ill pleased with the opportunities of
displaying his talents, which will be afforded by the machinery
placed in his hands.

Discussion,

At the Annual Meeting of the Medico-Psychological Association, London, 1900 .

The President. —I congratulate Dr. Hayes Newington on having been able to
carry out his scheme for a hospital as well as an asylum, and have no doubt that
we shall hear from him how the institution works. One point naturally pleased
me, namely, that idiots and imbeciles are being specially provided for.

Dr. Robert Jones. —The scheme now brought before us is most comprehensive,
and, to my mind, is as near the ideal as it is possible for an asylum to oe. All of
us know how important it is for us to separate our patients. They come, although
practically paupers, from different classes. There are the dissolute, the crossing-
sweepers, and, may be, the University graduates. It is cruelty to associate them

Digitized by VjOOQle

687

1900.] BY H. HAYES NEWINGTON, F.R.C.P.E0.

indiscriminately. Mr. Hine, at Claybury, has managed to give us wards for
twenty-four patients in the acute blocks, and has subdivided these not by glazed
partitions, but by actual bricks and mortar. These small wards are subdivided
into three, or even four, sections; and, although it is a most extravagant arrange¬
ment from the point of view of administration, still it answers most excellently.
Indeed, I am often asked by visitors, "Where are your noisy and acute patients ? ”
As to the female nurse for male patients, that is a matter regarding which I have
very little practical experience; but, after conversation with those who have tried
it, I have some doubt on the matter. Before you have female nurses for male
patients you should carefully select your patients, and see that there is in them a
certain tendency towards recovery. I do not think that they are suitable for acute
cases. I do not see why the benefits of moral control by women over men should
not apply to the staff as well as to the patients. We have at Claybury an asso¬
ciation room, where male and female nurses have social meetings, and it has
answered extremely well. I think that for the introduction of the boarding-out
system, if cottages for asylum employes were more freely dotted about the
estate one might be able to use them as a sort of screen for the patients to go
through, where they would live under the care of experienced members of the
staff prior to being selected for outside care.

Dr. Spence. —I congratulate East Sussex on having had such admirable plans
prepared for the new asylums. It occurs to me that it may prove rather expensive
in working; but if the work be done well it does not matter if it costs a little
more. I understand that Dr. Newington gives a large share of the credit to those
who have been associated with him in perfecting the plans now explained, and
specially to those gentlemen who have gone about the country visiting asylums and
selecting the best points.

Dr. Oswald. —In connection with the hospital there is apparently an arrange¬
ment by which all the bodily sick of both sexes can be shut off, so that the’whole,
or a certain proportion of them, can be nursed by women. From the nursing point
of view alone I am sorry to note this separation, because it is very necessary to
impress the nurse with the idea that there is a close connection between the men¬
tally sick and the physically sick. If you dissociate them you emphasise the
distinction between mind and body, and I have therefore always tried to treat these
classes together.

Dr. Turnbull. —My experience has been that there is a wonderfully small
proportion of patients who are unfit to be under female care. We find that the
female nurses gladly take charge of male patients, because they find it is very much
easier to manage them than those of their own sex. Men have objected to be
placed under the charge of women, but have ultimately expressed their appre¬
ciation, and have benefited very considerably.

Dr. Clouston. —The acute melancholiac is perhaps the patient who most
deserves our sympathy. He most needs nursing, and requires most at our hands.
Brain-sickness is to be properly nursed, irrespective of mental symptoms. I think
that the combination of bodily and mental nursing—the sinking of the notion of
the mental symptoms being the main thing—undoubtedly was at the bottom of
what I may venture to call this particular Scottish advance in the construction and
management of asylums. It was this class of patient which appealed to me, and
made me think of converting a wretched old refractory separate ward into a hos¬
pital for bodily and mental nursing under the very best nurse I had, and of sending
through this hospital every female nurse for training. I congratulate Dr. Newington
most heartily on his success in having practically shaped this general scheme,
which I most earnestly hope he will see realised as one of the best hospitals for
mental disease in the country. We all wish the Committee and him every success
in their philanthropic efforts for the insane of East Sussex.

Dr. Hayes Newington. —I thank you very much for the sympathetic remarks
which have! been made by those who have spoken. No doubt when you have had
an opportunity of studying the plans you will find more grounds for criticism.
With regard to what Dr. Jones said of acute wards of twenty-four, we did go one
better than that at East Sussex, because originally the acute wards were to hold
twenty each ; but, considering the expense, we arranged that there should be forty
in each ward, with three day-rooms. I note what he savs about the association of
the sexes, attendants, and so on. With regard to what fell from Dr. Spence,

XLVI. 47

Digitized by VjOOQle

688

GENERAL PARALYSIS OF THE INSANE,

[Oct,

I have endeavoured all through this paper, by using " we ” instead of “ I,” to
show how much 1 feel the kind co-operation of my colleagues. I am only too glad
to take this opportunity of expressing the wonderfully good feeling that has existed
amongst us all in this matter. We have all worked together in elaborating the
general ideas. With regard to Mr. Hine, I thank him heartily, not only on my own
account, but also, I am sure, on behalf of my colleagues; because it is one thing
to have an architect to carry out instructions, but it is quite another thing to have
one who knows routine requirements. I may say this: that with all the brains
which were engaged upon the work, it would not have come to much without Mr.
Hine’s wonderful power of taking the idea and working it out. In reply to Dr.
Oswald, the accommodation for the nurses at the acute hospital is off the wards.
We did not think it would be right at night to leave a large body of recent cases
without a considerable staff. The night nurses will be accommodated in the
nurses’ block. We have a large nurses’ home, capable of accommodating thirty-
seven, which is situated at the other end of the big building. We want to be pre¬
pared for any kind of treatment, and we recognise the fact that there are patients
who suffer from a bodily lesion, and we are prepared to treat them in the hospital.
If, however, one gets a case which is unduly noisy or destructive, for the benefit of
others I should send that patient off to the main asylum. With regard to the
lake, we debated as to what was to be done. We eventually decided to leave it as
it is, but to fence it in later on; but, curiously enough, two of the builders have
been drowned there already. I am very pleased to hear what Dr. Turnbull said
about the nursing of males by females. Our attention was first drawn to the
benefits of it years ago by Dr. Turnbull, from experience in his own very nice hos¬
pital, and he should have the credit of pushing the idea. I may say that during
our rounds visiting Various asylums we found that such nursing was successful. 1
have learned a very great deal from Scotland. I was at Morningside before Dr.
Clouston went there, and had experience of one of the very worst asylums, and
learned a valuable lesson of what to avoid. I have seen that asylum turned into
one of the very best.

A Contribution to the Morbid A natomy and the Pathology
of General Paralysis of the Insane. By David Orr,
M.B.Edin., Pathologist to the County Asylum, Prestwich,
and Thomas Philip Co wen, M.D.Lond., Assistant Medical
Officer, County Asylum, Prestwich.

At the last February meeting of the Manchester Pathologi¬
cal Society we made a preliminary communication upon this
subject, limited to a description of the changes found in the
cortical nerve-cells and the descending degenerations in the
spinal cord. Since then we have examined a much larger
number of cases, and can therefore give a fuller description, with
observations upon other points in the morbid anatomy of
general paralysis of the insane.

Early in our observations we were much impressed by the
differences in degree of the morbid changes found after death in
the nervous system, these apparently depending on the presence
or absence of convulsive seizures during life.

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D.

689

Our research has therefore been conducted as follows :

1. We have made careful clinical notes of all cases, especially
those of unusual interest, such as those running a very rapid
course, or those accompanied with convulsive or paralytic
seizures.

2. In all cases the cortex cerebri has been examined accord¬
ing to the most recent and reliable technique in order to show
the changes found in the nerve-cells, neuroglia, and medullated
fibres, the tangential layer being included among the last-named.

In twelve of these cases the spinal cord has been systemati¬
cally examined to ascertain the amount of descending degenera¬
tion, and to what extent the posterior columns, posterior nerve-
roots, and ganglia were affected in the disease.

Our reason for paying special attention to cases of unusual
rapidity and to those accompanied by fits, with the correspond¬
ing changes in the nervous system, was our belief that the
degree of toxicity incidental to this disease must necessarily
exercise a direct influence upon its course, and upon the micro¬
scopic changes found. We hope to demonstrate that such a
relationship does exist.

The Cortex Cerebri.

Our systematic examination has extended over a series of
twenty-three cases, and our methods have been the same
throughout, viz.:

Thin slices of brain from the fronto-motor region were fixed
in sublimate, and hardened in spirit, according to Heidenhain’s
method.

We have stained the sections with toluidin blue, Held’s
method, and Robertson’s methyl-violet method.

Robertson’s stain is much to be preferred, as it brings out the
profound degenerative lesions more clearly and stains the
chromophile elements much more distinctly, whether intact or
broken down. In addition we have found it to be a permanent
stain. In all cases we have fixed the tissues before post-mortem
changes had time to set in.

With regard to the nerve-cells, we may say that a general
description of the changes found at the different stages of the
disease will be best, as such changes are practically common
to all.

Digitized by VjOOQle

690

GENERAL PARALYSIS OF THE INSANE, [Oct.,

Nerve-Cells.

We find that the degenerative process affects all the nerve-
cells, even in early cases, but that the change is much more
early and apparently more rapid in the smaller cells, so that
our description of the initial stage of the degenerative appear¬
ances could only be studied in the large pyramidal cells.

The earliest change observed is that the chromophile elements
—although staining well—have lost their regular outline, and
very fine particles become detached and lie between the Nissl
bodies. The chromophile elements then tend to break down
into fine particles, sometimes around the nucleus, but more often
at the base or side of the cell, and always with this change
there is a general rarefaction of the chromophile bodies. As
the chromatolysis advances the perinuclear region becomes in¬
volved, or occasionally it is confined more especially to one or
other side of the cell. The degenerated area is seen to be
occupied by a mass of finely granular pigment, in which lie
small particles of broken down chromophile elements retaining
their affinity for the methyl-violet staining. The chromatolysis
then extends to the protoplasmic processes, the apical process
usually being affected last, and should one side of the cell be
more affected than the other, in like manner the processes arising
from the affected area are the more profoundly degenerate.
In the final stages the cell loses its processes and definite out¬
line, until only a small mass of diffusely staining, slightly granu¬
lar protoplasm remains, surrounding a pale, faintly staining
nucleus, to which in addition in many instances a small mass of
pigment is adherent. Finally, the granular protoplasm disinte¬
grates and disappears, leaving a faintly stained nucleus, in which
the nucleolus is absent or distinguished with difficulty.

Small pyramidal cells are much more early affected than
the large ones, and thus it is impossible to study the early
changes in the former. They are seen in the later stages in
various phases of advanced degeneration. The cell at this
stage is usually represented by a small portion of cytoplasm
containing a few broken down granules—the remains of the
chromophile elements—surrounding the nucleus. The processes
are lost; and in a large number there is a mass of pigment
attached to the outside of the nuclear envelope.

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D. 69 1

In some instances it can be seen that the process has begun
at the centre, i. e . perinuclear.

In the very last stage only a nucleus is left with a very small
portion of pale, diffusely stained cytoplasm attached to it ; and
occasionally free nuclei alone represent the once healthy nerve¬
cell.

Such are the changes which we have observed in the cyto¬
plasm of the nerve-cells. Post-mortem change has been
carefully eliminated, and the only departure from the above
description is that of temperature change occurring in cases
dying from hyperpyrexia, and in those who suffered from
continued high temperature for some time before death.

The appearances observed—(complete chromatolysis)—coin¬
cided with those induced experimentally upon animals by
Lugaro, Goldscheider, and Flatau, and with the severest type of
temperature change described by Marinesco.

It is apparent that the chromatolysis is chronic, and differs
from the changes met with in experimental poisonings, toxaemia
and anaemia (acute), because under these conditions one usually
finds a chromatolysis which commences at the periphery and
rapidly involves the entire cell. Although in general paralysis
the degeneration begins at the base of the cell, and more rarely
around the nucleus, it differs from the secondary chromatolysis
of Marinesco, induced by section of the nerve, because the pro¬
cess in general paralysis is more chronic, and there is a develop¬
ment of pigment in the cell which increases with the breaking
down of the chromophile bodies.

Such a chronic chromatolysis, accompanied by increase of
pigment, is by no means confined to general paralysis, but is
found among the cortical cells of the aged, uncomplicated and
complicated by insanity, as well as in those of the chronic insane.

We are inclined to believe with Marinesco (*) that all such
chromatolytic changes in the nerve-cell, accompanied by in¬
crease of pigment, are of an involutive nature, and that the
chromophile elements become chemically transformed into the
so-called pigment. According to Marinesco all prolonged
alterations in the nutrition of the nerve-cell are accompanied
be pigmentary change. In slow progressive anaemia, chronic
poliomyelitis, and after section of peripheral nerves—no repair
having taken place,—marked pigmentary changes are found in
the cells.

Digitized by VjOOQle

692 GENERAL PARALYSIS OF THE INSANE, [Oct.,

Most authors are agreed that the pigment is a regressive
and not a nutritive substance, although Obreja and Tatuse( 2 )
seem to be inclined to take up the latter view. These authors
found a disappearance, almost total, of the pigment in the cells
of the cord of a dog strychninised and of a person dying from
tetanus ; on the other hand, they have seen accumulation of
pigment in a case where the nerve-centres were inactive, as in a
person who has been long bedridden.

To us it seems that the small amount of pigment observed
in the cells of the strychninised dog, and in those of the person
suffering from tetanus, represented the normal physiological
pigment found in adult cells, as here the chromatolysis was
necessarily an acute one, and would not be accompanied by
pigmentary increase; while on the other hand, the nerve-cells
of the bedridden person might easily show a certain amount of
pigmentary change. Therefore the authors’ conclusion, that in
the nerve-cell the abundance of pigment is in direct relation to
the inactivity of the cell, and that the function of the pigment
is nutritive, cannot be accepted. The way in which the pig¬
ment develops pari passu with sl,ow destruction of the chromo-
phile bodies is entirely against such an opinion.

Regarding the chemical nature of the pigment many views
have been advanced. We cannot enter into that discussion
here, but most authorities consider that it is probably a complex
product, partly of a fatty nature, perhaps lecithin according to
Marinesco, or lipochrome according to Rosin. We agree with
Marinesco that it presents certain reactions of a fat, but there
is no doubt that in some respects there are points of difference.

We find that the pigment granules stain dark brown with
osmic acid and the Weigert haematoxylin method, and that on
the other hand they are insoluble in ether and chloroform.

Associated with the chromatolysis in the body of the cell
definite changes are to be observed in the nucleus, correspond¬
ing in degree to the changes in the cell. In sections stained
by the methyl-violet method, we note that in those cells where
the chromatolytic change is early, the nucleus shows no appreci¬
able departure from the normal. As the degeneration pro¬
gresses the nuclear network breaks up into very fine granules,
and the nucleolus tends to become paler and to pass towards
the periphery, probably on account of the loss of support of
the network which under normal conditions must hold it in

Digitized by VjOOQle

693

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D.

position. In cells showing more advanced changes in the
cytoplasm, there is an appreciable diminution in the size of the
nucleolus, which in many instances is seen to be attached to
the inner side of the nuclear membrane. When the cell is
completely degenerated, and the nucleus is free, the nuclear
membrane is very faintly stained, and only a few granules can
be observed arranged towards the inner side of its periphery,
all trace of a definite nucleolus being entirely lost.

With the Biondi-Heidenhain stain, used in dilute solution,
after sublimate fixation, as recommended by Levi ( 8 ), we have
endeavoured to make observations on the behaviour of the
acidophile and basophile portion of the nucleolus.

Our researches with the stain are still in progress, but at
present we are inclined to think that the basophile particle
loses its staining reaction and disappears sooner than the acido¬
phile.

Various theories have been propounded as to the mode of re¬
moval of degenerated nerve -cells , mainly on two lines—either by
leucocytes or by neuroglia cells.

Turner ( 4 ) has described and figured leucocytes destroying
and removing nerve-cells in senile dementia and general para¬
lysis. Bevan Lewis ascribes great importance to the part
played by neuroglia cells in the attacking and removal of
degenerated nerve-cells. Nissl( 5 ), in his most recent work on
the relation between nerve-cell degeneration and the neuroglia
in the various psychoses, affirms that neuroglia cells are capable
of incorporating the products of disintegration of the nerve-
cells. He is of opinion that when the nerve-cells become
affected the bodies of the neuroglia cells, normally scarcely
visible, become enlarged, and often contain coloured granules.
In the nucleus a nucleolus, normally absent, is formed, often
more than one.

Marinesco ( 8 ) is of opinion that the neuroglia cell acts with
the leucocyte as a destroying agent of degenerated nerve-cells.
From our own observations we are inclined to the opinion that
neither the neuroglia cell nor the leucocyte plays any part in
the destruction and absorption of dying nerve-cells. We have
examined numerous sections, and in no instance have we seen
any appearance suggesting such a process. There is no doubt
that it may be simulated by leucocyte and neuroglia nuclei
lying in close proximity to nerve-cells, but careful focussing

Digitized by VjOOQle

694 GENERAL PARALYSIS OF THE INSANE, [Oct,

reveals the fact that the cells in question are in quite a different
plane to the nerve-cells. We have never seen indentations of
the nerve-cell containing leucocytes , nor neuroglia acting as phago¬
cytes.

Lugaro (*) admits that the neuroglia may play some part in
the removal of degenerated nerve-cells, but supports our view
that the leucocyte has no phagocytic action. It is highly im¬
probable that any active part can be played by leucocytes or
neuroglia in such a slow chronic degeneration.

We hope to show later on that neuroglia proliferation is to
a great extent secondary to destruction of medullated fibres,
and that such a proliferation merely reacts to destruction of
tissue and irritation from the resulting toxins. As yet the
process of absorption of degenerated nerve-cells has not been
followed, as far as our knowledge goes, owing to the lack of
observation of the relationship of lymphatics to the nerve-cell.

Recently several observers have been working at this subject,
amongst whom Donaggio ( 8 ) is the latest. By a new method
of staining he claims to have demonstrated the existence of
fine canaliculi in the nerve-cell communicating with a peri¬
nuclear space. According to Holmgren ( 9 ) the canaliculi com¬
municate with extra-cellular vessels.

It seems probable that absorption of the products of degene¬
ration would be carried on by a lymphatic system, but in the
absence of more definite observation on the anatomical con¬
tinuity between such canaliculi and the general lymphatic
system of the brain an opinion on such a point must be mere
conjecture for the present.

Medullated Nerve-Fibres of Cerebrum.

In studying the medullated fibres of the cerebrum, we have
confined our researches to the motor areas, and have investi¬
gated the tangential layer, the fine plexus of fibres existing
between this layer and Meynert’s pyramids, the fibres of this
latter system, and the fibres in the white matter coursing to¬
wards the internal capsule.

We have used Weigert’s haematoxylin method, Robertson’s
modification of Heller’s method, and an osmic acid method of
staining fresh nervous tissue, previously described by one of

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D. 695

us( 10 ). Marchi’s method has been used in this study of the
tangential layer, and of the coarser fibres passing towards the
internal capsule.

Our examination of the medullated fibres extended over the
-same series of twenty-three cases in which we have previously
described the nerve-cell degeneration. We have divided the
above series into two main groups, according to their clinical
history.

(а) Ten cases in which no convulsions were present during
life. In this number are included two very acute cases of three
and four months* duration each, six running a rapid course and
dying within fifteen months from the onset of the disease ; the
remaining two were chronic cases, and died at the end of three
and four years respectively.

( б ) Thirteen cases in which many convulsions occurred pre¬
vious to death. These cases were for the most part chronic,
running a much longer course than the cases under the first
heading. The convulsions, even when general, showed a
marked preference for the right side with only two excep¬
tions.

Our object in so dividing the cases was to ascertain
whether the toxic influence, now admitted by all to be a
potent factor in the course of the disease, had any influence
upon the medullated fibres of the brain, commissural and
descending.

To take up the tangential layer first.

(a) In cases without fits .—In those running a remarkably
rapid course there was complete atrophy of the tangential
layer in four cases, and a very considerable amount of
atrophy in three cases. In one chronic case there was com¬
plete atrophy of this layer, and in another of the same nature
a very considerable amount. In one early case the tangential
layer was almost intact. This case was one of rather unusual
interest. On admission the patient suffered from mania, alter¬
nating with melancholia, but presented no physical signs of
nervous disease. Later unequivocal signs of general paralysis
developed—grandiose delusions, with progressive dementia ;
Argyll Robertson pupils, and very brisk knee-jerks. He died
four months later of pneumonia.

Post-mortem ,—The naked-eye appearances of the brain were
those usually seen in cases of general paralysis. There was

Digitized by VjOOQle

696 GENERAL PARALYSIS OF THE INSANE, [Oct.,

very advanced chromatolysis in the cortical cells, yet the
tangential layer was practically intact, as were the very fine
fibres lying between the tangential layer and Meynert’s pyra¬
mids.

(£) In cases with fits .—There was complete tangential
atrophy in nine out of the thirteen cases. In two the atrophy
was very advanced, but was not complete; and in the other two
about one third of the fibres was left intact.

Our conclusion must be, that in general paralysis there is a
marked affection of the tangential layer, which shows itself by
a degeneration and subsequent atrophy, of the finer fibres
first, and of the coarser fibres later, the latter persisting in a
very varicose condition for some little time after the former.

In examining sections prepared by the above-mentioned
methods, it is apparent that in the early stages the degene¬
ration affects some parts of the layer seen in the field more
than others, causing a breach of continuity, so that at one part
of the section the fibres may be fairly well stained, while at
other parts they may be in a more advanced stage of degenera¬
tion or completely absent.

It will be seen that all our series, except two, were either
cases of a very acute type, or chronic cases in which convulsions
occurred. It is unfortunate that we have not in the series
more than two of the simple demented type without fits.

In the very early case described above we pointed out that
the tangential layer was little affected. In one chronic case
without convulsions there was a considerable number of fibres
left. We would venture to suggest, therefore, that in these
acute cases very virulent toxins are developed, and cause the
patchy degeneration of the medullated fibres, and that these
toxins are of a non-convulsive nature ; whereas, in the more
chronic cases, it may be that until convulsive seizures are
established the tangential layer does not tend to degenerate so
rapidly. We hope to be able to show later on that convulsive
seizures exercise a direct influence in the production of degene¬
ration of the descending system of fibres, and it is not unreason¬
able to think that they must also affect the other systems of
medullated fibres in a similar manner.

Such a point could be easily settled by a systematic
examination of a series of cases of general paralysis, accom¬
panied or unaccompanied by convulsions, and especially of

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D. 697

early cases dying from intercurrent diseases within a few
months of onset.

We do not altogether agree with Tuczek and Mott that the
tangential system of fibres is the first to degenerate, and that
the disease spreads back to the trophic centres (the cells)*
It seems to us that the nerve-cell degeneration is a much more
constant and advanced change, as in several of our cases a
considerable number of the fibres of the tangential layer still
remained, although the disease had lasted some time; while
in every case, even in the very earliest, the affection of the
nerve-cells was of a very advanced character. In the single
early case we have examined, this point is brought out
markedly, but we reiterate that much more work is required
in connection with very early cases before a decided opinion is
given on such an important point. In the grey matter we
note the disappearance of the very fine fibres, and also of the
coarser fibres running from the grey into the white matter, as
the disease progresses ; and we agree with Epstein ( ll ) that the
amount of degeneration in these areas increases equally with
that of the tangential layer.

With regard to the degeneration of the fibres which course
from the cortex to the internal capsule, we prefer to discuss
this point when we come to consider the descending degenera¬
tions in the pyramidal tracts.

The Neuroglia .—After examination of the neuroglia, we do
not find that changes in the neuroglia are as constant or as
extensive in general paralysis as the older observers would
have us believe. In two very acute cases there was no per¬
ceptible affection of the neuroglia, and in one fairly acute
there was some neuroglia hypertrophy. In three acute cases
there was but a slight amount of neuroglia change ; two cases
of subacute character showed a fair to a considerable amount
of affection. In one chronic case there was no affection of the
neuroglia, and four showed a slight degree, and the remaining
chronic cases, ten in number, showed a fairly considerable
amount of neuroglia hypertrophy. When present, this
neuroglia change was found in the innermost layer of the
cortex, in the deepest layer of nerve-cells in the grey matter,
and in the white matter, and coincided in degree, to a con¬
siderable extent, with the amount of degeneration of medullated
nerve-fibres in the corresponding areas, replacing the atrophied

Digitized by VjOOQle

6gS GENERAL PARALYSIS OF THE INSANE, [Oct.,

fibres. It is possible that it may react in some degree to
irritation caused by products of degeneration. We consider
that the neuroglia change is quite a secondary one, plays no
active part in the destruction of the nervous tissue, and has an
entirely passive rdle.

The Cranial Nerves.

Degeneration in the nerves, and also their nuclei of origin,
has been studied and recorded by many observers, with a view
to determine the interdependence of the changes in the nuclei
and their corresponding nerves.

We have studied the degeneration in the cranial nerves by
means of the modified Marchi method. The nerves were
teased out (except in the case of the optic nerve), and were
examined in their whole extent within the cranial cavity. In
the case of the vagus nerves a portion was taken on both sides
from the neck. In every nerve there was abundant evidence of
degeneration brought out by the modified Marchi method.

On many of the myelin sheaths small isolated black patches
could be seen, indicating degeneration at these spots, which
patches tended to spread along the sheath, but very seldom
were seen to run into the large black droplets of altered myelin
which one so commonly finds in secondary degenerations in the
cord and peripheral nerves.

In many of the fibres there was very little trace of degenera¬
tion to be found, very small portions of the myelin sheath being
affected here and there, while in others there was a more grave
degree of affection, large segments of the sheath being involved,
with intervening portions of apparently healthy myelin. In
those fibres showing the greatest degree of degeneration the
medullary sheath is studded with numerous little black patches
of Marchi reaction, which are joined together in some places by
their extremities, leaving clear unstained spaces. Between the
fibres many small isolated droplets of myelin are to be
observed.

It is evident, therefore, that a degeneration of this nature is
a slow, progressive, and patchy one, and thus resembles markedly
the primary degeneration, described by Vassale( 12 ) as being
due to disturbance of nutrition resulting from experimental
poisoning.

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D. 699

Vassale distinguishes clearly the difference between primary
and secondary degenerations, and lays great stress on the fact
that whereas the latter is a much more rapid and destructive
process—the axis-cylinder being affected along with the myelin
sheath,—the former is a very slow one indeed—the axis-cylinder
remaining uninjured for a very long time,—and one from
which the myelin sheath can recover on removal of the toxic
agent.

As demonstrating the slowness of the primary degeneration,
he finds that in the early stage, which is of long duration, the
Marchi and Weigert methods give negative results, and that the
affected fibres can only be demonstrated by other methods of
staining, viz. safranin, Mayer’s carmalum, and nigrosin. He is
of opinion that in the last stages only of primary degeneration
the Marchi method is of value, the atrophied myelin sheath
then being merely represented by a few black droplets.

In the early stage of primary degeneration the staining
methods used by Vassale show definite modification of structure
in the nerves. The myelin sheath becomes thinner at certain
points, until ultimately portions are left staining less perfectly
than the remaining parts of the sheath. This localised thinning
and absorptive process very gradually progresses, until clear
spaces are left at these points.

When this stage has been reached by the degenerative
process we believe that the Marchi method can now demonstrate
the degenerated parts, for it has been seen that in the appearances
described by us clear spaces are left in the sheath, bounded by
spots of blackened altered myelin, and we consider that when
the process reaches a certain stage—earlier than that given by
Vassale—the Marchi method is of value in demonstrating the
change.

We venture to suggest, then, that in the cranial nerves the
process is a combination of slow degeneration and absorption,
and this fact seems to account for the absence of the large
degenerated droplets so characteristic of secondary degenera¬
tion.

The axis-cylinders have been examined by Van Gieson’s
method with negative result. The fibre stains well, and we
have not observed any traces of degeneration upon it. We have
examined the nuclei of origin of several nerves presenting the
above changes, and have found these nuclei but very slightly

Digitized by VjOOQle

700 GENERAL PARALYSIS OF THE INSANE, [Oct,

affected. The great majority of the cells present well-stained
chromophile elements showing perhaps a slight irregularity of
outline, and there is a tendency to hyper-pigmentation of the
■cell. A few of the cells only showed a moderate degree of
chromatolysis, and that of a chronic nature, accompanied with
the increase of pigment to which we have above referred.

It therefore seems to us the changes in the nerve-cells are
neither sufficiently extensive, nor advanced, to account for the
amount of degeneration found in the nerve-fibres, and in this
we agree with Campbell, ( 13 ) who has previously thoroughly
studied this subject. This author notes that the changes are
most advanced at the periphery of the nerves, and that such
changes were always most extensively found in the vagi. As
we have only studied the nerves in their course within the
cranial cavity, and the vagus nerve to the middle of the neck,
we cannot offer an opinion upon the first point.

Regarding the second point, our results differ very slightly
from his, in that although much degeneration was undoubtedly
found in the vagus, as much was present in the third and fifth
nerves, while the fourth, sixth and seventh showed but very
little less change, and the remainder of the cranial nerves
showed a fair amount of degeneration.

It is difficult to account for the failure of Dr. Mott,( 14 ) and
more recently Dr. Barratt,( 16 ) to demonstrate these changes in
the vagus, except in one case, in which a single fibre was found
to be degenerated.

Perhaps they have been unfortunate enough to examine very
early cases only, where the degeneration was in an extremely
early phase, and so could not be revealed by staining in osmic
acid, or by the Marchi method, even after dissociation. We
have referred to the changes in the cells of the nuclei of the
•cranial nerves, when they do occur, as being of the same slow
chronic nature as that occurring in the large pyramidal cells of
the cerebral cortex. Gerlach ( 18 ) in describing these nuclei of
origin, divides the changes observed into:

(а) Fatty and pigmentary degenerations.

( б ) Homogeneous swelling.

(. c ) Simple atrophy.

He finds that pigmentary degeneration prevails in syphilitic
cases, and simple atrophy in cases where alcoholic abuse is
*demonstrated. His terms—homogeneous swelling, and simple

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D. 701

atrophy—can hardly be taken as descriptions of the cells in
general paralysis, as such appearances are very seldom seen,
even by Gerlach himself, and to our minds they resemble the
changes due to hyperpyrexia, which we have observed in the
pons and medulla of patients dying after continued high tem¬
perature. He affirms that the nerve-cell lesions differ accord¬
ing to their aetiology, but our observations do not at all con¬
firm this opinion.

In conclusion, we are of opinion that the comparatively
slight affection of the cells, and the character of the degenera¬
tion found in the medullated sheaths of the nerves, associated
with absence of evidence of degeneration of axis-cylinders,
seem to point to a toxic factor attacking primarily the medul¬
lated sheaths of the nerves, leaving the axis-cylinders practi¬
cally intact until very late in the disease.

The Spinal Cord.

We have systematically examined the spinal cords of twelve
cases of general paralysis, our examination including the cells
of the anterior cornua, Clarke’s column, the medullated fibres,
paying especial attention to the descending tracts, and the
tracts in the posterior columns, with the posterior roots and
ganglia.

The methods of staining employed were toluidin blue,
Delafield’s haematoxylin, and Heidenhain’s iron haematoxylin
after sublimate fixation.

We find in the cells of the anterior horns changes similar to
those found in the large pyramidal cells of the cerebral cortex,
and in the nuclei of origin of some of the cranial nerves, and
although the majority of these cells are affected by the chronic
chromatolysis previously described, yet a certain number are
apparently healthy. In studying the cells of Clarke’s column,
we found the slow progressive staining by weak Delafield’s
haematoxylin to be much more trustworthy than the regressive
method of Nissl,or of any of its modifications. On account of
the peripheric disposition of the chromophile bodies peculiar to
those cells, recently insisted upon by Marinesco,( 17 ) one must be
exceedingly careful not to come to too hasty a conclusion as
to the presence of chromatolysis in these cells. We are aware

Digitized by VjOOQle

702

GENERAL PARALYSIS OF THE INSANE, [Oct,

that some writers have described a central chromatolysis in
these cells, with the nucleus passing towards the periphery, but
such appearances naturally cannot be interpreted as patholo¬
gical if one bears in mind that the nucleus is normally situated
at one or other extremity of the cell, and that the arrangement
of the chromophile elements round the periphery only is a
normal histological appearance.

In general paralysis we have occasionally found a slight
breaking up of the chromophile elements, and a tendency to
the increase of pigmentary granules in the cell.

Beyond such hyper-pigmentation the large majority of the
cells appear to be perfectly healthy.

Pyramidal Tracts.

We propose to describe the changes in these tracts first, as
it is in them that the cord lesions characteristic of general
paralysis are to be found. It must be understood that here
we speak of general paralysis uncomplicated by tabes, as dis¬
tinguished from a tabetic general paralysis, where the typical
changes of both diseases are presented.

In the twelve cases examined by us we have found a con¬
stant affection of the fibres of the pyramidal tracts, crossed and
direct, in all. There is a marked difference in the degree of
the degeneration in the different cases, depending on the pre¬
sence or absence of convulsions during life. Where there have
been no convulsive seizures during life the degeneration is
moderate in amount, and is fairly equal on the two sides; on
the other hand, when “ convulsions ” have formed a feature of
the clinical history, the degeneration is most marked on the
side corresponding to the motor disturbance.

The Marchi method has been used to demonstrate the
changes. The morbid fibres are shown stained black, but with
many unstained healthy fibres intervening ; where the case has
been complicated by convulsions, a “ mass ” degeneration is seen,
similar to the secondary degenerations found in hemiplegias.
The degeneration of the pyramidal tracts has been previously
described by Baedeker, Juliusberger, and Muratow, whose work
on this subject is quoted by Starlinger. ( 18 ) The latter has him¬
self conducted an elaborate research in a series of twenty-one

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. CO WEN, M.D. 70 3

cases of general paralysis, and his work confirms the opinion
which we hold on this subject, and communicated in a previous
note. Starlinger, besides examining the cord, medulla, and
pons in his cases, extended his research to the cortex, and
found that there definite regions only were involved. His view
contradicts the view that general paralysis is a diffuse disease
of the brain, the morbid process attacking preponderate^ the
motor convolutions. Most degeneration is found in the ascend*
ing parietal and frontal, but the adjacent parts of the frontal
convolutions, and the hinder part of the first temporo-
sphenoidal gyri are slightly involved. He is of opinion, how¬
ever, that the process merely radiates a little to those regions.

From the motor areas of the cortex he has traced the degene¬
rated fibres through the internal capsule into the pons, medulla,
and cord. With him we are entirely in accord, as we have
traced a similar course of distribution of degeneration.

We have referred to the large increase in degree of degenera¬
tion found in the affected side in general paralytics who suffered
from convulsions.

This characteristic is a constant one, and is found in every
case, and is obviously dependent on destruction of the cortical
cells in the corresponding hemisphere of the brain. To take
two typical cases :

(a) J. W—, male, aet. 46 ; three and a half years’ duration. General
paralysis with exaltation, Argyll-Robertson pupils, and brisk reflexes.
Had many left-sided convulsions during the last few months of his life,
often followed, as is common, by a transient left hemiplegia. The
spinal cord showed a very great preponderance of degeneration in the
crossed pyramidal tract on the left side, there being only a slight amount
in the similar region on the right side.

(b) J. H—, aet. 49, two years and four months* duration. General
paralysis with dementia. Pupils equal; inactive to light. Knee-jerks very
brisk. Soon after admission left hemiplegia suddenly developed without
preceding convulsion, which gradually passed off. Two months later right
hemiplegia developed similarly, which persisted longer. Nine months
later left hemiplegia again appeared, and persisted. This was followed
by right-sided convulsions, which continued off and on until his death,
which occurred three weeks after this.

• There was marked degeneration in both motor tracts of the cord, but
more marked on the left side. The degeneration was traced up through
the pyramids of the medulla and pons, where the difference in degree
was still very evident, to the cortex.

This case is different in some respects from the first one, as
here convulsive seizures were preceded by successive hemi-

Xl.vi. 48

Digitized by VjOOQle

704 GENERAL PARALYSIS OF THE INSANE, [Oct.,

plegias, which, however, persisted on the left side after the
third attack, showing a very profound implication of the cortical
motor cells, with corresponding progressive degenerations in the
motor tracts. Although suffering from convulsions on the right
side during the last three weeks of life, yet there was not time
for the full amount of degeneration to develop.

There can be but little doubt that such degenerations as we
have described are descending lesions, secondary to destruction
of the large pyramidal cells of the cortex. The amount of
degeneration in the motor tracts increases slowly in the ordinary
demented cases of general paralysis, and is also present in cases
running a rapid course, but should the case be complicated by
convulsions, such a destruction of nerve-cells ensues as to cause
a very much more marked and rapid secondary degeneration,
with the prominently unilateral distribution above described.
Although one can trace direct continuity of degeneration along
the motor path, it is possible that a toxic factor may play a
certain part in addition to the descending changes.

The Posterior Columns.

We have found the study of the lesions in these columns a
very difficult one, as the degenerations are subject to great
variations in extent and distribution.

There is great diversity of opinion among the many observers
as to these lesions. Some authorities are inclined to identify
the posterior column degenerations found in general paralysis
with those found in tabes dorsalis.

Thus Heveroch ( 10 ) and Vyrubow C 80 ) are inclined to consider
that the lesions of general paralysis bear a marked similarity to
those found in tabes dorsalis.

On the other hand Rubaud ( 81 ) takes exactly the opposite
view, and shows clearly how such lesions as are found in the
posterior columns in general paralysis differ markedly from those
of tabes.

He distinguishes such lesions from those of tabes by their
variability in situation at different levels of the cord, and by
their lack of anatomical continuity.

He believes that such lesions are not connected with corre¬
sponding changes in the posterior roots, but has found them

Digitized by VjOOQle

1900 .] BY D. ORR, M.B., AND T. P. COWEN, M.D.

705

accompanied by alterations in the cells of Clarke’s column,
which only, however, exist in certain segments of the cord, and
he thinks the medullated fibre lesions both exogenous and
endogenous are secondary to these.

In all the cases which we have examined, lesions of the pos¬
terior columns have always been present.

Degenerated fibres are found scattered diffusely amongst the
healthy fibres, and show no preference for any one tract or
column, the endogenous fibres being affected quite as much as
the exogenous, and occasionally the fibres of the external
columns are affected more than the internal ones, and vice
versa.

The intensity of the lesion varies considerably in the various
regions of the cord, and even in segments in close proximity to
each other.

These diffuse indefinite lesions are found in the great majority
of the cords of general paralytics, but at the same time there
is evidence to show that in a certain number of cases lesions
exist which tend to assume a definite arrangement, but which
are yet absolutely distinct from true tabetic lesions.

Sibelius ( M ) draws attention to a definite lesion occurring
specially in the cervical region, which is apparently in the situa¬
tion of the “ comma ” tract of Schutz. He has found this
appearance in six cases of general paralysis.

We have seen a cord presenting such an appearance in the
cervical region in an early and acute case of general paralysis.
It was more especially marked on the left side of the cord,
and occupied entirely the most internal portion of the postero¬
external column, and towards the surface of the cord it assumed
a curved form, passing towards the root zones. The lesion in
the postero-extemal tract on the right side was extensive but
much more diffuse.

The lesion on both sides diminished markedly as we passed
down the cervical region, and disappeared on reaching the
dorsal region.

Lesions such as Sibelius describes differ from the common
lesions of general paralysis, as they assume a definite area and
course, and are quite distinct from the more extensive system
lesions of the posterior columns which one finds in true tabes
associated with general paralysis.

We have not described the lesions found in tabetic general

Digitized by

Google

J*o6 GENERAL PARALYSIS OF THE INSANE, [Oct.,

paralytics, as they in no wise differ from the well-known morbid
appearances found in true tabes dorsalis.

The Posterior Ganglia and Nerve-Roots.

There is great diversity of opinion as to the extent to which
these structures are degenerated, and as to the relationship
which lesions of the ganglia bear to degeneration of the pos¬
terior roots.

Campbell ( 2S ) and Fiirstner (**) are of opinion that the changes
in the ganglia are insufficient to account for the changes in the
posterior roots, a considerable amount of degeneration being
found in the latter, while in the former little abnormality is
noticed beyond hyper-pigmentation of the cells.

Sibelius and Vyrubow take the view that the degeneration
of the posterior roots and columns are secondary to nerve-cell
destruction in the intervertebral ganglia, and describe certain
degenerative appearances in the cells. These alleged morbid
appearances consist in breaking up of the chromophile elements
into very fine granules, with increase of pigment, and also to a
distinct paucity of cells, clear spaces being left in which no
cell structure can be detected.

Before describing the morbid appearances seen by us, we
should like to refer shortly to some of the normal histological
features of posterior ganglia cells, as we think it not improbable
that some observers have mistaken the peculiar arrangement
of the chromophile elements in those cells for morbid appear¬
ances.

Lugaro, ( M ) in his recent work on the posterior root ganglia
of the rabbit, goes thoroughly into the histology of these struc¬
tures, and we have been able to confirm his results in our exa¬
mination of the spinal ganglia of a healthy dog.

We cannot here enter into a detailed account of the histo¬
logy of the ganglion cells, but would like to note the following
points for purposes of argument.

1. The nucleus is usually more or less eccentric.

2. The chromophile elements, as a general rule, are scattered
throughout the cell as fine granules—like dust—save towards
the periphery, where they are larger and of much more definite
form. In a small number of cells, however, the chromophile

Digitized by VjOOQle

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D.

707

elements are regularly formed, arranged concentrically round
the nucleus, and are much less numerous than the finely
granular ones in the other type of cell. It is very important
to note that there is a zone at the periphery of the cell in
which no chromophile elements exist, and that where the axis-
cylinder leaves the cell there is a distinct lunule which is quite
clear. In certain cells one can detect also a small, clear, peri¬
nuclear band.

For the study of these cells the choice of a fixative is of the
utmost importance, and one must be exceedingly careful that
in hardening and embedding, shrinkage of the tissues is reduced
to a minimum, as should this occur the cells become detached
and fall out of their spaces. We have, therefore, adopted
Lugaro’s method of fixation in Mann’s fluid and in saturated
sublimate solution, with subsequent embedding in celloidin com¬
bined with paraffin.

Having carefully compared the posterior root ganglia in
general paralytics with the above-described normal histological
appearances, we are inclined to the opinion that the pathological
changes in general paralysis have been somewhat over-esti¬
mated. We have found comparatively little affection of the
ganglion cells, the majority showing a hyper-pigmentation ; but
undoubtedly a few show a chromatolysis of varying degree, the
granules tending to disappear in certain parts of the cell, usually
towards the periphery, these parts either staining diffusely or
being occupied by pigment.

While hesitating to venture an adverse opinion to such an
experienced and accurate observer as Dr. Mott, yet it seems to
Us that the appearances figured and described by him ( 26 ) of
some of the cells of the posterior ganglia do not differ from the
normal histological structure. We refer particularly to the cells
described by him in which the chromophile elements are seen
as finely broken-down granules, and a peripheral clear part in
which no granules are present. There can be no doubt that
cells presenting such features have in no wise departed from
the normal.

We would point out, further, that where spaces are seen in
which no cells are present, one must hesitate before concluding
that such an appearance is a morbid one, as the cells can be
seen in normal ganglia to have fallen out where shrinkage has
occurred, as a result of imperfect fixation.

Digitized by VjOOQle

708

GENERAL PARALYSIS OF THE INSANE, [Oct*

We have always found degeneration in the posterior nerve-
roots by the modified Marchi method. This degeneration
varies in amount and intensity in the different regions of the
cord. It is of the same patchy character as that found in the
cranial nerves, but of less intensity. It does not seem to bear
any relationship to the degeneration found in the posterior
ganglia or posterior columns.

Conclusions .—We feel that there are several points on which
we have touched but lightly. We refer more especially to the
very delicate fibres found in the grey matter of the cortex, to
the tangential layer, and to the tabetiform lesions in the pos¬
terior columns of the cord. With regard to the last point
there is yet much more work to be done, and until we have
seen more cases presenting definite tabetiform lesions we hesi¬
tate to form a definite opinion as to their nature.

With regard to the pathology of general paralysis, it would
seem as if there was a primary affection of the nerve-cells of
the cortex cerebri limited almost entirely to the motor areas,
and that associated with the degenerative changes in these cells
toxic substances are produced which affect the nerve-fibres pri¬
marily throughout the nervous system. It is only in this way
that one can account for the degenerations which are found in
the cranial nerves and the posterior nerve-roots, and it is pro¬
bable that the diffuse scattered lesions found in the posterior
columns owe their origin to this source.

In addition to these primary lesions secondary ones occur,
and we agree with those observers who consider that the lesions
in the pyramidal tracts are secondary to destruction of the
cortical nerve-cells, as the descending changes can be traced
throughout the whole motor tract from the cortex cerebri to
the lumbar cord, and are seen to be intensified when large de¬
struction of cortical nerve-cells occurs after convulsions.

It is yet too early to dogmatise as to the causation of general
paralysis—a disease which is as yet so little understood ; but
it seems reasonable, from what evidence there is, to put forward
such a proposition as the following:—That the nerve-cells of
certain individuals are liable to a premature decay, which decay
may be precipitated and intensified by certain exciting causes
of a toxic nature, such as alcohol, syphilis, influenza, lead¬
poisoning, and the like.

There is no pathological evidence at present to ascribe to

Digitized by VjOOQle

Digitized by

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1900.

Fig. 1.

Fig. 2.

To illustrate paper by Drs. Obb and Cowen.

Balt and Danielsson, Ltd.

Digitized by VJU* c IV,

1900 .] BY D. ORR, M.B., AND T. P. COWEN, M.D.

709

any one of these a predominating influence in the determina¬
tion of the onset of this disease, with the single exception of
one of its forms, namely, general paralysis associated with a
true tabes.

In this disease, which is not at all a common one in our ex¬
perience, there is both clinical and pathological evidence that
syphilis is by far the most frequent antecedent and probable
exciting cause.

References.

1. Marinesco, G. —Revue Neurolog., Oct. 30th, 1899.

2. Obreja ct Tatuse.— C. R. de la Soc. des Sciences Midicale de Bnearest,
Nov., 1898.

3. Giuseppe Levi. —Rivista di Patologia, fasc. vii, 1898. '

4. Turner. —Journal of Mental Science , July, 1898.

5. Nissl. — Archivfiir Psychiatrie, Bd. xxxii, H. 2, 1899.

6. Marinesco, G. —Pathologic de la cellule nerveuse, Paris, 1897.

7. Lugaro. — Rivista di Patologia , 1896, p. 356.

8. Donaggio. — Rivista Speriment. di Freniatria , fasc. i, 1900.

9. Holmgren.— Anatomische Hefte, H. 38 (xii Bd., H. 1), 1899.

10. Orr. — Journal of Path, and Pact., Feb., 1900.

11. Epstein. — Monatsschr.fur Psych, u. Neurol ., 1898, Bd. iv.

12. Vassalb. —Rivista Sperimentale di Freniatria , fasc. iv, 1896.

13. Campbell. —Journal of Mental Science , April, 1894.

14. Mott. —Report of Pathologist to London County Asylums , May, 1898.

15. Barratt, Archives of Neurol. Lab., London County Asylums , vol. i.

16. Gerlach. — Neurol. Centralb., No. 3, 1899.

17. Marinesco, G. —Revue Neurolog., Oct. 30, 1899.

18. Starlinger. —Monatsschrift fur Psychiatrie und Neurol., Jan. 1, 1900.

19. Hevbroch. —Revue Neurolog., Nov. 30, 1899.

20. Vyrubow. — Neurol. Centralb., No. 19, 1899.

21. Rubaud. —Revue Neurol ., June 15, 1899.

22. Sibelius.— Revue Neurol., April 15, 1899.

23. Campbell. —Journal of Mental Science, April, 1894.

24. Furstner.— Neurol. Centralb., No. 10, 1900.

25. Lugaro. —Rivista di Patolog ., fasc. iv, 1900.

26. Mott. —Archives of Neurol. Lab., Lond. County Asylums, vol# i.

Explanation of Figures.

Fig. 1.—Nerve-cell, showing rarefaction of the chromophile elements. Zeiss
obj. apoch., 2 mm. Comp. oc. 4. Toluidin blue.

Fig. 2 . —Nerve-cell showing chromatolysis with increase of pigment at one
extremity of the cell. Similar magnification and staining.

Fig. 3. —Nerve-cell, showing the above-described pigmentary change. Similar
magnification and staining.

Fig. 4.—Nerve-cell with advanced chromatolysis and hyper-pigmentation.
Similar magnification and staining.

Fig. 5.—To show the degeneration of the fibres in the tangential layer. Note
that only the coarser medullated fibres remain. From a case of chronic G.P.

Fig. 6.—To show the degeneration of the vagus nerve brought out by the
modified Marchi method. Teased specimen.

Digitized by LjOOQle

Table showing Relation of Convulsions to Medullated Fibres and Neuroglia of Cortex.

710

GENERAL PARALYSIS OF THE INSANE, [Oct,

Digitized by VjOOQle

number left 1 3rd and 4th

1900.] BY D. ORR, M.B., AND T. P. COWEN, M.D.

711

Digitized by VjOOQle

712

PREPARATIONS AND LANTERN SLIDES,

[Oct.,

Demonstration of Preparations and Lantern Slides from
the Pathological Laboratory of the London Asylums ,
at Claybury . By J. Shaw Bolton, M.D.Lond.

The preparations I am about to exhibit are taken from cases
that have occurred during the past three months at Claybury.
The first three are, I am afraid, of no neurological interest, but
they are somewhat rare. The first is a case of aneurysm of the
thoracic aorta. The patient died suddenly from haemorrhage.
Her age was forty, and she had had three attacks of haemorrhage
previously to the fatal one. She was a chronic drunkard and
had had fits. The shape of the clot is rather curious. It is
more or less cylindrical, and seems to have burrowed down into
the chest, pushing the lower lobe of the left lung forward as its
sac. The next specimen is one of rupture of the first part of
the arch of the aorta. This patient was an old woman of eighty,
who had been resident for about a year, and then developed an
attack of bronchitis. In the course of two or three days she
got rather worse, and one evening told the nurse she thought
she was going to die the following morning. She did die, and
the interesting point about it is, that the only other case of
rupture of the aorta I remember seeing occurred in a man of
about forty-five, and he, also, the day before he died, said he
thought he was going to die. The blood had ruptured the
aorta in a T-shaped manner about an inch above the coronary
arteries, and passed down between the pericardium and over the
wall of the aorta and ruptured into the former. The next
specimen is an exceedingly rare one. The man was about
seventy-seven years of age, and he had symptoms of sensory
asphasia. He was quite unable to remember even his own
name, or any other name, but if a name was mentioned to him
he at once recognised it In the same way, he could not write
a single word, but he at once recognised a word which was men¬
tioned to him, and he was able to write it. The aphasia was
associated with symmetrical lesions of the angular gyri. The
man died quite suddenly one evening while talking to another
patient, and the cause of death was heart failure due to aneurysm
of the left ventricle. I do not remember ever before seeing,
except in a museum, an aneurysm of the left ventricle. The

Digitized by VjOOQle

1900.] BY J. SHAW BOLTON, M.D. 7IJ

true wall of the ventricle is about two to three millimetres in
thickness, the pericardium is generally universally adherent, and
the anterior part of the left ventricle is about an inch in thick¬
ness, owing to the existence of this aneurysmal clot.

Dr. Bolton then exhibited lantern plates of the cerebral lesions
found in this case, and proceeded to describe and illustrate two
cases of gross lesion of the right cerebral hemisphere. Both
patients suffered from emotional instability and from epilep¬
tiform seizures, and neither developed dementia. The intact
left hemisphere of the first case weighed only 500 grammes, and
the patient was in the asylum for eight out of the ten years
during which the lesion had existed. The left hemisphere of
the second case weighed within the normal limits, and the
patient earned her living as a washerwoman for ten years
after the lesion occurred, and was only under asylum treat¬
ment for a few weeks. He drew attention to the difference
in weight (nearly 100 grammes) between the right and left
hemispheres in the two cases, and suggested that the emo¬
tional instability was probably due to a loss of balance between
the two hemispheres. He explained the long residence of the
first case in the asylum on the ground that her hemispheres*
weighing normally only 500 grammes each, would probably,
when 100 grammes were lost from one of them by a lesion, be
unable to carry on their functions in a manner consistent with
freedom from asylum regime.

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

The President. —I am particularly interested in the last two specimens, which
show an extremely interesting condition of the convolutions often found in the
brains of imbeciles. In fact, had I not been told that they were cases of insane
people, I should have been inclined to say they were. In cases of low intellect it
is not at all uncommon to find convolutions which are from three eighths inch ta
one eighth inch in width.

Dr. Clouston. —In reference to the lack of control probably being connected
with a one-sidedness of action between the two hemisphere, a French author, over
thirty years ago, published a large series of weights, showing that in epileptic
insanity, more than any other form of mental disease, there is a lack of symmetry
between the weights of the two hemispheres. As to whether the particular kind
of wasting described by Dr. Bolton would cause such a lack of control is, I think,
a difficult question to decide. My own opinion is that lack of control is always an
energising quality; and it seems to me to be a somewhat too easy and too gross
an explanation to say that a man loses control because one side of his brain is
bigger or more healthy than the other. We know that atrophies, softening, and
all sorts of degenerations are owing to vascular causes; but it strikes me very
forcibly that some of the atrophy in Dr. Bolton's cases was owing to an innate
lack of trophic power in the brain cells and parts of the cortex. One often sees

Digitized by VjOOQle

714

LANTERN DEMONSTRATION,

[Oct.,

general atrophy without the least localised vascular defect. I have had such a
case under my care. His speech gradually became circumscribed to the two
words “ oh, yes ”; and when emotionally excited he had two other words. When
he wanted an extra cup of coffee he would push out his cup and say, “ Oh, yes ;
damn you.” That comprised his whole vocabulary. There was no vascular
lesion whatever; the two sides of the brain were uniformly atrophied; and I was
perfectly satisfied that the atrophy took place from an innate want of trophic
power.

Dr. Clapham said that, from his own observations, he was inclined to concur
in the view that a good deal of the loss of control was due to loss of symmetry as
regards the weight in the two sides of the brain.

Dr. Bolton. — I am very pleased to find that the President agrees with my
remark with reference to the small brains found in asylums, and I hope, in the
course of two or three years, when I have systematically examined this question,
to be able to prove definitely that there is in asylums a large class of cases, who,
if they were treated out of asylums, as was suggested in the President’s address
yesterday, would probably not have to go to asylums at all. I think that this
would apply to my first case. I have not undertaken any microscopical examina¬
tions, because these are at present in the hands of Dr. Treadgold, who is investi¬
gating the condition of nerve-cells in idiots. When speaking of the loss of balance
I was not referring to an isolated phenomenon, but to what is practically a general
physiological law, namely, that a great number of the symptoms, not only in mental
but in ordinary brain disease, are due to loss of balance between associated groups
of neurones. The frequency with which patients suffering from one-sided lesions
are liable to epileptic fits agrees with what I said, for this question of loss of moral
control I conceive to be similar to the loss of physical control in the case of epi¬
leptic seizures. As regards the atrophic condition of the hemisphere in the first
case, I would point out that the whole of the atrophy was in the middle and lower
Rolandic area, and outer surface of the temporal lobe. In the second, the greater
part was post-Rolandic in position. In reply to Dr. Dawson, as to the associa¬
tion centres of Flechsig, the posterior association centres were certainly affected
without the patients suffering, but the lesions were in the right hemisphere,
whilst the left hemisphere was quite healthy. As to the frontal region being
concerned with the power of control, I may say that so far I have not seen
sufficient evidence to make me believe that this is so. I have for some time
been inclined to think that the frontal lobe is concerned with the power of
attention, as distinct from control. The question of control is, I think, dependent
upon the balance of action between the two hemispheres.

Lantern Demonstration on Changes in the Cortical
Nerve-cells in General Paralysis . By George A.

Watson, M.B.

The slides were taken from sections of the cortex of several
cases of juvenile general paralysis, mostly stained by Nissl’s
method or one of its modifications. The work was done at the
London County Asylums Laboratory at Claybury.

i. Slides were shown illustrating cases which had compara¬
tively little congestion of vessels and little evidence of an
inflammatory process. The cells in these cases exhibited only
a chronic atrophic change, and the cells were much fewer in

Digitized by VjOOQle

1900.] BY GEORGE A. WATSON, M.B. 715

number than normal. No acute changes were found in this
class of case.

2. Slides illustrating great congestion of the vessels both of
the pia and throughout the cortex, with thickening of their
walls and leucocyte infiltration in the perivascular lymphatic
spaces. Many of the cells in these cases showed acute degenera¬
tive changes. Various stages in these changes were illustrated,
from swelling of the cell and its nucleus with commencing dis¬
appearance of the chromophile elements at the periphery of the
cell and along its processes, to almost total disappearance of
these elements and extrusion of the nucleus. A section of
spinal cord was also shown with recent degeneration of some
of the fibres of the crossed pyramidal tracts—these fibres being
the projection fibres of certain of the pyramidal cortical cells,
which had undergone acute destruction.

3. Several slides, by the kind permission of Dr. Mott, were
shown from the cortex of animals which were the subject of
experiments by Dr. Leonard Hill, in the production of experi¬
mental anaemia by the ligation of three or four of the cerebral
arteries. Cells were exhibited showing the effects of anaemia of
from half an hour to five days* duration, and these were com¬
pared with similar changes found in the cortex of certain cases
of general paralysis, viz. those with marked venous congestion.

It was explained that the acute changes in the cells in the
two conditions were probably due to the same cause, although
produced in an opposite manner, in the experimental cases the
anaemia being caused from the arterial side, in general paralysis
from the venous; in the latter congestion or inflammatory
stasis in the veins leading to anaemia of certain areas of the
cortex.

It would appear that a slow atrophic degeneration is the
primary condition as regards the cells in general paralysis, but
that frequently owing to vascular disturbanqes (especially in
those cases which have “ seizures ”) an acute destruction of cells
in certain areas occurs from time to time.

Digitized by VjOOQle

7 i 6

SOME PATHOLOGICAL CHANGES,

[Oct.,

Some Pathological Changes met with in the great Nerve
Cells of the Insane , with Special Reference to the
condition known as “ Reaction at a Distance .” By
John Turner, M.B., read at the Annual Meeting, July
27th, 1900, and illustrated by lantern slides.

The pictures I am going to show are taken from photo¬
micrographs of the giant pyramidal nerve-cells of the upper
part of the ascending frontal convolution, and the neighbouring
paracentral, and my remarks refer entirely to this variety of
cell. They have been studied in sections, stained after modifi¬
cations of Nissl’s method, and in film preparations in which
the entire cell is seen.

More than 300 cases of insanity of all forms, of all ages,
and of both sexes, have been examined.

I do not intend to describe all the different alterations seen
in the cells of these cases, but only to refer to and illustrate a
few of the more obvious and universal changes met with. By
universal I mean where the whole or a preponderating ma¬
jority of the cells are similarly affected. There are changes—
various forms of chromatolysis, etc.,—which are found to a
greater or less extent in all cases, and although these may be
very important they will not be referred to.

I.—Reaction at a Distance.

Of the changes affecting all the cells by far the most inter¬
esting at present, to my mind, is that which is identical to the
change produced experimentally in animals by dividing the
axis-cylinder of a nerve-cell, the so-called “ reaction at a
distance.” It is the change about which we have the most
knowledge derived from experiments on animals, as to its
cause, and its course and termination. If a nerve-root is cut
through, certain changes are set up in the nerve-cells from
which it originates. These have been studied by Nissl, Mari-
nesco, Van Gehuchten, Flatau, and a host of others, chiefly in
connection with the motor nerve-roots of the cranial nuclei,
with fairly harmonious results. One of the earliest changes

Digitized by VjOOQle

1900 .]

BY JOHN TURNER, M.B.

717

noticed, and which begins within a few hours after the sever¬
ance of the nerve-root, is a degeneration of the Nissl bodies,
beginning at the centre of the cell, and spreading in all direc¬
tions. The bulky Nissl bodies are broken up into smaller
and smaller granules; the cell increases in volume, and the
nucleus wanders to the side. These changes begin from twenty-
four to forty hours after the injury, and proceed, getting
more pronounced, for fifteen to twenty days.

If the cut ends of the nerves are allowed to re-unite, then
after that period there is a gradual restitution of the cell, but
with this stage we shall have very little concern. Ultimately
there are always found, even after the restitution of the greater
number of the cells, a few which are very pale, which are
reduced in size, and which have evidently degenerated beyond
the power of restitution. Now a similar series of changes, but
passing on to the degeneration of the cells, is found affecting
practically the whole of the large pyramidal and giant-cells of
the cortex in certain forms of insanity, and in two of these
cases, in which I examined the spinal cord, there was found by
Marches method a degeneration of the crossed pyramidal
tracts, which was in one case most marked in the lumbar and
lower dorsal region, where it was obvious to the naked eye
after the cord had been hardened in Muller's fluid, as a triangu¬
larly shaped pale patch; but higher up in the cervical region
this patch of degeneration was barely visible, and after the
treatment with osmic acid, the black spots of degeneration
were more numerous in the former than in the latter region,
whilst in the cortex in the immediate neighbourhod of the
degenerated cells no degenerated fibres were seen. (*)

Thus there appears to be associated with this condition of
the nerve-cells an ascending degeneration of the nerve-fibres
occurring in a motor tract. This is a question which has of
recent years occupied considerable attention, but in the cases
previously studied it has been brought about by injury to a
peripheral part of the axon, and as far as I know has not been
noted after changes in the cells themselves.

We can understand this phenomenon on the assumption
that the most distant parts of the neuron are the first to suc¬
cumb to trophic disturbances in the central part. (Pictures were
shown illustrating the Marchi reaction in cross and longitu¬
dinal sections of the crossed pyramidal tract in one of these

Digitized by VjOOQle

7 iS

SOME PATHOLOGICAL CHANGES,

[Oct.,

cases; also several normal stichochrome giant-cells entire and
in section, and then a series of pictures illustrating various
stages in degenerating nerve-cells corresponding to those ob¬
tained by experiment.)

Fig. i shows an early stage in the condition. The cell is
swollen, the granular degeneration of the centre has involved
nearly the whole cell body, which has now in its central part a
pale, blurred, or washed-out appearance ; at the extreme peri¬
phery and in the apex are still numerous and bulky Nissl
bodies. The lower end of the cell is occupied by yellow pig¬
ment. The nucleus, which is large and inflated, is somewhat
displaced to the side of the cell.

Fig. 3, an entire cell, shows a very advanced stage. The
cell is small, stained of a pale lilac tint, and much pigmented.
There is no trace of chromophilic matter in the body or
branches of the cell. The nucleus and its contained nucleolus
are pushed right up against one side. A process can be seen
passing off from the pigmented portion of the cell.

Roughly speaking, only in certain grave forms of melan¬
cholia, usually terminating quickly in dementia, and in certain
imbeciles do we get the above changes, so far as my experience
extends. I do not mean to say that one does not meet with
occasional instances in other cases, but not to the marked
extent found in those I have mentioned, where, indeed, they are
practically the only kind seen, and in advanced cases will be
found implicating, but in a lessening degree as we descend, the
majority of the anterior cornual cells from the cervical region
to the lumbar enlargement.

Dr. Wiglesworth was, I believe, the first to point out this
condition, as early as 1883, in two cases of so-called melan¬
cholia atonita.

The following is a very brief rdsumJ of the sixteen cases in
which I have met with the change.

1. I. B—, a female aet. 45. History of alcoholism. The
insanity is of eighteen months* duration, and was characterised
by depression and occasional violent fits. When admitted she
was delirious and exhibited involuntary jerking of the limbs.
She died of pneumonia after a residence of a few weeks.

2. J. W—, female ; when admitted was excited and unruly;
rapidly became demented, and after six months* residence died,,
aet 53.

Digitized by VjOOQle

1900.]

BY JOHN TURNER, M.B.

719

3. E. E. W—, a female. Became insane when twenty-
seven, and remained in a state of delusional insanity for many
years. Imagined that plots were formed against her, and con¬
spiracies to blow her up with dynamite. Became acutely
melancholic in 1898, and by three months later was demented
with marked twitching of muscles and diarrhoea, to which she
quickly succumbed, act. 45.

4. M. E. B—, female. Always hysterical; for past year
nervous and apprehensive, and lost the use of her arms and
legs. Admitted in a state of delirium, and died four days later
of bronchitis, aet. 37.

5. A. E. C—, female. Chronic melancholia of ten years
duration. Profoundly depressed, restless and agitated. Died
of diphtheria, aet. 69.

6. A male. Acute delirium with loss of power in legs, and
involuntary jerkings of his muscles. Died five days after
admission, aet. 36.

7. W. A—, a male. Chronic melancholia of seven years
duration, passing into dementia with paresis of lower limbs.
Died of phthisis, aet. 52.

8. A. C—, female. Admitted from another asylum in a
state of dementia inanimate, and dirty in habits ; after three
years* residence developed difficulty of swallowing, and jerky
movements of hands and feet, which rapidly got worse, so that
when interfered with she had an accession of spasm affecting
her whole body. Her temperature rose to 109° F. just before
her death, aet. 39.

9. C. Le G—, a male. At first melancholic, then passed
through a period with delusions of exaltation, and bodily sym¬
ptoms resembling general paralysis. Became demented and
died, aet. 46. A history of syphilis.

10. F. B—, female. Became insane when thirty-one.
Acute melancholia passing into a chronic condition, worse at
night. In December, 1899, cellulitis of the leg supervened on
an injury, and she rapidly became demented and died, aet. 55.

11. I. E—, male. Admitted in a feeble and demented con¬
dition with a diagnosis of locomotor ataxy (not confirmed by
microscopic examination of spinal cord). Died a few days
after admission of bronchitis and chronic Bright’s disease,,
aet 45.

12. A. E. B—, female. Very melancholic and agitated,.

xlvi . 49

Digitized by VjOOQle

720 SOME PATHOLOGICAL CHANGES, [Oct,

with intervals when quite rational. Became depressed and
demented a year after admission, and died exhausted, aet. 3 7.

13. E. J—, female. After suffering from melancholia for a
year was admitted here in a state of acute delirium with twitch¬
ing of muscles of left arm and hand, and lips. Died of pneu¬
monia, aet. 45.

14. A. G—, female. Admitted suffering from chronic
alcoholism with delirium; rapidly became demented with
twitching of muscles of left hand, etc., and died of chronic
Bright’s disease, aet. 41.

15. R. T—, female. An imbecile, very childish and incap¬
able of looking after herself. Died of phthisis, aet 24.

16. A. S—, female. An imbecile, dull and inanimate, and
dirty in her habits. She died of phthisis, aet. 27.

The first seven of these cases have been described more fully
in Brain , Winter Number, 1899 (pp. 575—585).

The motor symptoms there referred to were marked in many
of the later cases, notably Nos. 8—11,13 and 14.

They were also a prominent feature in the two cases de¬
scribed by Wiglesworth.

At first sight it seems hard to understand why two such
diverse conditions as melancholia and imbecility should be
associated by similar cell changes, but I believe that we can
reasonably account for this association on the assumption that
states of melancholia and mania depend on dissolutions of the
nervous system, affecting respectively the sensory and motor
sides of the reflex sensori-motor mechanisms of which the
nervous system is constructed ; that is to say, in melancholia
we get an interference with and blocking of the impulses
coming in on the sensory side of the nervous system.

W. B. Warrington found that on cutting through the pos¬
terior nerve-roots of the spinal cord, at certain cells in the
anterior horns of corresponding segments presented the ap¬
pearance of reaction at a distance, and his explanation is that
motor cells degenerate when they are prevented from function¬
ing either by section of their axons or by depriving them of
the sensory impulses which normally come to them. If this
be correct, it is obvious why, when we have an interference
with the sensory terminations of the reflex, such as I suppose
to take place in melancholic conditions, a corresponding de¬
generation is met with in the motor cells with which these

Digitized by

Google

i goo.]

BY JOHN TURNER, M.B.

7*1

sensory channels are in communication. And further we can
see why in imbeciles, in whom there is very generally a blunt¬
ing of all or most of the senses, and consequently a corre¬
sponding lack of sensory impulses to their higher motor nerve-
cells, there should also be found this alteration.

II.—Cells of Pyrexia.

When rabbits are subjected to heat so as to raise their tem¬
perature six to eight degrees (F.) above normal for several
hours, certain changes are found in the cells of the anterior
horns of the spinal cords. And we find in men that diseases,
in which there is a persistent (/. e. not falling at certain times
of the day) rise of temperature of several degrees, are asso¬
ciated with cells of a similar character in the cord and in the
brain.

We can recognise by studying different cases, etc., stages in
this change. The cell appears to swell, and to present a gradual
diminution in the size of its Nissl bodies, which in the centre
of the cell begin to crumble ; the achromatic substance takes
on the stain, so that ultimately we get an uniformly coloured,
dull , rather pale cell, showing no, or few, very fine threads of
chromophilic matter in the apex. The dendrites also lose
their Nissl bodies and stain uniformly and pale.

It is necessary to point out that, although these cells occur
in pyrexial states, precisely similar ones are met with in diseases
in which either there has been no pyrexia, or in which the
pyrexia has been too slight to account for them.( 2 )

The film preparations give a better picture of this variety of
cell, as they show the wealth of uniformly stained dendrites
appertaining to each cell, and also by this method we can
demonstrate a very important characteristic, and that is the
great fragility of the cell and its processes ; a very slight
pressure is apt to cause the apex or other process to fracture,
and in advanced conditions breaks up the cell body. Usually (/. e.
in other than this condition) the films allow of very con¬
siderable pressure without fracturing the cell processes or per¬
manently altering the shape of the cell, their great elasticity
permitting them to return to their normal shape when the
pressure is removed.

Digitized by VjOOQle

72 2 SOME PATHOLOGICAL CHANGES, [Oct.,

This feature of fragility is one means of differentiating this
kind of cell from others which in sections present very similar
appearances to pyrexial cells.

III.— Cell Changes met with in Acute Delirious

States.

A number of slides were shown illustrating the changes met
with in acute delirious mania, and other conditions of delirium.
The whole cell is intensely stained, and in advanced cases it
presents an ill-formed mass with few or no processes, and
showing no detail. In films they retain their usual shape and
number of processes until a very late stage of the change, but
in sections, subjected to dehydrating agents, they shrink and
appear as dark masses lying in wide pericellular spaces, and
are generally deeply pigmented, and their dendrites are often
fractured across, probably due to the shrinking of the cell by
the alcohol.

Increased density with dark staining of the nucleus appears
as one of the early changes. Ultimately this portion is often
much shrunken, and occasionally displaced. Fig. 2 shows a
cell in this condition.

IV.— Some of the Uses of Films.

That films can ever take the place of sections is an idea not
for one moment to be entertained, but they afford a valuable
control to the very artificial picture of cells seen in optical
section.

They are easily prepared, and are ready for inspection an
hour or so after an autopsy, and often, especially in doubtful
cases of general paralysis, allow of a definite diagnosis being
made. They show the cell in a state most nearly approach¬
ing to its natural condition, and they show the entire cell and
all its processes. They give a truer idea of the amount of
pigment it may contain, and enable us to test its fragility or
elasticity, etc.

Delicate changes in the nucleolus are brought out, which are
often obscured or not visible in sections. Fig. 4 shows a cell

Digitized by VjOOQle

Digitized by

JOURNAL OP MENTAL SCIENCE, OCTOBER, 1900.

1900J

BY JOHN TURNER, M.B.

723

with a greatly swollen nucleolus, which measured 13^, instead
of as usual 8 or 9 n ; it was only faintly stained. This swollen
condition was a common characteristic of the nucleoli of the
giant-cells seen in films taken from the brain of a girl who died
in an epileptic fit.

Both the pallor and enlargement were lost in sections of the
same brain, and the nucleoli appeared much the same size as
usual and darkly stained. It is also an excellent method for
examining the smaller vessels and capillaries of the cortex.

Two slides were shown of cells with pigment tumours, one
of which (Fig. 5) is reproduced. The cell shows a peduncu¬
lated outgrowth of yellow pigment, which it will be seen con¬
tains a large number of Nissl granules, staining blue in the
specimen, and it is an interesting question why these appear
here ; it is unlikely that the excrescence existed as a part of
the cell body, and then took on pigmenting changes ; and on
the other hand, if the growth was primarily pigmenting, it does
not seem very obvious why it should contain chromophilic
particles, unless they were pushed in with the advancing
deposit and growth of the pigment.

(*) Note .—In some cases, as e. g. in one mentioned in Brain (Winter No.,
1899), degenerated nerve-fibres are found in the white matter immediately
adjacent to cortex,—a figure is given showing these. ( 8 ) Dr. Mott has recently
in his ‘ Croonian Lectures ’ shown that the neuroglobulin of the nerve-cells
will, on prolonged heating, coagulate between 107*6° and 109*4° F. He supposes
that under these conditions there is a diffusion of the nuclei proteid into the
achromatic substance of the cell, which coagulates and causes its death. This
does not, however, exclude the possibility of other agencies besides heat,
bringing about a diffusion and coagulation of the neuroglobulin, and resulting
in a similar condition of the cell.

Explanation of Figures.

Fig. 1. x 580. Swollen cell showing early changes characteristic of divided
axon. In the lowermost part is some yellow pigment. From a section.

Fig. 2. x 580. Section of a densely stained cell with a fractured process at
right side and a mass of pigment in its lower half.

Fig. 3. x 400. An entire cell, showing advanced and probably irreparable
changes characteristic of divided axon. The nucleus and nucleolus is seen as a
dark spot quite up against the right side of cell. No Nissl bodies visible. The
cell is small and stains faintly. The lighter portion is yellow pigment.

Fig. 4. x 400. An entire cell showing great increase in the size of nucleolus.

Fig. 5. x 400. An entire cell with normal stichochrome appearance, and
showing an outgrowth of pigment.

Digitized by VjOOQle

7 2 4

MICROSCOPIC EXAMINATION.

[Oct,

A Microscopic Demonstration of the Normal and Patho¬
logical Histology of Mesoglia Cells . By Dr. Ford

Robertson, Edinburgh.

Dr. CLOUSTON in the unavoidable absence of Dr. Ford Robert¬
son made the following remarks :—The first fact that I have to
direct the attention of the meeting to is that Dr. Ford Robertson
has devised a new method of examining nerve-tissues by deposit¬
ing platinum in them. By the use of this platinum method he
has demonstrated, amongst other things, that what is called the
neuroglia is composed of two sets of elements instead of one, as
is generally considered. The neuroglia, as exhibited by this and
other methods, is attached to the arteries, to the fibres, and to
the brain-cells, forming a generally supporting medium. Dr.
Robertson has discovered that in addition to this there is
another set of cells, which he has called the mesoglia cells, con¬
sisting in a typical form of a cell-body, a nucleus and a number
of processes. These processes are in no way connected either
with the vascular substance or with the nerve-cells or the nerve-
fibres. The mesoglia cells are entirely different from neuroglia
cells in appearance, and are found in both the white and grey
matter, and in such abundance that Dr. Robertson thinks that
there are as many mesoglia cells as there are neuroglia cells
existing all through the brain. Sometimes they have no pro¬
cesses, sometimes two processes, but the illustrations show a
typical mesoglia cell from the dog and from man. The exact
function of these mesoglia cells we certainly do not know, but
they certainly do not act in any way as a support to the
general brain structure. The mesoglia cells seem to have a
phagocyte action in certain pathological conditions. They
supply, if not all, at least the greater part of the amyloid bodies
which are found in some of the chronic brain degenerations. I
think you will agree that it is very important that Dr. Ford
Robertson should have discovered a new element in the brain,
the particular use of which will doubtless be demonstrated by
some of the large number of enthusiastic workers on this
subject.

Digitized by VjOOQle

1900 .] PHYSICAL CHANGES DURING MELANCHOLIA. 725

Some Observations on the various Physical Changes
occurring during the Acute and Subacute Stages
of Melancholia. By Lewis C. Bruce, M.D., M.R.C.P.
Edin., Physician Superintendent, and H. de Maine
Alexander, M.D.Edin., Assistant Physician, Perth
District Asylum, Murthly, N.B. ,

During the course of a series of investigations upon the
arterial pressures in recently admitted cases of insanity, we were
struck by the fact that the arterial pressures in cases of acute
melancholia of recent onset followed a more or less definite
course.

We found that during the early period of the attack, when
the pulse was quick, the temperature sometimes elevated, the
patient sleepless, and the mental symptoms acute, that the
arterial pressure was high, varying from 140 to 180 mm. Hg.
If the patients were kept in bed and the arterial tension taken
regularly night and morning, we found that in the course of a
period of very variable duration the tension gradually fell to
120 to 130 mm. Hg., this being preceded by a fall in the
pulse rate; the temperature tended to be slightly below
normal; all the mental symptoms lost their acute character, and
the patients began to sleep again at night. So regularly did
this sequence of events occur that we found ourselves almost
unconsciously talking of the acute and subacute stages of
melancholia.

Having got, as it were, a test in the sphygmometer between
these two stages, we proceeded to examine into the physical
cbndition of our patients when the blood-pressure was high—
the acute stage,—and when the blood-pressure had fallen—the
subacute stage.

We took first the urinary system. In all seven patients
were examined. We found that in these patients in the
acute stage of melancholia, the amount of urine excreted per
twenty-four hours averaged 29*5 ounces, and the excretion
of urea averaged only 200 grains per diem. (The average of
urine in ounces, and the urea in grains, per twenty-four hours,
in the acute and subacute stages, is given in the accompanying
diagrammatic table.)

Digitized by VjOOQle

726 PHYSICAL CHANGES DURING MELANCHOLIA, [Oct,

In four out of the seven urines examined albumen was
present, not in sufficient quantity to be estimated, but suf¬
ficiently plentiful to be easily detected by boiling and precipi¬
tation with cold nitric acid.

In the subacute stage the secretion of urine rose to 41*2
ounces per twenty-four hours, and the excretion of urea to 430
grains per diem ; albumen was never detected. These obser¬
vations were verified when opportunity offered, and we believe
they are fairly correct. Only one patient out of the seven
examined varied from the above rule; in his case, even when
actually melancholic, the amount of urine and urea excreted
never fell below the average of health. We have not included
these results in the diagrammatic table as we consider his case
an unusual one.

Integumentary System .—During the acute stage the skin was
in every case abnormally dry. In no case did we ever find a
trace of nitrogenous excrete products in the perspiration of
these patients.

In the subacute stage the skin became softer and more
healthfully moist. At least two patients sweated profusely—
especially at night—and the sweat contained much waste nitro¬
genous material.

Circulatory System .—Acute stage:—The pulse was quick, 90
to 120 per minute, hard, and irregular. Arterial pressure was
high, 140 to 180 mm. Hg.

Subacute stage:—Pulse 70 to 80, softer, regular, but easily
excited by a sleepless night, indigestion, etc. Arterial pressure
lower, between 120 to 130 mm. Hg.

Alimentary System .—The stomach contents were examined
in three cases. We found in the acute stage, after a test
breakfast, that the quantity of HC 1 . and pepsin present was
deficient, the digesting power of the filtered fluid upon the white
of a hard boiled egg was nil after ten hours, and the motor
power of the stomach was weak.

In the early period of the subacute stage the stomach had
not yet gained power, and the digestive fluid was deficient in
acid and pepsin, and still unable to digest the white of hard
boiled egg; but at the end of ten hours there were signs of
feeble digestive power.

Later, when the patients were nearer recovery, the gastric
functions were active, and in five hours a portion of the white

Digitized by VjOOQle

1900 .] BY L. C. BRUCE AND H. DE M. ALEXANDER. 727

Urine for
24 hours.

Digitized by VjOOQle

728 PHYSICAL CHANGES DURING MELANCHOLIA, [Oct.,

of a hard-boiled egg, similar in size to those previously used as
tests, was almost completely digested ; but the motor power of
the stomach was still apparently deficient.

In one acute case, at least, the salivary secretion was much
disordered, the patient complaining of a bad taste in the mouth
and constantly spitting.

Every one of the seven patients during the acute stage had
flabby, furred tongues, with varying symptoms of impaired
digestive power.

Nervous System .—In every acute case the skin reflexes were
active, and the muscles of the limbs were readily thrown into a
condition of inco-ordinate fibrillary tremor. This condition is
not marked in the subacute stage.

Nutrition was deficient in the acute stage and the early
period of the subacute. After that weight was gained steadily.

Hallucinations of a vivid nature were characteristic of the
acute period, and affected the patient's conduct. In the sub¬
acute stage the hallucinations, if present, were not complained
of, and as a rule did not affect the patient’s conduct.

To sum up, then, our observations, we believe that the majority
of recent cases of melancholia pass through a definite course
prior to recovering or becoming chronic, and we divide that
course into an acute stage and a subacute stage. The acute
stage is characterised by the following symptoms:

(i) Acute Mental Symptoms .—Great depression, restlessness,
vivid hallucinations, sleeplessness. (2) Pulse rapid, hard,,
tending to be irregular, 90 to 120 per minute. Arterial
pressure high, 140 to 180 mm. Hg. (3) Temperature tending
to be febrile, 99 0 F. to ioo° F. (4) Urine scanty, excretion
of urea deficient, trace of albumen present (5) Tongue furred
and foul. No desire for food or drink. Digestive power of
stomach upon coagulated albumen practically nil. Motor
power weak. (6) Skin dry.

The Subacute Stage is characterised by the following
symptoms :

(1) Mental symptoms less acute. The patient generally
sleeps well. Hallucinations, if present, do not affect conduct.
(2) Pulse regular, softer, 70 to 80 per minute. Arterial
pressure 120 to 130 mm. Hg. (3) Temperature never above
98’4°. (4) Urine more abundant, excretion of urea consider¬

ably increased. Albumen never detected. (5) Tongue clean,.

Digitized by VjOOQle

1900.] BY L. C. BRUCE AND H. DE M. ALEXANDER. 72£

taking food more readily. Digestive power of stomach juice at
first weak, but later active. (6) Skin becoming moist; some¬
times perspiration profuse.

Treatment .—If these observations are correct, we believe
that treatment should be directed to:

(i) Lowering the blood-pressure. (2) Increasing the
excretion of urea. (3) Obtaining a healthy action of the skin*
(4) Assisting digestion and assimilation by artificially digesting
the food.

So far we have only had experience of lowering the general
arterial pressure, for which purpose we use erythrol tetranitrate,.
upon the recommendation of Dr. Maurice Craig. Out of our
seven cases we have had three very satisfactory results ; half a
grain of erythrol tetranitrate given night and morning reduced
the blood-pressure, induced sleep, and relieved the patients of
acute symptoms. These three cases were all recent and treated
at once, and the results of treatment strongly point to this con¬
clusion that, if you can get a case of melancholia in the early
acute stage, before the brain cells have undergone any organic
change, relief, and perhaps rapid recovery, may follow this simple
treatment. Of this, however, we are certain, that if you succeed
in reducing the general blood-pressure you relieve the acute
mental symptoms, and the patient generally sleeps without
hypnotics. In some cases erythrol tetranitrate entirely fails,
to reduce the general blood-pressure, and in these cases one
must fall back upon the usual hypnotics. Even then it is quite
remarkable what an effect a good night’s sleep has—even when
obtained through the medium of a hypnotic—in temporarily
lowering the general blood-pressure and relieving the acute
mental symptoms. We do not know why in one case erythrol
tetranitrate should act like a charm, and in another apparently
similar case it should fail; but when this drug fails to act we are
inclined to look for a physical cause.

To increase the excretion of urea we employ ammonium
carbonate in ten-grain doses thrice daily.

The skin is excited to act by means of hot air baths.

The admissions to Murthly Asylum are, however, few, and
since coming to the conclusions stated in this paper no case of
acute melancholia has been admitted, so that at present we are
unable to say whether these measures will in future shorten the
course of attacks of acute melancholia.

Digitized by

Google

^30 PHYSICAL CHANGES DURING MELANCHOLIA. [Oct,

In conclusion, we may state that we treat all our melancholic
patients in bed during the acute stage.

In the subacute stage we believe that moderate exercise is
more beneficial than complete rest.

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

Dr. Rayner. —I cannot but feel that Dr. Bruce has hit on a very great truth set
forth in his brief and valuable paper. At Hanwell I always treated very acute
melancholiacs with rest in bed, with the best results; and I am quite convinced of
the usefulness of reducing pulse-tension. I have generally found that more effect¬
ually done by hot vapour baths or packs rather than by hypnotics. I lately had a
case of most acute melancholia with marked insomnia, together with a high
tension pulse, which could not be lowered by any means until the vapour bath was
used. As soon as the tension was reduced the patient got sleep and convalesced
very rapidly. I would also support Dr. Bruce’s observation with regard to the
secretion of urine. It is my rule to induce melancholiacs to drink as much water
as possible.

Dr. Dawson. —I should like to know whether Dr. Bruce has found that erythrol
tetranitrite produced excitement. Since reading Dr. Craig’s paper I have tried it
in a good many cases, and in two of extremely acute agitated melancholia, at least,
it caused excitement.

Dr. Mickle. —I think that the cases spoken of by Dr. Bruce as acute melan¬
cholia are those in which one gets very good effects by inducing copious perspira¬
tion, and purging with mercurials. Peptonised foods, of course, are also useful
in such cases. I think that if we can avoid the use of very strong narcotics
it is better for the patient in the end. With regard to ammonium carbonate,
I have been careful under like conditions not to give it, because it is so easily
changed into urea in the system.

Dr. Clouston. —Some cases of melancholia undoubtedly have a very quick,
hard pulse, and there are certain melancholiacs whose pulse is always over 100,
sometimes running up to 120, 130 or even 140. That will go on during the
whole of the early stage of melancholia. In the cases that do not improve it will
continue for a year, and I have known it last for eighteen months. I have tried
erythrol, but I am bound to state that hitherto I have never met with any drug or
treatment that seemed to affect the pulse until a certain improvement took place,
as it were, in the natural course of the disease.

Dr. Jones.— Dr. Mott pointed out, I think, that brain-matter decomposes into
glycero-phosphoric acids and cholin, and he has made very interesting experi¬
ments with the latter. Whether the cases that have been referred to are due to
the accumulation of cholin, owing to metabolic changes in nerve-cells, we are not
told. I am very much interested in this question, and very grateful to Dr. Bruce
for his paper, but I think we must be a little careful in arriving at our conclusions.
We have had seven cases quoted, and I should like to know what the ratio of the
excretion of phosphates was to the excretion of urea; also whether there was any
relation between the arterial tension, as caused by renal mischief, because we have
in some of the cases the presence of albumen in the urine. Another sentence
drew my attention, namely, “ If we are able to lower the blood-pressure before
the brain cells undergo any organic change, recovery may take place; ” this is a
strong phrase to use, for we at present know but little about changes in the brain
cells. I am pleased to learn of the success of Dr. Bruce’s treatment, and I consider
his paper a valuable contribution to the clinical history of melancholia.

Dr. Bruce. —I have never seen erythrol tetranitrite produce excitement. We
began with half-grain doses, increased to two grains per diem. Our experience
has been, that if it does not succeed within forty-eight hours it is well to stop the
drug altogether. Ammonium carbonate was suggested by my colleague Dr.
Alexander’s recollection of the late Professor Rutherford’s lectures. Sweating
increases urea, and in the cases so treated there was an enormously increased

Digitized by VjOOQle

THE INSANE JEW.

7 31

1900 .]

excretion. But it is quite possible that the ammonium carbonate may be changed
into urea and then excreted. I never saw it do the patients any good whatever,,
but it was only tried in three cases. No man, however skilful, is able to estimate
pulse-tension exactly. The sphygmometer takes a little time to learn, and each
instrument requires knowing, just as you have to know your rod or gun, but when
once it is known one can obtain most trustworthy results. I have seen a quick pulse
in melancholia lasting for nearly a year, and during all that time the pulse rate was
120 a minute. I believe that when the patient is in the acute stage of melan¬
cholia you will elicit all the other symptoms, if you look for them. We have
no criterion for dividing melancholia into various stages. Before using the
sphygmometer I could not understand why one patient excreted 600 grains of
urea during twenty-four hours and another only 200; but we always noticed
that when the acute stage passed into the subacute (after only a few hours or
after forty-eight hours) that the patient had a very heavy excretion of urea.
Some excreted 600 or 700 grains. In those cases in which the quick pulse
persists for a year, I believe that there is some organic change taking place-
in the patient’s brain. I think that Dr. Mott said that cholin lowered tension.
In a general paralytic, after a congestive attack the tension falls, as proved
experimentally by Dr. Mott; but I do not think the same changes take place in
the brain of a melancholiac as occur in a general paralytic. As regards renal
mischief, there was absolutely none in the cases brought before you. Of these
patients five have recovered, and the other two are convalescing. If you get a
case of melancholia early, before the brain tissue becomes too deeply involved,
and keep the blood-pressure reduced for ten days, the patient recovers. I have
seen eiythrol act like a charm in such a case, ana have only seen it occasion head¬
ache in two cases. Why it acts in one case and not in another I cannot tell.
From recent observations I am inclined to think that, in a case of melancholia
with great and persistent tension you must look for the cause. I treated a case
of puerperal mania to recovery. Afterwards she fell into a state of acute melan¬
cholia with persistent high tension dependent upon mammary abscess. We
opened the abscess, and the blood-tension has fallen.

The Insane Jew. By Cecil F. Beadles.

A COMPLETE analysis of the mentally-afflicted Jew is far
too vast a subject to bring before this meeting, and any attempt
to give you the entire result of my investigation into the subject
would occupy far too much of your time.

Under these circumstances I propose to briefly touch on one
or two of the more salient features that an examination of
something over 1000 cases has revealed, and I look forward
to hearing the experience of others who have been, brought
into contact with members of the race that have become in¬
sane.

First and foremost of all the conclusions that have been,
arrived at, is the abnormally great predominance of general
paralysis amongst the men. The fact that this fatal disease is.
unusually common amongst the Jewish inmates at once forces.

Digitized by VjOOQle

732

THE INSANE JEW,

[Oct,

itself upon the attention of all who take charge of the male
wards in Colney Hatch Asylum. The same, I am informed
by Dr. White, is observable at Stone Asylum, which receives
the Jews from the City. But when we work out the figures,
the result is remarkable.

Reckoning on the admissions, we find that over 21 per cent,
•of all male Jewish admissions were cases of general paralysis.
If we take individuals only it forms 23 per cent. In the
Commissioners’ Report for 1899, general paralysis formed only
13 per cent, of the average yearly pauper admissions into
county and borough asylums. In the four London County
asylums of Hanwell, Banstead, Cane Hill, and Claybury, during
the year 1898, only 10 per cent, of the male admissions were
cases of general paralysis. Forty-one per cent, of the male
Jewish deaths are due to this disease. This may be compared
with the deaths in county and borough asylums in 1898, where
general paralysis accounts for 26 per cent, of the total male
deaths.

What a striking difference 1 Amongst the Jewesses the pro¬
portions hold much the same ratio to the entire admissions and
deaths as do those of the non-Jewish element.

What is there to account for the extraordinary difference ?
There is a growing belief that syphilis plays an important part
in the production of this mental disease.

A question of the very first importance might be solved did
we but know whether syphilis was common or the reverse
amongst the Hebrew race. But it is beset with difficulties
such as are inseparable from all Jewish questions that are
approached. I have made inquiries in various directions.
The result would seem to show that syphilis is fairly frequent,
though doubtfully to the same extent as amongst the popula¬
tion in this country at large.

We must therefore look to other factors. Drunkenness
would certainly seem to be less common amongst the poorer
Jews than is the case amongst the lower classes of English.
On the other hand, sexual excess figures in high ratio as an
assigned cause for insanity.

By those who come in contact with the race in hospital and
private practice, the men are looked upon as neurotic, the
women as hysterical. Neurasthenia, and all that that term
implies, would seem to be a common complaint amongst those

Digitized by VjOOQle

1900.]

BY CECIL F. BEADLES.

733

seeking medical aid. Hereditary insanity probably figures
high in the race, but it is impossible to get at the proper pro¬
portion which this holds.

The mental strain resulting from excessive zeal in acquiring
riches, and the worry and annoyance which must invariably
accompany this greed for worldly goods, doubtless play no
small part in the mental breakdown of these people.

It is difficult to arrive at the exact amount of insanity that
is present amongst the Jews, owing to the absence of any exact
figures, both as regards the entire Jewish population of this
•country, and of the whole of the Jewish inmates of our asylums.
But so far as figures are available, the proportion works out to
about the same as that of the total population of England and
Wales ; and for London in particular, perhaps slightly more
than the former and a trifle less than the latter. It would
seem that the Jews form about i‘S per cent, of the certified
pauper lunatics of London at the present time.

The average age at which Jews become insane is distinctly
earlier than is the age of the non-Jews. This is so of both
sexes. The admission age for Jews is thirty-seven; that for
Jewesses is thirty-six. The average age of all admissions into
the London County asylums in 1898 was forty-three for both
men and women.

The ages at death bear somewhat similar proportions. The
Jew’s average age is forty-four; Jewesses forty-seven. That of
the entire London lunatics was fifty-one for men and fifty-five
for women.

As Colney Hatch is the special Jewish asylum for London,
and the majority of the poorer members of the race who be¬
come insane are brought to that asylum, the relapsed cases
find their way back to the same institution. For this reason
one can better trace and follow up the course of a case than
one can amongst the non-Jewish insane. The relapsed cases
form 14 per cent, of the admissions, which is twice the amount
formed by the entire admissions to London County asylums.
This high figure is not entirely accounted for by the explana¬
tion already given ; it is due in part to a greater frequency of
relapses and the number of Jewish patients discharged as only
relieved.

The recovery rate appears good ; better, in fact, than
amongst the non-Jewish patients, but there are certain reasons

Digitized by VjOOQle

734

THE INSANE JEW,

[Oct.>

to partly account for this. The recovery rate to the total
admissions amongst the Jews is 34/4 per cent, (males 26*1,
females 42*0); that of all the London asylums in 1898 was
30*49 per cent, (males 26*56, females 34*02). The recovery
rate compared with the daily average number resident, and
with the total number under treatment for recent years, comes
out even better. It is dependent for the most part on the
females.

The death rate is less amongst the Jewish patients. This
again is due mostly to the small number of deaths amongst
the women. The large amount of general paralysis naturally
swells the number of fatal cases amongst the men.

The good recovery rate and low death rate amongst the
women is in no small degree to be accounted for by the dis¬
covery of an interesting fact. This is the large proportion that
the various forms of puerperal insanity hold to the total ad¬
missions. In over 15 per cent, of all the Jewish female indi¬
viduals admitted to the asylum, the insanity was traceable to
and associated with child-bearing.

Now in the four asylums, Hanwell, Banstead, Cane Hill, and
Claybury, where the amount of Jewish admissions may be
ignored as practically non-existing, puerperal insanity formed
only 3 per cent, of the total female admissions, and the puer¬
peral states are given as the assigned cause for insanity in only
4 per cent. The Commissioners give a rather higher figure
for their five-year average, viz. 8*8 per cent, of female cases
dealt with.

By deducting the Jewish from all female admissions into
Colney Hatch for the past ten years, I find the proportion of
puerperal cases in this asylum to be 6*18 per cent, of the non-
Jewish admissions.

The difference in these figures, if not quite as remarkable as
was the proportion of general paralysis in the men, is yet very
striking.

We all know that puerperal cases are the most hopeful and
the most recoverable of all cases received into our asylums, and
this is so with the Jewesses. I think we must find an explana¬
tion of the foregoing in the neurotic temperament of the Jewish
women, the early age at which marriage takes place, together
with impaired nutrition from unhealthy occupations and sur¬
roundings in overcrowded centres. The excessive child-bearing

Digitized by VjOOQle

1900.]

BY CECIL F. BEADLES.

735

of the race would scarcely come into play, seeing that mental
breakdown is most often associated with the first parturition.

Notwithstanding the seemingly good recovery rate for the
Jewish insane, I am not inclined to look upon the prospects of
complete mental recovery of those who have been mentally
afflicted as particularly hopeful. Jewish patients are rarely
discharged, except to friends, and the relatives of Jews are
continually wishing to take the afflicted patients out of the
asylum, even when they are obviously insane or far from well.
The number of Jewish patients that are discharged relieved to
friends is out of all proportion to the non-Jewish patiepts. Of
those that are entered as recovered, the large majority are dis¬
charged after a month’s trial, and they are rarely returned to
the asylum until after their discharge is effected ; but the
number that break down soon after and are brought back as
new cases is very considerable. This is shown in the fact that
27 per cent, of all the Jewish admissions into Colney Hatch
have had previous attacks.

The foreign element in the Jewish insane, as we know it, is
tremendous. Over 80 per cent, of the patients were either
themselves, or their parents, born abroad. They mainly come
from Russian Poland, or German states. The impoverishment
and stress of living many of these have experienced before
reaching this country would surely help to wreck their nervous
systems.

Of the cases that accumulate in the asylum I have not a
good word to say ; they possess all the worse features, in an
exaggerated degree, of the chronic and hopelessly insane.

I have touched but lightly on a few points of insanity as
affecting members of the Hebrew race. There is much more
that might be said, and possibly at no distant date I may
publish in greater detail the results that have been forthcoming
from my inquiry. For the present I have said perhaps suf¬
ficient to show that there are some features of interest con¬
cerning the insane Jew.

What Colney Hatch Asylum is for the Jews of the County
of London, Stone Asylum is for the Jews of the City of
London. As a considerable number of Jews reside within the
City bounds, and mostly in its poorer districts, it stands to
reason that a fair number find their way into the City Asylum.
Dr. Ernest White, its Superintendent, being unable to be

XLVI. SO

Digitized by VjOOQle

736

THE INSANE JEW.

[Oct.,

present at this meeting, has asked me to present his views
on the insane Jew as he knows him. Briefly these are—

There is a relatively large proportion of Jews admitted from
the east end of the City. The majority of these are paupers,
though there are a few private patients. They are all of low
vitality and readily succumb to pulmonary and other diseases.
General paralysis of the insane is very common amongst male
Jews, and runs a rapid course ; the disease is rare amongst
female Jews. Epilepsy is rare in the Jewish insane. Syphilis
is very rare amongst both the males and females. Drink is
more frequently a symptom than a cause of insanity with
them. Mental anxiety and worry are the most frequent causes
of mental breakdown. They are all excitable and live ex¬
citable lives, being constantly under the high pressure of
business in town. In all forms of mental disorder the prospect
of recovery in Jews, both males and females, is less than with
other patients, though the recoveries are fairly satisfactory
amongst those under thirty years of age. The Jewish patients
supply many of the noisy and troublesome patients in an
asylum ; they are all very indolent, frequently faulty in habits,
morally degraded, and are destructive of clothing.

This excellent summary corresponds in all respects with the
estimate one arrives at from a study of the Jewish insane in
Colney Hatch Asylum.

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

Dr. Savage. —In private practice I see a very large number of insane Jews, and
certainly agree with Dr. Beadles that the race, as represented in England, is highly
neurotic. They present every form of neurosis inclusive of diabetes; but in my
experience there is very little general paralysis either among the men or the women.
Just as other races are affected, general paralytics among Jews have nearly all had
some history of syphilitic degeneration. The forms of moral depravity common
among Jews are very marked and disproportionate, and perhaps that is not alto¬
gether surprising, considering the history of the race.

Dr. Shuttle worth. —My former experience amongst imbeciles and idiots led
me to suppose that the proportion of defective children in the Jewish race in this
country was somewhat small. At the Royal Albert Asylum amongst 1600 or 1700
patients I only remember one Jew. This was in the North of England, and it may
be that Jews are not so numerous there as in the South. At Earlswood we had
about two Jews out of 500 patients. Since I have been engaged in other work,
however, I have been struck with the mental instability of Jewish children. The
parents, among the upper classes, are exceedingly neurotic; and I have seen a
great number of children of unstable mental condition, sometimes, but not always,
characterised by a considerable amount of moral perversion. After a good deal
of experience at a large Jewish school in Whitechapel, I am not prepared to say
that the children are more depraved or more degraded than children in other
centres of London. The type to which they belong is as a rule not a very low

Digitized by VjOOQle

ALCOHOLIC HOMICIDE,

1900.]

737

grade ; but they are all highly nervous, and require very careful training by teachers
before they make very much progress.

Dr. Mickle. —Dr. Beadles’ statistics as to the frequency of insanity amongst
the Jews are in accordance with those we already possess on the subject. Certain
observers throughout Russia took a very accurate census years ago, and showed
that although the Jews as a race suffered very much more from insanity and from
nervous diseases than the other inhabitants, they had a much less percentage of
general paralysis. That is in curious contrast \* ith the very large percentage of
general paralysis which appears to have occurred At Colney Hatch among the
Jews drawn from London and the immediate environs. With regard to the large
percentage of recoveries in Jewish patients, that may be easily accounted for. The
moment a patient is better the relations desire his discharge, and there is a tempta¬
tion to enter him as recovered. It is an absolute necessity among people who are
highly neurotic that there should be a very large percentage of what may be summed
together as periodical insanities, yielding returns of repeated recoveries. That
accounts for the large recovery rate amongst the Jews, who are essentially marked
by hereditary mental degeneration. Owing to the defective condition of the
literature of the subject, I have only come to recognise these facts by being able to
follow the cases during many years.

Dr. A. E. Macdonald (New York).—Our experience in America is very much
that which has been detailed. Our hospitals are largely occupied by Jews, and we
can corroborate what has been stated by the reader of the paper as being in accord¬
ance with our own observations.

The President. —My experience at Darenth generally agrees with that of Dr.
Shuttleworth, as there was a very small number of Jewish children there. But my
more recent hospital experience has convinced me that nervous diseases, especially
epilepsy, are very common among them. I have also seen a good many Polish
Jews, who work in close rooms as tailors in London, and who suffer from neuras¬
thenia or early stages of melancholia.

Alcoholic Homicide . By W. C. Sullivan, M.D., Deputy
Medical Officer, H.M. Prison, Pcntonville.

•

The subject of alcoholic homicide has been so often and so
ably treated in this and kindred societies, so fully discussed in
the literature of mental pathology, that some explanation seems
due from anyone who again invites your attention to this
hackneyed theme.

In mitigation of censure I cannot allege that in the facts
which I desire to bring before you there is any saving quality
of freshness. I can but plead that as long as opinions on any
question remain uncertain, and reflect their uncertainty in
vague and arbitrary practice, a useful function may be served
by bringing the old facts and the old arguments to the test of
renewed debate. The problem of alcoholic homicide is in that
position to-day, and thereby it holds a perpetual title to dis¬
cussion. With that explanation I submit to you my paper;

Digitized by L.00Q

738

ALCOHOLIC HOMICIDE,

[Oct,

and if it succeeds, as L trust it will, in eliciting the matured
views of those leaders in our specialty present at this meeting,
my purpose will be attained and my presumption will be justi¬
fied.

The standpoint of this inquiry is essentially clinical. It is
based on a series of eighty observations, comprising thirty-six
cases of homicide and forty-four cases of grave homicidal at¬
tempts, in which the criminal act could in some considerable
measure be assigned to the influence of alcoholism. From the
study of these observations it is proposed to sketch in outline
the clinical type of alcoholic homicide, and further to trace
through the characters of that type the connection between the
intoxication and the act. To this end a detailed analysis of
our figures would profit us little, for too many disturbing,
factors enter into the mechanism of homicide to admit of our
bringing, a mass of observations to such common denominators
as a purely statistical method would demand. The occasional
application of that method to the points where its use may be
legitimate will be better made in the course of our discussion.

Now what are the characteristics of the homicide of alcohol¬
ism ? To bring ourselves at once in contact with the actual
we may take a concrete case, in which these characteristics are
fairly exemplified.

Obs. i.—K—, aet. 28, a sailor. Father mentally un¬
stable, suffered from fits (of uncertain nature); paternal uncle
died insane. Patient himself said to have had sunstroke.
When sober appeared of normal feeling and intelligence ; when
intoxicated was violent. Drinking for about ten years at intervals
determined by his occupation ; convicted three times as drunk
and disorderly, the first occasion six years before his crime.

On the evening of the eleventh day of a severe drinking
bout was seen to go home with his wife, being apparently on
boisterously affectionate terms with her. During the night killed
her by cutting her throat with a razor as she lay in bed, and
made an almost successful attempt to commit suicide with the
same weapon. Professed to have no memory of the act, and
could not at any subsequent time suggest a motive for it.
While under treatment for his self-inflicted wound suffered from
severe alcoholic symptoms, nervous and digestive.

This case is a good example of the automatic type of alco¬
holic homicide. As in the corresponding form of alcoholic

Digitized by VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

739

suicide, there is an entire absence of apparent motive; the act
is committed in a state of acute intoxication by a drunkard of
some standing ; no trace is left in the agent’s memory ; and
finally, to show the identity in nature and origin of the two im¬
pulses, the murder is followed by a suicidal attempt. It is in
the automatic form that alcoholic suicide finds its extreme and
purest type; so is it with alcoholic homicide. Without
violence to the facts, it would be' easy to arrange our observa¬
tions in such serial order as to show how by the gradual attenua¬
tion of its salient characters our typical instance could be
brought into connection with all the clinical varieties of this
form of alcoholic crime. Considerations of time* and space,
however, demand a less lengthy procedure ; it must suffice,
therefore, to illustrate this relation by indicating briefly the
grading of tone in a few of the more essential characters of our
type. ‘

Let us first take the question of stimulus from the environ¬
ment—the influence whose varying degree marks in a certain
measure the connection of alcoholic homicide with homicide by
the relatively normal non-intoxicated criminal. In our typical
observation stimulus from without seemed entirely absent
From instances of this kind up to cases where the provocation
is so nearly adequate that the act is hardly abnormal, one might
form a chain of cases differing in the degree of apparent impor¬
tance and 1 relevancy of the extrinsic cause. In one observation,
for iristarice, the alleged and only apparent motive for a homi¬
cidal attempt 1 was the fact that the victim had neglected to
prepare a meal with sufficient expedition : in numerous cases
the plea iiV palliation of wife-murder was nothing more plausible
than the womhnV addiction ?to“ nagging.” At the other end of
the series we should find k few instances where the alcoholic
murderer was genuinely' aggrieved by pecuniary injustice or
marital infidelity, and where presumably the rble of the intoxi¬
cation in determining the act was relatively less significant. ‘

In connection with this point of extrinsic stimulus we'have
also to bear in mind a consideration which, as we shall see later,
is vitally important in the whole question of alcoholic action,
viz. What may be termed the psycho-motor excitability of the
alcbholic. As is well known, the motor tendency of the image
is in certain phases of intoxication considerably exalted, and
whether it comes as a suggestion from without, or is due to the

Digitized by VjOOQle

740

ALCOHOLIC HOMICIDE,

[Oct.,

influence of the earlier upon the successive stages of an act, it
acquires a force out of proportion not only to the initial stimu¬
lus, but also to the primary emotional erythism of the subject.
The second mode of agency—the influence of the earlier on
the later stages of the act—would account for the transition
often observable from the trivial inception to the ultimate ex¬
cessive violence of aggression, and would also explain that
exaggeration of fury which so frequently characterises the
homicide of the alcoholic. Cases of external suggestion are
less common, or at least less obvious. The following observa¬
tion may perhaps be regarded as an instance of this influence,
though the;absence of corroborative evidence, and, assuming his
veracity, the blurred condition of the culprit’s memory, leave
the point in doubt.

Obs. 2.—P—, aet. 31. No fixed occupation. Mother died
of a “ fit ; ” said to have been demented for some time before
her death. A cousin on the maternal side idiotic ; another
committed suicide. A brother suffered from convulsions in
childhood.

Prisoner was always idle and unstable ; lost several engage¬
ments through drunkenness ; drinking for over ten years before
crime ; was once convicted summarily for drunkenness. Had
had rheumatic fever and syphilis, and suffered from mitral
disease.

Three days before the crime, prisoner took a room in a
brothel, and went on a steady drinking bout with one of the
girls of the house. On the day of the crime, in the after¬
noon, he went out with this girl; having had some drink in
a tavern they entered a cab, directing the driver to take them
back to the brothel. On arriving there P— got out of the
cab, and told the driver that he had killed the girl, that she
had asked him to do so. She was stabbed to the heart with
a penknife. P— could give no further account of the affair :
the woman told him to stab her, and he obeyed, as one might
in a dream.

A clearer instance of the same agency is given in a case
recorded by Prosper Despine, where one of four drunkards.
Who were carousing together, suggested the hanging of the
most intoxicated of the party—a suggestion promptly carried
out, with results which only failed of being fatal through the
accident of outside intervention.

Digitized by VjOOQle

igoo.]

BY W. C. SULLIVAN, M.D.

741

Let us now turn our attention to the state of consciousness
at the moment of the crime. In our first cited observation
there was, after the event, an absolute blank in the perpe¬
trator’s mind : next to instances of this sort are cases where
memory is more or less blurred, where the act is vaguely re¬
membered though not its motive, or where there is an apparent
recollection of intent and motive but a total amnesia of the
actual occurrence. Finally we reach those cases where the
agent’s consciousness is entirely lucid, and presents no break
in continuity between the phases coincident with the act and
the phases considerably anterior to it.

Closely bound up with this point is the question of so-called
“ motive,” taking that word in its narrower popular sense.
Considering, for simplicity’s sake, only cases of purely alcoholic
origin, i. e . those in which the part of environmental influence
is trivial, we find the fact of motive apparently clear in most
conscious homicides. The alcoholic who has a more or less
definite delusion of his wife’s infidelity, and who murders
her in a condition of fairly lucid consciousness, explains his
act as the result of his belief. But another drunkard, who
has not developed such delusions, may do a precisely similar
act in an automatic phase, and will be quite at a loss to
assign a motive for it. Now in cases of this latter sort it
sometimes happens that though the alcoholic acted automatic¬
ally, and though he had no delusion before or soon after
his crime, he develops later ideas which, had he entertained
them at the moment of his act, would have been held to
constitute his motive. For instance, in two cases of our series
the prisoners, who had committed their offences in a state of
obscured consciousness manifested some time subsequent to
their incarceration, ideas, in one case of poisoning, in the other
of marital infidelity, whereby in a confused fashion they retro¬
spectively justified their actions. Facts of this nature are very
significant of the real relation of the alcoholism to the act.

In determining the condition of consciousness which accom¬
panies the act, the chronicity of the intoxication would appear
to be a factor of special importance: this is so at least to
the extent that, while in all cases the homicidal tendency
implies a certain chronicity in the poisoning, this degree is
notably more considerable in conscious deliberate homicide;
the converse does not hold true, for even in very late stages

Digitized by VjOOQle

742

ALCOHOLIC HOMICIDE,

[Oct.,

of the intoxication we may encounter automatic homicide.
For instance, in one of our cases the murderer, who com¬
mitted his crime in a state of automatism, was over eighty
years of age, and his drinking habits dated from early man¬
hood.

We have said that in all cases a certain chronicity of in¬
toxication is requisite. This is conspicuously evident in regard
of individuals who were primarily of relatively normal organ¬
isation. In such subjects the development of homicidal
impulses is invariably related to an advanced stage of alco¬
holism. But the rule needs qualification in the case of
individuals in whom there exists initially some degree of
mental instability, hereditary or acquired. There may then
be a very precocious development of impulsive automatism.
In one or two instances, indeed, in our series the appearance
of this condition was so very early in the alcoholic career
that the rdle of the intoxication was largely overshadowed by
that of the primary mental disorder. Cases of this kind form
the transition to insane homicide independent of alcoholism.

Another feature of alcoholic homicide which we have indi¬
cated is its association with suicidal impulse. This character
is closely connected with the factor of environmental stimulus.
That is to say, in cases where the homicidal act is in any
important degree determined by influences from the environ¬
ment, there is far less likelihood of an accompanying suicidal
tendency than there is in cases where the aggressive impulse
is of mainly intrinsic origin. This consideration applies both
to cases where the external stimulus is of a kind naturally
to provoke the emotion of anger, and to cases where, as in
Despine’s observation and in our own Obs. No. 2, there is
merely a direcf suggestion of the act, initially at least with¬
out angry emotion. Where, on the other hand, the environ¬
mental factor is insignificant, the coincidence of suicidal
impulse is frequent. In our series the association of the
impulses was noted in fifteen instances, all being cases where
the extrinsic influences were slight or apparently absent. In
automatic cases the impulse to suicide is evidenced by an
actual attempt; in conscious and deliberate cases either by an
attempt or by elaborate preparations, as in the following obser¬
vation.

Obs . 3.—L—, aet. 46. No occupation ; well educated and

Digitized by VjOOQle

BY W. C. SULLIVAN, M.D.

1900.]

743

of independent means. A brother, weak-minded epileptic ;
nothing else notable in the family history.

L— drunkard from about the age of twenty. Owing to
his suspicion and threats his wife was obliged to leave him,
and arrangements were made for the payment to her of a
separate allowance. L— continued drinking, and after a
time professed to be dissatisfied with the financial conditions
of the separation. An interview was appointed at the office
of the wife’s solicitor ; L— arrived with a revolver, locked
the door, and shot at his wife and the solicitor. It was found
that before repairing to the interview L— had visited an
undertaker, and had made detailed arrangements for his own
funeral.

The remaining points in alcoholic suicide, which are some¬
what characteristic, concern the special expression of the
impulse—the victim against whom it is directed, and the
weapon by which it is executed. With regard to the former
we may note that in the large majority of cases the victim is
the wife or mistress of the murderer. This sexual relation¬
ship existed in twenty-four out of the thirty-six actual homi¬
cides in our series.

Consonant with the impulsive nature of the crime, the
weapons employed were generally articles of domestic use, or
tools customary in the murderer’s ordinary avocations.

We have completed our clinical sketch of alcoholic homicide :
it remains to discuss the interpretation of the facts which we
have observed, to investigate the mechanism lying behind them.

This portion of our inquiry I would preface by a quotation
from the master analyst of the unconscious in mind.

“ Every internal organ of the body,” says Dr. Maudsley, “ has
independently of its indirect action upon the nervous system
through changes in the composition of the blood, a specific ac¬
tion upon the brain through its intercommunicating nerve-
fibres, the conscious result whereof is a certain modification of

the mood or tone of mind.These organic effects of

the physiological consensus of organs determine at bottom the
play of the affective nature ; its tone is the harmonic or discor¬
dant outcome of their complex interactions ; the strength of the
force which we develop as will and the emotional colour in
which we see life have their foundation in them.”

Now in the chronic intoxication by alcohol there is disorder

Digitized by VjOOQle

744

ALCOHOLIC HOMICIDE,

[Oct.

of function throughout the economy ; the organic sensations
which are the core of the affective personality are altered in
character ; and there results a depressed emotional tone, which
becomes more dominant as the higher cerebral functions
dwindle, more stable as the visceral conditions from which it
arises grow more fixed.

The clinical study of chronic alcoholism yields us this result;
and, did our inquiry envisage any other of the chronic intoxica¬
tions, its lesson would have been the same. Everywhere we
should find that cerebral enfeeblement accompanied by general
visceral disorder has as its psychic expression dementia with
negative emotional tone, manifest in disorder of feeling, thought,
and will.

Let me so far trespass on your patience as to recall briefly
a few of these other varieties of the toxic temperament. In
chronic lead-poisoning dementia and depression are the basis
of the mental state : Tanquerel des Planches notes the extreme
irritability of saturnine patients, the ease with which slight pro¬
vocation inflames them to maniacal frenzy; their melancholic
attacks with destructive and suicidal impulses, visual hallucina¬
tions, and following amnesia are exact counterparts of the
delirium of alcohol. In chronic ptyalism the clinical picture is
the same: summing up its action, Kussmaul says that mercury
“invariably depresses the emotional tone, and renders the
patient sad ; it excites painful visual hallucinations, and some¬
times leads to a true raptus melancholicus In pellagrous
poisoning the same symptoms are met with: Dr. Sorbets has
emphasised the disposition to suicidal and homicidal acts which
accompanies the dementia in the advanced stages of the dis¬
ease ; Roussel has pointed out the special character of the
suicide of the pellagrous, its appearance of half-unconscious
execution in a state of “ torpeur intellectuelleIn the intoxi¬
cation by bisulphide of carbon, again, there is the same evolu¬
tion of dementia with apathy and depression ; Delpech, in even
the small series of cases which he has recorded, cites one
instance of suicide and one of homicidal violence in subjects
suffering from this poisoning in its chronic form.

Thus in all these intoxications we find an identity of organic
disorder involving a corresponding identity of mental disorder.
Chronic alcoholism is only a special instance of this relation,
though of course deriving from the accident of its enormously

Digitized by VjOOQle

BY W. C. SULLIVAN, M.D.

1900.]

745

preponderant prevalence a practical significance that cannot
attach to the rarer poisons.

And as the dementia and depression which are the essential
psychic results of this general visceral disorder are common to
all these intoxications, so of necessity are also their expressions
in action. In all of them we note the impulse to suicide, and
to suicide under similar appearances ; and in all we find the
allied impulse to violence, to homicide.

The visceral disorders produced by the chronic intoxication
involve, therefore, a special proneness to the development of
those reflexes which underlie the emotion of anger. In lesser
degree this undue readiness of reaction is shown in response to
real environmental stimuli, and seems morbid only because it is
disproportionate to its provoking cause. In more markedly
toxic cases, where the organic factor is of greater potency,
extrinsic stimulus may be insignificant, or may appear entirely
absent. These are the observations which show in least
equivocal form the relationship of the intoxication to the act.
For clearness* sake we shall limit our view to cases of this
nature, and amongst these to cases where initially the subjects
were of relatively normal brain.

We start from the typically automatic homicide, where the
crime is committed in a state of actual drunkenness, and the
agent remembers nothing about it. Here the visceral dis¬
orders, transitory or permanent, which chronic intoxication has
wrought in the drunkard have laid the foundation of a new
affective nature, a new temperament prone to impulses of
aggression. But this nascent temperament is still under the
control of the higher centres; before it can dictate action without
appeal it needs that these higher centres be paralysed by the
added acute intoxication. Later on the disordered organic
stimuli become more articulate, the memory of the act is
clearer, though its motive be still obscure to the agent ; it will
be that a “ something,” he knows not what, “ came over him .”
In a further stage an obscure motive may appear, some sus¬
picion, perhaps, which in sober moments is, professedly at
least, abandoned. And later still we come to those cases
where the act is deferred until the vague organic intimations
have been formulated in a definite delusion, crystallised in
shapes determined by the antecedents of the individual, by the
circumstances of the immediate environment, and perhaps, too,

Digitized by VjOOQle

746

ALCOHOLIC HOMICIDE,

[Oct.,

by some obscurely specific character in the visceral sensations,
as when the dyspeptic drunkard suspects poison in his food*
or the impotent drunkard distrusts the honour of his wife.

In cases of this kind the translation of morbid feeling into
morbid thought is completed before the occurrence of the
homicidal act, and thus the illusion is given that the delirious
idea is the cause of the impulse. The true origin of the
impulse, its immediate dependence on the disorder of ccenaes-
thesia is consequently better seen in the earlier automatic
cases, and best of all, perhaps, in these instances to which we
have referred, where, subsequent to the automatic execution of
the crime, a continuance of the morbid travail which generated
the impulse evolves a delirious idea of corresponding content.
Thus in relation to the impulse the disorder of thought is of
very secondary importance ; it may never occur, or it may
only appear long after the impulse. Its real significance is
that it denotes a more profound disorganisation of the normal
ego , a later period in the growth of the pathological tem¬
perament.

Beyond the delusion there is one more stage in the morbid
process to mark the complete ascendency of the affective
disorder in the mental life.; governing action and governing
thought it may at last extend its command to the senses of
external reference, and evoke the relevant hallucination to
justify its impulse, and to confirm its delusion. No observation
in our series will so well illustrate this evolution as a case
discussed some years ago in the Journal from the medico¬
legal aspect by Dr. Savage, and more fully reported by Dr.
Cassidy. I refer to the case of Baines, who was tried in 1886
for the murder of his wife. I may quote the facts in some
detail, as they are a very epitome of the psychology of
alcoholism.

Obs. 4.—David Baines, aet. 41, fish dealer. No definite
evidence of hereditary taint; his long resistance to alcohol
suggests a normally stable brain. His drinking habits dated
back some twenty or twenty-five years, and within two or
three years of his crime he had several attacks of delirium
tremens; also, without actual delirium, he often suffered from
hallucinations, tremors, and insomnia. Under the influence of
drink he was wont of late to become extremely violent, and
would manifest suspicions of his wife’s fidelity ; he would then

Digitizec. y VjOOQle

1900.]

BY W. C. SULLIVAN, M.D.

747

accuse her, watch her movements, threaten, or even assault
her; on two occasions when in this state he attempted to
commit suicide. When sober he did not entertain, or at least
did not express these ideas.

From June to Christmas day, the date of the murder, Baines
drank very heavily. On Christmas Eve he had a violent
quarrel with his wife; the wrangling lasted late into the night;
Baines stayed up, walking about the house, talking to himself,
apd occasionally beating his head against the wall. Early on
Christmas morning the woman went to a neighbour's house to
ask the time. Baines, who had got possession of a knife and
had sharpened it, followed her there and stabbed her fatally.
Arrested immediately after he said: “ It is all over last night's
affair; I saw it with my own eyes ; I did it deliberately over
that.” Thirty hours later he was hallucinated and delirious,
his ideas referring to the murder of his wife and to his own
bodily condition, “ his inside was taken out, half of his penis
was cut off.”

Questioned subsequently regarding his crime, he stated that
his wife, who constantly deceived him, brought a man to the
house on Christmas Eve; he went *to bed, leaving them
together, and soon after, the door being partly open, he heard
filthy conversation between them, and on looking out saw them
having connection in the presence of the children. After this
the woman and her paramour left the house separately. Baines
slept for the rest of the night. Next morning, armed with a
l^nife, he followed the woman to the neighbour's house ; his
intention was merely to frighten her, but at the last moment
“ something came over me, and I could not help doing it—I
don’t rightly know how it happened-r-I was not master of
myself.”

This remarkable case is an almost diagrammatic illustration
of the genesis of alcoholic homicide. As the psychical
counterpart of the organic disorders consequent on twenty
years of intoxication, the affective personality is altered, the
emotional tone is depressed ; the suicidal impulses are im¬
mediate expressions of this morbid change; gradually the
influence extends to ideation, and disorder of feeling evokes
correspondent disorder of thought, taking the form of delusions
of marital infidelity; these ideas and the disposition to react
in the direction they indicate become more prominent with

Digitized by VjOOQle

748

ALCOHOLIC HOMICIDE.

[Oct,

temporary aggravation of the alcoholism ; later on, exacerba¬
tion of morbid feeling calls up the visual hallucination of the
wife’s adultery, and the homicidal impulse issues in action.
And as it were to give still more unequivocal indication of
the essential condition underlying these various phases, we
have in the subsequent hallucinatory attack, with its delusions
of visceral and, most notably, of genital mutilation, a final
emphasising of this leit motif of vitiated organic feeling.

With this case we may fitly close our review of alcoholic
homicide. Everywhere we have found behind the divergencies
of clinical appearance the same unity of organic causation.
On the bodily side diffused visceral disorder reacting on an
enfeebled brain, on the mental side an altered, a depressed,
affective personality—that is the formula of the toxic tempera¬
ment

This temperament has as its immediate expression the
destructive impulse—suicidal or homicidal,—which issues in
action sometimes with and sometimes without a corresponding
disorder of ideation. When such disorder does exist, its rela¬
tion to the act is merely through dependence on a common
cause in vitiated organic sensation. And in the case of the
delusion this dependence is more remote ; it is, in a certain
measure, an inference, presenting some analogy with the ex post
facto explanations which epileptics and hypnotics sometimes
offer of their automatic acts ; or, to invoke a larger fact, it may
be compared with the normal tendency of our consciousness to
assign to our actions “ motives ” which may differ widely from
the real organic determinants of the will. Indeed, in the
insane drunkard the commentary of consciousness on the
motives of conduct is in some ways nearer to the truth, in that
it at least draws its inspiration more directly from the same
visceral source whence arose the impulse it would interpret;
its explanation is not merely reasoned from the occurrences of
a less immediately relevant environment.

We rest, then, in the conclusion that in the phenomena which
we have studied the fundamental factor is the disorder of
organic sensation ; that disorder generates morbid action and
morbid thought ; but action is the first-begotten, thought is a
later and feebler offspring.

The excessive length of this paper will be my sufficient
excuse for omitting the discussion of the practical aspect of

Digitized by VjOOQle

1900 .] PSYCHOSES ON NERVOUS GLYCOSURIAS.

749

the question,—the legal responsibility of the alcoholic. I con¬
fine myself, therefore, to simply indicating that the clinical facts
of alcoholic homicide are an excellent illustration of the futility
of standards of so-called responsibility which would professedly
judge action solely by reference to the agent’s consciousness.

Discussion.

At the Annual Meeting of the Medico-Psycholygical Association, London, 1900.

Dr. CLOUSTON. —We have to face a great difficulty with regard to alcoholic
homicide. A man commits murder when he is drunk, and the crime is thereby
aggravated; he commits murder whilst labouring under alcoholic insanity, and is
consequently held irresponsible. I have always thought that there was a close
relationship between alcoholic homicide, mania, and convulsions. It is merelv an
accident that one man when drunk will stab his wife, another will have a short
attack of mania, and another will have convulsions. The result is due merely to
what particular organic system the toxic agent acts upon. 1 can recall three simi¬
lar cases to those mentioned by Dr. Sullivan. There is no doubt whatever that
there are some cases where alcoholic homicide may be put down to a reversion to
the savage condition of our ancestry.

The Influence of Psychoses on Nervous Glycosurias. By
David Blair, M.A., M.D., County Asylum, Lancaster.

The rarity of glycosuria among the insane .—When one
observes how frequently nervous influences can be regarded as
predisposing factors in glycosuria, one naturally expects in
communities of the insane to find the condition common. Yet
I think the asylum medical officer who follows the routine
habit of making a careful examination for sugar in the urine of
every case with which he is entrusted, is rarely rewarded for his
trouble. The frequency with which it does occur is differently
stated by different individuals. But with one exception, the
percentages of the insane who suffer from this dystrophy would
appear to vary in different asylums from about five to two.

Apart from insanity, various circumstances influence the pre¬
valence of the affection. It is far more common among the
higher than the lower classes. Dr. Hale White found sugar in
the urine of 4 per cent, of the inmates of Bethlem, but in only
2*6 per cent at the Surrey County Asylum.

The condition is much more commonly observed in men
than in women. Kleen gives three males to one female, while

Digitized by

Google

7 SO

PSYCHOSES ON NERVOUS GLYCOSURIAS, [Oct.,

out of twenty-three cases of non-diabetic glycosuria recently
reported by Saundby only three were females ; so that we are
quite prepared for the high percentage of five recorded by Dr.
Bond among male patients.

But the difficulties in the way of full and exhaustive investi¬
gation for statistics of this kind can hardly be overcome. It
is as incredible that every observer has accepted the same
quantity of sugar in urine as the standard of pathological
significance, as that there has been entire uniformity in the
specimens of urine from which statistics have been compiled.
If, however, we strike an average of these percentages, and
tentatively accept it as a standard of the prevalence of glyco¬
suria among the insane, we find it certainly not greater than
that recorded of sane persons.

Its prevalence among the sane .—Emil Kleen states emphati¬
cally that if samples of urine be taken an hour after dinner
from one hundred brain workers between the ages of forty and
sixty, it will doubtless be found that fifteen of the hundred
samples contain an amount of sugar that is distinctly pathologic.

Worm-Muller, the Norwegian specialist in diabetes, found
pathological quantities of sugar in eighteen, and Nylander in
fourteen samples of urine from one hundred healthy individuals.
These observations have been confirmed by the similar experi¬
ence of others, and seem to show the great commonness of
slight but pathologic glycosuria. The term healthy as here
applied is probably only relative. Careful inquiry would
doubtless elicit collateral symptoms of a /more or less nervous,
gouty or dyspeptic nature. Yet the statistics are sufficiently
applicable for comparison with those of asylums, and tend to
show that glycosuria, far from being specially prevalent among
the tenants of these institutions, is markedly less than among
sane people.

The comparative rarity of this condition among the insane
is somewhat remarkable, and is not without significance. For,
however imperfectly understood, the different pathological con¬
ditions underlying glycosuria may be, there can be no doubt
that in most cases these affect the central nervous system.

Glycosurias other than nervous .—Of course besides nervous
glycosurias several other forms are well known and have been

Digitized by VjOOQle

1900.]

BY DAVID BLAIR, M.A., M.D.

751

recorded. It appears after the ingestion of large quantities of
grape-sugar, both in the healthy and diabetic subjects. It is
found in morbid conditions of the liver and pancreas. Finally,
almost any poisonous substance, if injected into the blood,
impedes the assimilation of carbo-hydrates and causes glyco¬
suria.

But alimentary glycosuria is only physiological, while the
toxic form will disappear shortly after the elimination of the
poison from the system. Pancreatic and hepatic disorders are
probably quite as common among the general public as the
insane.

Division of nervous glycosurias .—Nervous glycosurias may be
conveniently divided into those which are associated with
organic lesions of the cerebro-spinal and sympathetic systems,
and those which accompany functional nervous disturbances.

With the first of these we have little to do. For in the
first place I do not know that it has ever been shown that,
apart from the insanity, other lesions of the nervous system
are commoner among the insane than other people. But,
although this were fully established, it is very doubtful if
glycosuria is more frequently met with among those affected
by such lesions than among ordinary brain-workers. I am
quite aware that it would be almost impossible to cite any
lesion of the nervous system with which this condition has not
been recorded. Nor do I desire to cast any doubt on the
obvious causal connection which exists between different parts
of the brain and cord and glycosuria. But is not our know¬
ledge of this connection rather evolved from experimental
pathology than from the records of clinical experience ? One
observer, Kahler, in twenty-three cases of organic disease of
the central nervous system, found that in only four was the
power of assimilating carbo-hydrates appreciably diminished,
and this is the highest percentage I can find. Certainly in
the cases of this kind which have come within my observation
I have always failed to find glycosuria.

Functional nervous glycosurias .—It is, however, that group
of cases which refer their onset to functional nervous dis¬
turbances in which we are specially interested.

Glycosuria is a disease of the highly nervous and emotional,

XLVI. 51

Digitized by VjOOQle

752 PSYCHOSES ON NERVOUS GLYCOSURIAS, [Oct.,

a fact which is proved by a comparison of its prevalence
among different races, as well as among different sections of
the same race. The highly nervous Hindu is so susceptible
that almost every family among the upper classes in Calcutta
has lost one or two members from this dystrophy, while
one author estimates the deaths from diabetes in the same
city at ten per cent, of the entire mortality.

On the other hand, among the Chinese, whose emotional
life is so slightly developed, the condition is hardly to be met
with. One observer who practised among 15,000 Chinese
labourers came across only one case in a seven years* sojourn.

Among the aborigines, or any people beyond the pale
of culture, it is hardly to be found. But with the advance of
civilisation, attended by keener emotions, more earnest
struggle for existence, and higher nervous development—in fact,
pari passu with the very conditions which accompany the
increase of insanity—we find more glycosuria.

Hereditary influences and alternation of neuroses, —Still further,
a nervous predisposition is by far the most common of the
hereditary influences which are so important in the aetiology of
this affection. Diabetes itself is often hereditary, but it is more
frequently the mere manifestation in one individual of a neurotic
history which in his forebears showed itself in some form of
mental disease. Dr. Maudsley has recorded as his experience
that it is not uncommon to find a history of diabetes in the
parents or near ancestors of insane patients. Dr. Savage states
that diabetes in a parent may be directly related to insanity in
the offspring; and further asserts that this alternation may
occur not only in the family but also in the individual. A
patient may suffer from diabetes for a time and may become
insane, when all symptoms of diabetes disappear, only to re¬
appear on the recovery from the insanity. Thus we have sug¬
gested one reason for the rarity of glycosuria among the insane
—namely the alternation of neuroses. But I think it even
more depends on another consideration. When glycosuria and
insanity occur in the same individual the one is not due to the
other, but they are more probably both due to the same cause.

Immunity of the insane from the causes of glycosuria ,—But
the blunted sensibility which is so attendant on pronounced

Digitized by VjOOQle

1900 .]

BY DAVID BLAIR, M.A., M.D.

753

insanity prevents the action of the cause which would produce
glycosuria in a sane person just as asthma is abolished by
dementia. For example, grief and bereavement are well-
known causes of this dystrophy, especially among those who
have a predisposition to neuroses. As these nervous disturb¬
ances are often transient, so is the excretion of sugar which
accompanies them. But if they are prolonged and become
permanent, so will the glycosuria.

Should a person thus affected by the pangs of grief suddenly
become maniacal, the susceptibility to painful emotion seems to
vanish. In short, the cause of the glycosuria will cease to exist
for practical purposes, and with the cause the effect. Such at
all events would appear to be suggested by the following cases
which have recently come before my notice.

Case i.— M. L— was admitted to the Lancaster County Asylum on
April 15th, 1897. Before admission she had been employed in a con¬
fectioner’s shop; had suffered for some time from headaches and
had been run down physically. Finally, she had been cruelly jilted by
her lover, as a result of which she became extremely wretched. When
first entrusted to our care she threw herself about, screamed, laughed,
cried, and was in speech and action irrational and erotic. For a time
there was marked tenderness over the uterus and ovaries, and she only
menstruated once during the first six months.

Towards the end of July her excitement began to abate, till one day
she became suddenly depressed and attempted to strangle herself. In
the mornings now she was bathed in perspiration without obvious cause.
A few riles were detected at the apex of the right lung, but there was
nothing abnormal about the temperature, respiration, or pulse. At
the same time her urine was observed to contain a considerable per¬
centage of sugar, with phosphates and a slight trace of albumen. The
knee-jerks were found to be totally abolished. For ten weeks the urine
was daily examined, and every second or third morning on an average
sugar was found present, while the specific gravity was not less than
io 3 °.

From the earliest detection of the glycosuria she was put to bed and
kept exclusively on a milk diet. During this period she was very de¬
pressed and disinclined for conversation. At times, however, she con¬
fided to the nurse what she had suffered before admission. About the
middle of October her mental gloom began to clear, one knee-jerk
returned, followed in a short time by the other, while her urine ceased
to contain sugar. From this date she rapidly became more cheerful
and energetic, and was soon discharged restored to her mental and phy¬
sical health.

Case 2. —The next case was about fifty-two when she broke down
mentally. The cause of her insanity was ascribed to persistent worry

Digitized by VjOOQle

754 PSYCHOSES ON NERVOUS GLYCOSURIAS, [Oct.,

over lack of success of business, with the struggle to keep up appear¬
ance despite the “ res augusta domL”

She entered the asylum on January 25th, 1894, acutely melancholic
and suicidal. She had attempted suicide immediately before admission
by drinking half a pint of brandy and an ounce of laudanum. She was
in a very low, hopeless state; said it were well if she had never been
bom; that she had done wrong all through and could not see her way
to right She had to be fed by the stomach-tube and required a padded
room at night.

She had always been regular, sober, industrious, and affectionate, but
highly nervous and excitable.

There is no note of her urine having been examined at this time.

From being acutely melancholic she became maniacal, and suffered
almost continuously from chronic mania for nearly six years. She was
very cheerful, erotic, slept well, and rushed headlong at every man she
met to embrace him. She conversed rationally, but always on flippant
topics. Her reading consisted exclusively of silly love stories. She
was very clean and neat in appearance, but posed as a young girl,
decked her head with leaves and flowers, and promised to be recognised
a queen. She heard unmoved of the death of her husband, to whom
she had been greatly attached. At rare intervals during this period she
became slightly depressed and hypochondriacal, but this condition in¬
variably passed off in a day or two. She often complained of indefinite
pains for which there was no physical sign. I frequently examined her
urine, but never found a trace of sugar.

About the beginning of May of this year quite suddenly she became
acutely depressed and returned to the identical mental state in which
she was when admitted. She resisted her food with great violence,
constantly marched up and down in an agony of despair, and required
a padded room at night. She exercised no control over her excreta,
but her urine, whenever it could be got, contained a considerable per¬
centage of sugar. After a few weeks her depression became less acute,
she began to take her food, and exercise self-control, while simultane¬
ously the quantity of sugar in her urine decreased. She is still sad and
subdued, but I think she is a nearer approach to her normal self than
she has been since admission more than six years ago. A trace of
sugar is still at times to be found in her urine, but not more, I think, than
is often met with in old people without special significance. The
specific gravity has fallen to 1015 or even less.

Comparison of the two cases .—The history of these two cases
is almost parellel though, unfortunately, incomplete. It is
impossible to say if the initial depression that ushered in the
insanity was attended by glycosuria, although I think it highly
probable.

It is certain that it was entirely absent in all specimens of
urine examined during the maniacal period. We are equally
sure that it accompanied the onset of that depression which
marked the mental change preceding recovery and coincident,

Digitized by VjOOQle

igoo.]

BY DAVID BLAIR, M.A., M.D.

755

I think, with the re-awakening in the patient of the realisation
of these depressing circumstances which caused her nervous
" breakdown.” The glycosuria in both cases disappeared co-
incidently with the recovery of the patient.

Phase of insanity in which glycosuria is most commonly seen .—
In connection with the phase or degree of insanity with which
sugar in the urine is generally found, the investigations of Dr.
Bond are interesting.

Out of 114 recent cases of melancholia he found sugar in
the urine of eleven, whereas in eighty-two recent cases of
mania he found sugar in the urine of none. As the exuberant
feelings of mania usually express themselves in muscular
activity, the freedom of the urine from sugar during maniacal
periods might be ascribed to the increased consumption of
blood-sugar in the muscles. While conversely, as feelings of
mental depression are commonly associated with muscular in¬
activity, the appearance of sugar in the urine during periods of
melancholia might be held to arise from decreased consumption
of blood-sugar in the muscles. Such a contention is probably
true to some extent, but is negatived in the latter case I have
described. Here the melancholia was so acute and the patient
so restless, that the expenditure of muscular energy was much
greater when melancholic than maniacal; while her consumption
of food during the former period was much less than in the
latter.

In neither of the cases was there polyuria or increase of thirst
or appetite.

Epilepsy and glycosuria .—It is stated that epilepsy is attended
by glycosuria. I cannot speak of epilepsy among the sane, but
my experience of epilepsy among the insane would suggest that
the occurrence of sugar in the urine in this connection is quite
exceptional. I have examined the urine of insane epileptics
many times both before and after fits, while I have had it drawn
off and examined during fits ; but I have never once detected
sugar.

Thyroid preparations and glycosuria. —Diabetes has been said
to abound in paradoxes; one of the most recent refers to the
action of thyroid extract. It is about as common to see it
lauded for its therapeutic value in diabetes as accused of the

Digitized by

Google

756 PSYCHO-PHYSICAL PERCEPTION, [Oct,

production of glycosuria. One writer says it is capable of pro¬
ducing true diabetes.

I have used the drug to a considerable extent. During its
administration I have watched the urine of the patients care¬
fully, and have never seen sugar result from its ingestion. I
have satisfied myself that the preparation of thyroid I use does
itself contain lactose, which is less soluble, but a much stronger
reducing agent than sucrose. It precipitates cuprous oxide
when gently heated with alkaline cupric solution, but does not
ferment with common yeast unless it has been inverted into
glucose and galactose, which both ferment. Lactose passes un¬
changed into the urine after smaller amounts are taken than do
the other saccharids.

Probably in some of the cases reported the sugar may have
been only alimentary or have resulted from hypodermic injection
of the drug.

Psycho-physical Perception. By F. W. Edridge-Green,

M.D., F.R.C.S.

In the perception of a sensation there are the following
factors to be taken into consideration :

1. The physical stimulus.

2. The sense-organ receiving this stimulus.

3. The nerves conveying the effects of the stimulus.

4. The centre of memory receiving the whole impression.

5. The perceptive centres conveying to the mind informa¬
tion concerning individual portions of the impression.

Therefore, imperfect perception may be due to a defect in
any one or more of the above five factors.

1. The physical stimulus .—The physical stimulus is the force
which acting upon the body gives rise to a sensation. It is
often confused with the sensation itself, whereas the two are
quite distinct For instance, the force which acting upon the
eye gives rise to the sensation of light, when falling upon the
back of the hand gives rise to the sensation of heat, and may,
when falling upon the head, covered by hair, give rise to no
sensation whatever. Again, different physical stimuli may

Digitized by VjOOQle

1900 .]

BY F. W. EDRIDGE-GREEN, M.D.

757

cause the same sensation, as a blow on the eye causing the sen¬
sation of light It is very probable that there are many forces
of which we are not cognisant, because they do not act upon
any sense-organ, and yet these forces may be of the greatest
importance. All physical stimuli agree in their ill-defined
character, and the fact that they can be arranged in a series
which has no definite commencement, no definite termination,
and no definite unit. It is easy to arrange time in a series, but
it is impossible to conceive a commencement to time, or that
time can ever end, or that we can conceive a portion of time
which cannot be subdivided ; the portion of time that light
takes to pass through the space of an inch can be divided into
millionths. It is the same with the stimuli that cause the sen¬
sation of heat: there is a perfect series from the lowest to the
highest possible temperature, and it is evident that there are
innumerable gradations from one degree to another. In the
case of the physical stimuli which give rise to the sensation of
light, we know that similar stimuli exist below the red and
above the violet, and that a regular series exists from the red
to the violet. There may be waves far below the red or above
the violet which may be performing very useful work in the
scheme of nature, but of the existence of which we can only
conjecture.

2. The sense-organ receiving the physical stimulus .—The effect
of the sense-organ upon the physical series which I have just
mentioned is that the series now has a definite commencement
and a definite termination. For instance, though we know that
the rays below the red and above the violet are physically
similar to those of the spectrum, they are not perceived.
Very high and very low notes are not perceived. It is the
same with all other physical stimuli. As an example of the
sense-organ I will take the sense of sight, as this is character¬
istic of the others, and is the one at which I have specially
worked. I believe that light acting upon the retina liberates
the visual purple from the rods and a photograph is formed.
The impression is conveyed to the brain through the cones and
optic nerve-fibres. * Kiihne, who made so many observations on
the visual purple, stated that it could not be essential to vision,
and could not be the visual substance, because it is absent from
the cones, and only cones are to be found in the fovea centralis,
the region of most distinct vision. He also stated that frogs

Digitized by

Google

75 8 PSYCHO-PHYSICAL PERCEPTION, [Oct.,

whose retinas had been bleached saw as well as other frogs.
The last objection does not seem to me of much moment, as the
retina might be secreting sufficient visual purple for the purposes
of vision. The first objection furnished me with a ready means
of testing the truth of my theory. I have made numerous
experiments which prove that light may fall on the fovea cen¬
tralis without producing any sensation. The following experi¬
ments can be repeated by anyone.

(1) If we look at two small isolated stars of equal magnitude,
either may be made to disappear by looking fixedly at it, whilst
the other remains conspicuously visible. I found that the
phenomenon was most marked on a dark night and when the
star looked at was in a portion of the sky comparatively free
from other stars, and when only one eye was used. On a very
dark night a considerable number of small stars occupying the
centre of the field of vision may be made to disappear, whilst
stars occupying other areas of the field of vision are plainly
visible.

(2) Other lights or objects when small and with dark sur¬
roundings, as, for instance, a piece of white cardboard on black
velvet, may be made to disappear in a similar manner.

* (3) No change can be observed if a very bright light, a group
of stars, or a uniformly illuminated surface be made the object
of the experiment.

(4) If we look at an illuminated object through a pin hole in
a piece of black cardboard surrounded by black velvet, we find
that unless it be very bright it will not be visible at all. On
moving the eye so that the image does not fall on the centre of
the retina the object appears brighter.

This view of the relative functions of the rods and cones of
the retina is, as far as I am aware, entirely my own, and every
experiment I have made on after-images, perception of lumino¬
sity, etc., supports not only the theory that there is a visual
substance, but that this visual substance is purple. I find that
the after-image of any spectral colour and of white light is
purple, if we take care not to look at the colour too long. The
following is an easy method of proving this. Look at a dull
white cloud for a second or two and then close the eyes, cover¬
ing them with the hands so that no light can enter the eyes
through the eyelids. A dull purple will first be seen, and for a.
few seconds this gets brighter and brighter, giving the sensa-

Digitized by VjOOQle

1900 .]

BY F. W. EDRIDGE-GREEN, M.D.

759

tion of a bright purple light. This gradually fades away with¬
out changing colour. It is best seen if the eyes be kept
closed before being exposed to light, and then only opened for a
second. The image is positive the whole time, the bars of the
window are seen dark. The after-image is bluish at first, and
then rapidly changes to purple. It is difficult to see an after¬
image of this kind if the eyes be previously exposed to light
for some time. These after-images are quite distinct from the
well-known negative after-images. The purple probably only
gives the sensation of purple when in excess. Several very
important experiments bearing on this point have been made
by Mr. Shelford Bid well.

It will be seen from this view that the cones themselves are
not directly sensitive to light, but only to the products of de¬
composition of the visual purple. The actual length of the
spectrum varies in different persons, just as individuals differ in
their ability to perceive very high and low notes. I have
shown that we may have shortening of either end of the spec¬
trum without any other defect of colour perception. In
these cases there is loss of light perception as well as colour
perception, which is not the case in colour blindness due to
defective psycho-physical perception.

3. The nerves conveying the effects to the physical stimulus .—
The visual substance, being decomposed by light, sets up by
chemical, mechanical, or some other physical action, impulses
which are conveyed to the brain through the cones and optic
nerve-fibres, the cones being the terminations of the perceptive
fibres in the retina.

4. The centre of memory receiving the whole impression .—
This I believe to be situated in the optic thalami; space will
not permit me to give my reasons here.

5. The perceptive centres conveying to the mind information
concerning individual portions of the impression .—The whole
impression being brought to the centre of memory, different
portions of the impression, colour, form, size, luminosity, etc.,
are conveyed to the mind through definite perceptive centres.

A psycho-physical series .—By a psycho-physical series I
mean a physical series as it appears to the mind. A psycho¬
physical series is a sensation which is referred to external
objects. It is obvious that the product of the physical

Digitized by

Google

760 psycho-physical perception, [Oct,

stimulus may be considerably altered before it reaches the
mind.

The chief points in which a psycho-physical series differs
from a physical series are, that it has a definite commence¬
ment, a definite termination, and consists of certain definite
units. The limitation of the series is probably due to the
external sensory apparatus, and any unit of a physical series
not coming within the defined range is not perceived. A high
note which is heard distinctly by one person may be quite
inaudible to another, and therefore he can form no opinion
respecting its qualities. It is the same with the sense of
smell. Professor Ramsay informs me that he has met with
many persons who are unable to distinguish that hydrocyanic
acid has any odour whatever, whilst they are able to recognise
other odoriferous bodies. It is obvious that if this condition
were general, prussic acid would be said to be odourless.
Therefore, the definite standard length of a psycho-physical
series having been found for the majority of persons, any
increase in this length for any individual will be a gain, and
any decrease a loss for the person examined. When the
psycho-physical series is shortened, the physical stimuli occupy¬
ing the shortened portion will not be perceived, and the same
result will be produced as if the physical stimuli did not
exist.

Unfortunately we cannot form series of other physical
stimuli in the same way that we can with the rays of light,
and therefore the study of the psycho-physical perception of
these stimuli is attended with as much difficulty as the study of
colour without the aid of the spectrum. Taking, for instance,
odours, we are unable to range these in a series, though a good
deal of light has been thrown upon the subject by Professor
Ramsay, who suggests that a series might be formed in
accordance with the molecular weight of the odoriferous
body.

An absolute psycho-physical unit —The absolute psycho¬
physical units are the basis of every psycho-physical series.
When a person has succeeded in obtaining a match which to
him appears perfect, it is evident that he has brought both
stimuli within one of his absolute psycho-physical units, because
all physical stimuli included in one of these units are regarded
as identical. When a violin is tuned to the piano the following

Digitized by VjOOQle

BY F. W. EDRIDGE-GREEN, M.D.

761

1900.]

takes place. The A string of the violin is tuned until it is
vibrating in harmony with a certain A of the piano. When a
person has succeeded in getting the two strings to vibrate in
apparently perfect unison, it is evident that he has brought the
two into one of his absolute psycho-physical units.

A musician with a more accurate ear, to use the common
expression, would probably not be satisfied with the result
Again, a person with no ear for music, to use the ordinary
expression, would be perfectly satisfied with a match which was
markedly incorrect to most persons. A person who could not
distinguish any difference in sound between the bass and treble
notes—and I have met with such cases,—would be perfectly
satisfied with any match whatever. The perception of weight
could be ascertained by giving a number of persons a series of
weights, and telling them to pick out those which are identical.
To sum up, a perfect match indicates that the physical stimuli
are included in an absolute psycho-physical unit.

An approximate psycho-physical unit —An approximate
psycho-physical unit contains physical units which appear to
be nearly alike. A difference can be distinguished between
different portions of an approximate psycho-physical unit;
but it is a slight difference. An approximate psycho-physical
unit may be defined as a portion of a psycho-physical series
containing absolute psycho-physical units the similarity between
which is greater than the dissimilarity. A few examples, taken
from the sense of taste, will make this clear. All physical
stimuli which could be correctly defined by the word “ sweet ”
would come within one approximate psycho-physical unit.
There are many varieties of sweetness apart from the intensity
of the sensation; thus sugar, honey, glycerine, and saccharin
have each a particular characteristic sweetness, which would
enable them to be distinguished from each other. If portions
of the same liquid were sweetened with the above four sub¬
stances, it would be evident enough on tasting one of these
portions that it was sweet, but it would not be so evident
which of the four substances had been used. On tasting
successively the four liquids, the sweetening agent used for
•each would be evident. When we have obtained two mixtures
which apparently taste exactly alike when compared very
carefully, the physical stimuli are included in an absolute
psycho-physical unit. An approximate psycho-physical unit

Digitized by VjOOQle

76 2

PSYCHO-PHYSICAL PERCEPTION.

[Oct,

can be recognised without comparison; thus it is not necessary
to taste an acid substance to find out whether another substance
is sweet or not. The approximate psycho-physical units in a
series are comparatively few.

It is when we apply this theory to colour that we get the
strongest confirmation. Every fact of colour-blindness and
colour perception falls naturally into its place, and appears as
a consequence of the theory. The spectrum forms an admir¬
able example of a psycho-physical series; the approximate
psycho-physical units are the colours which have received
definite colour names, such as red and green ; the absolute
psycho-physical units are the varieties of the different colours,
such as sage green, olive green, yellow green, etc. The colour
blind may be classified according to the number of colours
they see in the spectrum, five, four, three, two, or one, and they
form a regular series from the normal sighted to the totally
colour blind. When the spectrum is shortened the junctions
of the colours are found to be nearer the unshortened side than
in the normal sighted.

Space has only permitted me to give my views in the barest
outline, and further information on the subject will be found in
my two volumes in the International Scientific Series, but in
this paper I have put the subject in a different form and added
many facts which are not to be found in my books.

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

Dr. Hayes Newington. —These problems are very curious, and one that has
always been most curious to me is how a first-rate violinist can play out of tune.
Dr. Green mentioned the great pain that occurs to a first-rate violinist when any¬
body plays out of tune, but how can a first-rate violinist play with a lot of other
instruments, and yet play out of tune P I knew a case years ago of a very first-
rate amateur who led an excellent orchestra. To me it has always been a puzzle
that a thorough musician, hearing what the pitch of the music going on around
him was, could receive an impression and coin it, so to speak, into a pitch of his
own, and not discover the discrepancy.

Dr. Jones.— A most interesting case is where, with total deprivation of a par¬
ticular sense, it is possible for a person to have a delusion of that sense; that is to-
say, in a case of congenital deaf-mutism, is it possible that the patient can have
hallucinations of the sense of hearing ? Dr. Dundas Grant informs me that it is
quite possible. It is a very subtle point, and little is known about how the outside
world does affect the terminal sense-organs; whether the changes are physical*
chemical, bio-chemical, or electrical. Sir William Crooks has suggested upon
the theory of the X rays that there may be some very subtle mental waves acting in
a very peculiar and subtle way upon nerve-cells. This Society has encouraged
psycho-physical, or experimental psychological papers, and it has been a great
pleasure to hear one by Dr. Edridge-Green, who is a well-known authority upon,
these subjects.

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

763

1900.]

Dr. Edridge-Grebn, in reply to the question raised by the President as to
whether the disappearance of lights was not caused by exhaustion of the retina,
said that the retina would become more readily fatigued by a bright light, whereas
the experiment was made best with a feeble light and the difficulty increased in
proportion to the brightness of the light. In his dark room he used four doors,
and so had an absolutely dark room, and he arranged his lantern so that the
centre spot only could be seen, and one eye was used. In a few seconds all light
disappeared, leaving the whole field of vision quite dark. When the star was in
a dark part of the sky, directly one looked at it, it disappeared, so that there was
not enough light to cause exhaustion. He had mentioned two of Kuhne's argu¬
ments, and a third was that there were many animals that did not possess visual
purple, and were yet able to see perfectly well. He had not thought this was
important enough to mention, because they might have a similar substance that
was colourless to our eyes. When reading a paper at the Royal Society some
years ago, he had explained how trichromic cases of colour blindness saw colours.
Up to that time no person had mentioned any such case. Physicists said that
normal vision was trichromic, but it is not. With regard to the point raised by
Dr. Newington, he suggested whether there was not a tendency to get back to
the natural scale. It had been pointed out to him that a certain violinist was
playing out of tune, and on calculating the points on the string it was found he
was passing on to the natural scale, while the rest of the musicians were playing
on the arbitrary scale, and that he was really playing in tune. He thought
that if the musician were better than his fellows, he was extremely likely to be
put down as defective. As an illustration, he mentioned a case which had been
brought to him as colour blind, and on examination he found that the man
could see seven colours in the spectrum. In another case, that of an artist's
pupil who was said to be more or less colour blind, on examining the patient he
round that he possessed extraordinary colour perception, so much so that he could
recognise what an Associate of the Royal Academy could not, namely, the faintest
wash on a white surface. With regard to Dr. Jones’s remarks, the sense of colour
could be destroyed so as to leave the perception of light and shade perfect;
everything was seen in degrees of light and shade just like a photograph.

Dr. Hayes Newington said he did not think the explanation was quite satis¬
factory, because practically there was no natural scale. The scale in which the
violinist was playing was uniformly abnormal in whatever pitch the rest of the
orchestra were playing.

Clinical Notes and Cases.

On Two Cases of Leptomeningitis . By J. O. Wakelin

Barratt, M.D.Lond., F.R.C.S.Eng., Pathologist to the
West Riding Asylum, Wakefield.

In the following two cases of leptomeningitis the opportunity
occurred of studying not only the histological, but also the
bacteriological conditions present; and in this respect the cases
are of more than usual interest, particularly the second one.
Both were complicated by the co-existence of changes in the
pia arachnoid prior to the advent of a terminal leptomeningitis.
The clinical history throws but little light upon the semi-

Digitized by VjOOQle

764

CLINICAL NOTES AND CASES.

[Oct,

purulent effusion into the meshes of the pia arachnoid. Much
more information is, however, afforded by the post-mortem
examination. In neither case was the leptomeningitis recog¬
nised during life, the co-existence of other lesions rendering the
diagnosis of this condition of much difficulty.

Case i. —This case of leptomeningitis occurred in a patient who
suffered from extensive tuberculosis affecting bone in various situations
and subsequently invading the lung tissue. Amyloid degeneration was
present in a marked degree. Streptococci were present in the exudation
in the meshes of the pia arachnoid.

Clinical Account .—Patient was a male epileptic imbecile, twenty-three
years of age at the time of his death, which occurred one year after ad¬
mission to the asylum. Prior to admission here patient had been for
two years in another asylum. Patient required hand feeding, had a
vacant expression, and answered questions in a loud voice at random.
He was in a spare condition at the time of admission, with discharging
sinuses on the front of the chest, said to have formed during the pre¬
ceding twelve months, and from which portions of the right second rib
were shed. The pupils were equal and reacted briskly. There was
slight congenital defect of speech. Gait feeble. Knee-jerks present.

The heart’s action was rapid. Mitral sounds loud; first sound im¬
pure. There was dulness over the apices of both lungs, especially the
right. Expiration was, here and there over the chest, prolonged and
harsh in character. The urine was amber-coloured and cloudy, with a
copious deposit of mucus, but free from albumen; sp.gr. 1012.

As time went on patient’s mental state underwent little change. At
intervals of about a fortnight or longer he had a succession of three or
four fits, which left him very prostrate for a time. The sinuses on the
front of the chest underwent improvement, but the patient’s physical
state gradually deteriorated, a psoas abscess forming on the right side
about two months before death. No suspicion of leptomeningitis was
entertained during life.

The patient’s mother stated that the tuberculosis was of seven years’
standing.

Post-mortem Appearances .—The skull-cap, which was thick and dense
generally, was thinned at the anterior part of the left temporal region
over an area measuring 35 mm. by 30 mm. At the outer border of this
area the bone was thickened by osteoplastic deposit. Between this
area and the dura mater was a collection of cheesy material about 6 mm.
thick. The dura mater was adherent to the margin of this area. On
the inner surface of the dura mater, at the vertex, chiefly on the right
side, a very thin reddish pellicle was observed.

The pia arachnoid membrane (Fig. 1) was slightly opaque and
milky in aspect, especially about the vertex, but also to a less ex¬
tent at the base and over the upper surface of the cerebellum. This
membrane stripped readily over the left motor area without causing
erosions of the subjacent cortex. The subarachnoid space contained
in excess of clear yellow fluid, except in the following situations, where
foci of thin pus, not sharply limited, but merging gradually into the sub-

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

765

I 900.]

arachnoid fluid, were noticed :—opposite the left temple, corresponding
in position to the collection of cheesy material between the bone and
dura mater; over the posterior part of the upper end of the left ascend¬
ing parietal convolution; in both fissures of Sylvius, particularly on the
left side near the bifurcation; in the cisterna magna and cistema
pontis; and on the upper surface of the cerebellum near the entrance
of the veins of Galen. On cutting up the brain the exudation was found
to extend from the Sylvian fissures to the islands of Reil, but was other¬
wise essentially confined to the situations mentioned above.

The appearance of the pia arachnoid is well seen in Fig. 1. This
membrane, instead of its usual net-like character, was granular in aspect,
being occupied by a semi-solid exudation. This is well seen in the
fissure of Sylvius (f s.) f where the exudation is extremely abundant, but
is also well seen in several other sulci at their outer part. The disten¬
sion of the subarachnoid space with clear fluid, which was also promi¬
nent at the time of the post-mortem, has disappeared in the hardened
section shown in this figure.

The brain, which was symmetrically formed, and weighed 1215
grammes, exhibited some wasting of the cerebral cortex, not consider¬
able in degree, together with slight widening of the sulci. The cerebral
tissue was soft (the post-mortem examination was made twenty-four
hours after death), but exhibited in no part any gross focal lesion.
The ventricles were distended to a moderate degree with fluid. The
ependyma was everywhere smooth, with a thin coating of lymph
deposited irregularly on its surface. The choroid plexuses were healthy
in aspect. No microscopic change was present in the basal ganglia,
cerebellum, pons, and medulla oblongata.

The heart (195 grammes) was small, the myocardium being atrophied
and somewhat friable. The aortic valve was thickened, but no other
lesions were noted. There was commencing atheroma of the root of
the aorta.

The right pleura exhibited extensive old adhesions; the left was
healthy. The right lung exhibited considerable tubercular consolida¬
tion and caseation, chiefly at the right apex, with several fibroid scars
scattered through its substance. The left lung exhibited scars here and
there, particularly at the apex; but no tubercles were present.

The liver (3255 grammes) and spleen (185 grammes) were greatly
enlarged and exhibited marked amyloid change.

The kidneys (right 105 grammes, left 105 grammes) were small.
The capsules were slightly adherent in places, the surface of the kidneys
presenting a mottled mulberry aspect, and the cortex being atrophied.
On microscopical examination considerable cirrhosis was noted, together
with amyloid change, chiefly affecting the pyramids.

The peritoneum was free from tuberculosis. **The small intestine
showed amyloid change.

The right stemo-clavicular articulation was tuberculous, and discharged
externally by a sinus lying over the sternum. The lower dorsal and
upper lumbar vertebra were carious ; a psoas abscess, not discharging
externally, was present on the right side.

Several scars, as well as a small sinus, were seen on the front of the
chest, due to old caries of the sternum and of the anterior ends of the

Digitized by VjOOQle

766 CLINICAL NOTES AND CASES. [Oct,

upper two right and the upper three left ribs and of both clavicles.
There was also an old scar over the left side of the sacrum.

The body was extremely emaciated. Bedsores were absent.

Microscopical and bacteriological examination .—Sections of the pia-
arachnoid made in the situation of the inflammatory exudation (Fig. 2 A)
exhibit a dense infiltration of this membrane with new cells, chiefly
multinucleated and with scanty cytoplasm, and identical with pus cells.
In addition a fair number of mononucleated cells with more abundant
cell-protoplasm are also met with. As the latter predominate where the
^exudation visible to the naked eye is least marked, they must be regarded
as forming part of the cell infiltration, which accompanies the opacity and
thickening of the pia-arachnoid associated with chronic brain atrophy.
No basophile cells were met with. In addition to the cell infiltration
of the pia-arachnoid, there is abundant fluid exudation, which, however,
is for the most part absent from the section shown in Fig. 2 A. No
well-formed fibrin fibrils are recognisable. In some places the nuclei
in the exudation do not stain well and the section assumes an amorphous
aspect, most of the formed structures having become disintegrated.
The appearance of these foci is seen in Fig. 2 B.

In addition to the cell infiltration above described, and the excess of
fluid in the meshes of the pia-arachnoid, blood-vessels are seen of vary¬
ing size, usually much more numerous than in the section shown in
Fig. 2 A. Strands of wavy connective tissue are also seen, especially
under a high magnification. These are everywhere abundant, and where
the small-cell infiltration is least marked it is readily seen that the con¬
nective tissue of the pia-arachnoid is increased in amount.

The cortex, stained by v. Giesen’s method, exhibits little structural
change. The nerve-cells are well seen; there is no increase in the
neuroglia cells, and the blood-vessels are not increased in size. As a rule
perivascular cell infiltration is not observed in the cortex, but occasion¬
ally a vessel is seen descending from the pia-arachnoid, as in Fig. 2 A,
round which new cells can be recognised for a short distance from the
surface. The optic nerves, stained by Marches method, showed degene¬
rated fibres in moderate numbers.

Sections of the exudation, stained by Loeffleris or Gram’s method,
show streptococci in the badly-staining areas referred to above, in which
few formed elements are recognisable (Fig. 2 B). The chains which
these form are frequently of considerable length. Sometimes they are
present in large numbers; sometimes, as in Fig. 2 B, they are scanty,
and in places they are absent from the exudation. They are chiefly
found in the necrotic areas ; less frequently do they lie among the in¬
filtrating cells, and they are not found in those parts of the pia-arachnoid
which are free or nearly free from inflammatory exudation. The dia¬
meter of the individual streptococci varies somewhat even in the same
chain. The average diameter is about 7/1. As already indicated they
retain the stain by Gram’s method. No tubercle bacilli were found in
the exudation in the meshes of the pia-arachnoid.

Film preparations of the exudation made at the time of the post¬
mortem examination showed abundant pus cells, together with a few
streptococci staining by Loeffler’s and by Gram’s method.

Inoculations on agar, peptone broth, and peptone gelatine were made,

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

767

1900.]

but no growth occurred. This failure is probably to be explained by
the circumstance that micro-organisms are not present in all parts of the
exudation.

Summary .—In conclusion attention may be specially drawn to the
following points of pathological interest in the case under consideration.

1. Two pathological conditions existed together in the pia-arachnoid
membrane at the time of death, one recent, the other of old standing:

(a) The patient suffered from a leuco-serous exudation distributed in
a patchy manner in the meshes of the pia-arachnoid, there being inter¬
vening areas apparently free from inflammatory exudation, though dis¬
tended, like the ventricles of the brain, with clear yellowish fluid. The
exudation contained streptococci in large numbers, agreeing in morpho¬
logical appearances and staining reactions with Streptococcus pyogenes
albus [Figs. 1 and 2]. Lymph was also present upon the ependyma
lining the ventricles, in which streptococci of the same appearance and
similarly staining were found. The subjacent cerebral cortex, stained by
v. Giesen’s method, was free from gross change.

( b) The pia-arachnoid also exhibited the changes commonly found
associated with chronic brain atrophy in asylums ; that is to say, it was
thickened and opaque in aspect, and distended with clear fluid in the
areas lying between the semi-purulent foci, showing under the micro¬
scope an abundance of connective tissue, in the meshes of which were
found numerous mononucleated cells with much cytoplasm, all which
changes were prior to the onset of the terminal leptomeningitis.

2. The leptomeningitis occurred towards the close of a widely dis¬
tributed advanced tuberculosis affecting bone and lung tissue, and
attended by extensive amyloid changes in the liver, spleen, kidneys, and
intestines. No suppurating lesions coming to the surface were present,
with the exception of a sinus over the sternum; this was presumably the
source of the infection of the meninges of the brain. A cheesy deposit
was found between the dura mater and bone opposite the left temple,
but no tubercle bacilli were found in the pia-arachnoid.

3. During life no symptoms were noted suggesting the possible exist¬
ence of leptomeningitis.

Case 2. —The patient was an epileptic dement in whom lepto¬
meningitis occurred asa terminal complication. The autopsy revealed ex¬
tensive suppuration in the liver; ascites and jaundice were also present.
Diplococci were found in the exudation in the meshes of the pia-
arachnoid.

Clinical Account —Patient, a female, suffering from epilepsy since
puberty, was admitted into the asylum at the age of thirty-three, with a
diagnosis of epileptic dementia, the present being her first attack of in¬
sanity. On admission she was excited, incoherent in her speech, and
violent towards others. She exhibited considerable defect of memory.
Patient was a soldier’s daughter; married at the age of fifteen ; had five
children, three living, two dead of bronchitis. The epileptic fits occurred
regularly at the menstrual period. No history of insanity, epilepsy,
apoplexy, or drink in patient’s family; patient had received no injury
and had not suffered from any fever.

The pupils were equal and reacted normally. Sight good. Speech

XLVI. 52

Digitized by VjOOQle

768

CLINICAL NOTES AND CASES.

[Oct,

well formulated. No facial tremor or asymmetry; tongue straight,
scarred on edges and tip. Hysterical tremor of limbs at times. Com¬
plained of a sharp piercing pain through temples, which had persisted
for some years past. The respiratory, circulatory and digestive systems
were normal, except for defective appetite. The urine hadsp. gr. 1018,
was acid, pale, and free from albumen or deposit.

Subsequently to admission patient's condition showed but little change.
The fits continued, usually at periods of about one month. Patient
was at times quarrelsome and excited, and her memory continued defec¬
tive. These symptoms appear to have slowly augmented as time went on.

Eight months before death, which occurred fifteen years after admis¬
sion, slight icterus appeared. The liver dulness diminished; the
abdomen was soft and not tender. Patient was free from pain. Sube-
quently the jaundice became more marked, but physical examination
remained negative. Patient was emaciated and feeble. Three and a
half months before death the icterus was much improved, and patient’s
physical condition also improved, but she became demented. Seven
weeks before death the jaundice became aggravated and ascites developed
with remittent pyrexia, the temperature rising in the evening to about
104°. This continued for about three weeks, when the patient died
comatose, with a temperature of 105° F. Leptomeningitis was not
diagnosed during life.

For the clinical notes of which the above is an abstract I am indebted
to Dr. E. Birt.

Post-mortem examination .—The skull-cap was thick but not dense, the
diploe being present in fair thickness. The dura-mater appeared healthy,
and was free from thickening or adhesion to the skull-cap. The sub¬
dural space was empty. The pia-arachnoid was fairly thin, and its trans¬
parency but little changed. The subarachnoid space contained clear
yellowish fluid, except in the following situations, where a thin semi-
purulent exudation was present, both on the free surface of the brain and
extending into the sulci; on the outer surface of both cerebral hemi¬
spheres near the great longitudinal fissure, especially in the frontal region ;
in the cistema magna ; and in the cisterna pontis. The clear fluid in
the subarachnoid space was not, it may be observed, in large amount.
The longitudinal and lateral sinuses were healthy. The arteries at the
base of the brain exhibited atheroma, not marked in degree.

The brain (1370 g.) exhibited little change in aspect beyond the fluid
and exudation in the meshes of the pia-arachnoid just described, and
the corresponding atrophy, slight in amount, of the brain mantle. The
lateral and third ventricles were dilated, but not to a considerable
extent, containing only a small amount of fluid. The ependyma was
everywhere free from granulations, but on its inner surface a very thin
coating of lymph was observed. The choroid plexuses presented no
change. No focal lesions were found in the cerebrum, pons, cerebellum,
or medulla.

The lungs showed oedema and congestion, the left having a creta¬
ceous nodule at the apex. The pleurae were healthy.

The heart (330 g.) was large and flaccid. The heart-muscle was pale
but of fair consistence. All the valves were normal. The coronary
arteries were free from atheroma.

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

769

1900.]

The peritoneal cavity contained seven pints of clear bile-stained fluid.

The liver (1870 g.) was enlarged, fatty, and exceedingly soft and
flabby. It exhibited numerous small, softish, yellowish-white nodules
beneath the capsule and scattered through its substance; also numerous
small abscessses, deeply seated, and one about two and a half centi¬
metres in diameter in the centre of the right lobe. The gall-bladder,
which contained gall-stones, was distended, measuring about twelve
centimetres by seven; the cystic duct was not much enlarged. The
hepatic and common bile-ducts were much widened, the latter admitting
the passage of two fingers.

The spleen was unchanged in aspect and presented no lesion.

The kidneys (R, 180 g.; L. 185 g.) were large, yellowish, very flabby
and anaemic; they contained no cyst or calcareous deposit. Capsule
thin and transparent, stripped readily. The adrenals exhibited no
change.

There was considerable induration about the head of the pancreas.

Attached to the margin of the ductus communis choledochus in the
second part of the duodenum, and projecting in a polypoid form into
the lumen of the gut, was a pyriform soft growth measuring about three
centimetres in length, and about two centimetres in diameter. With
this exception no change was found in the alimentary canal. No en¬
largement of the glands of the mesentery could be detected.

The uterus presented a small fibroma in its anterior wall. The
ovaries were small and fibrous. The Fallopian tubes and ligaments of
the uterus were free from enlargement or inflammation.

The body was much emaciated. The abdomen was considerably
distended. The surface was everywhere of a citron-yellow colour.

Microscopical and Bacteriological Examination .—Special attention was
given to the condition of the pia-arachnoid membrane and to that of
the liver.

As already mentioned, there was inflammatory exudation into the
meshes of the pia, focal in its distribution, accompanied by a diffuse
fluid distension of this membrane. After hardening the condition of
the pia-arachnoid, especially in respect of the solid effusion, was much
more readily and more accurately studied. It was found that not only
was the exudation more dense than appeared at the time of the post¬
mortem examination, but that a certain amount of inflammatory exuda¬
tion was also recognisable where previously only fluid distension was
apparent. In the most affected situations (which have been already
enumerated in the preceding section) the meshes of the pia-arachnoid
are filled up in an irregular manner with an opaque, greyish-white,
puttv-like material, giving this membrane a finely mottled, muddy charac¬
ter (Fig. Ill); elsewhere the opaque exudation was thinner, and dis¬
tributed in small masses or points in the areolae of the pia, while in a
few situations (as in the upper mesial sulci of the left frontal lobe in
Fig. Ill) no trace of exudation could be recognised.

On making sections of the pia-arachnoid in different situations, the
thickness of its connective-tissue framework, where the inflammatory
exudation was relatively inconsiderable, could be recognised to be in¬
creased, though to the naked eye this membrane appeared at the
autopsy to be fairly thin and delicate. At the vertex in the deeper part

Digitized by VjOOQle

77 o

CLINICAL NOTES AND CASES.

[Oct.,

of the pia-arachnoid, where the semi-purulent exudation is least, a fairly
abundant infiltration of cells having large nuclei and abundant cyto¬
plasm is seen (Figs. IV and V). This condition is evidently part of
the pathological change in the pia-arachnoid ordinarily seen when, as
in this case, the brain mantle is atrophied and the subarachnoid space
contains fluid. Elsewhere the pia-arachnoid presents a small-cell infil¬
tration varying in degree in different situations, and separated from the
molecular layer of the cortex by the layer of large protoplasmic cells
just mentioned. Where the small-cell infiltration of the pia-arachnoid
is considerable, extensive areas of this membrane may be densely
packed with cells, no other structures being recognisable. In such
cases foci of disintegration can sometimes be recognised, as in the case
previously described. Elsewhere the small-cell infiltration was less
abundant, and more or less diffuse, but smaller foci formed by the
small cells were frequently found distributed in the meshes of the pia-
arachnoid. In some situations, again, the meshes of this membrane
appeared distended with a fibrinous exudation, consisting sometimes
of well-defined interlacing fibrils (Fig. IV), and sometimes resembling
an irregular sponge-work. It was, however, frequently difficult to dis¬
tinguish between the fibrin fibrils and the finer collagen fibres, even
when a fibrin stain was used.

The small-cells infiltrating the pia-arachnoid were 8 p to 9 /1 in
diameter, and contained irregular, horse-shoe shaped, or more frequently
multipartite, nuclei (Fig. V), with somewhat scanty protoplasm, and
were indistinguishable from the multinuclear leucocytes found in the
blood. The large protoplasmic cells were similar to the one represented
in the lower right-hand comer of Fig. V. They were largest and most
abundant close to the molecular layer of the cortex, and were some¬
times distributed irregularly, sometimes arranged side by side in rows
between the connective-tissue strands. No basophile cells were seen.

The areas of small-cell infiltration were frequently quite free from
micro-organisms. In a limited number of situations, especially where
some disintegration was observable, the small amount of interstitial
amorphous material lying between the ceil nuclei (Fig. V) contained
short, elongated micro-organisms, sometimes singly, more frequently
arranged in diplococci, varying slightly in size, but usually about 1 /1 in
length, and staining by Loeffler’s method. Where present in large
numbers these micro-organisms sometimes appear to lie on the cells,
and it is occasionally difficult to say whether the diplococci are on, in,
or between the cells. Nevertheless, by far the greater number of the
micro-organisms are clearly extra-cellular, and any other disposition is
quite exceptional. The diplococci generally failed to exhibit a distinct
capsule.

The blood-vessels of the pia-arachnoid are numerous, and usually
filled with blood, except where the cell infiltration is dense, when few
or no vessels can be seen. The small-cell infiltration is nowhere
definitely perivascular, even at the edges of the large collections of these
elements.

The vessels of the cortex, whether the inflammatory exudation in the
pia was marked or slight, usually exhibited some degree of thickening,
but were free from surrounding cell infiltration. The cortex itself,

Digitized by VjOOQle

CLINICAL NOTES AND CASES.

1900.]

77 1

stained by v. Giesen’s method, showed no marked structural altera¬
tion

The optic nerves exhibited degeneration, not marked in degree, by
Marchi’s method of staining.

The exudation in the pia arachnoid, examined in cover-slip prepara¬
tions at the time of the autopsy, was found to exhibit fairly numerous
diplococci *8/i to 1 fi long, which stained readily by Loeffler’s and Gram’s
methods, and some of which were encapsuled, and resembled in these

Fig. VI. — Case 2. — Culture
from the exudation into the meshes
of the pia arachnoid membrane of
Case 2, made upon nutrient agar.
Twenty-four hours’ growth. Trans¬
lucent colonies resembling fine
droplets of dew, just visible to
the naked eye, are seen upon the
surface of the agar.

Slightly magnified.

respects, and in their general aspect, Fraenkel’s Diplococcus pneumonia.
The lymph covering the ependyma of the ventricles, similarly examined
on cover-slips, showed numerous polymorphonuclear leucocytes, between
which were diplococci, which, when stained by Lceffler’s method, corre¬
sponded in shape and size to Fraenkel’s diplococcus. They exhibited
no distinct capsule, and, like the preceding, were not contained in cell-
protoplasm.

At the time of the autopsy inoculations from the inflammatory exuda-

Digitized by VjOOQle

772

CLINICAL NOTES AND CASES.

[Oct.,

tion into the pia-arachnoid were made upon two peptone-agar tubes,
care being taken to avoid accidental contamination. At the end of
twenty-four hours at 37 0 C., colonies were observed in each tube having
the form of droplets of dew (Fig. VI), just recognisable with the naked
eye, and arranged along the line of inoculation. During the two follow¬
ing days they increased in size, but their growth soon ceased. Cover-
slip preparations from these cultures showed that they were made up of
diplococci of the same size as those above described, not exhibiting
capsules, not unfrequently arranged in short chains, rarely in long
chains. These micro-organisms stained by Loeffler’s method, and also
by Gram's method. No further growth took place after the expiration
of a week. The cultures appeared to be quite pure, no other micro¬
organisms beyond those just described being met with, and no other
colonies developing subsequently.

To recapitulate, the diplococci present in the meshes of the pia
arachnoid were frequently encapsuled, and resembled FraenkePs Diplo -
coccus pneumonia in morphological characters and in growth upon
agar. Both in cover-slip preparations of the exudation and in agar
culture the diplococci stained readily by Loeffler’s method, and also
retained the stain by Gram’s method. Nevertheless in sections of the
pia-arachnoid after the brain had remained for ten days in Orth’s fluid,
and subsequently for nine weeks in Muller’s fluid, the micro-organisms
in the exudate slowly gave up the stain by Gram’s method, and were
completely decolourised if left long enough in alcohol. The same is
true of the lymph present on the ependyma of the ventricles. This
change in staining reactions must be attributed to the hardening fluid
used, since the diplococci present in the exudate examined at the
autopsy and in agar culture retained the stain by Gram’s method^ 1 ) The
staining reaction exhibited by the micro-organisms in the exudation
taken at the post-mortem examination and by the cultures indicate that
they must be regarded as identical with Fraenkel’s Diplococcus pneu¬
monia, and serve to differentiate them from Weichselbaum’s Diplococcus
intracellularis meningitidis, ( a ) which closely resembles FraenkePs diplo¬
coccus in morphological aspect and growth on agar, but does not stain
by Gram’s method, and is mostly intra-cellular, and also from the diplo¬
coccus described by Still, ( 8 ) which is not stained by Gram’s method,
and on agar grows more rapidly, forming larger and thicker colonies.( 4 )

Sections of the liver, hardened in alcohol, showed in the foci of
abscess formation numerous diplococci lying among the pus cells
closely resembling those found in the pia-arachnoid in form and size,
and staining both by Loeffler’s and by Gram’s method.

The polypoid growth in the duodenum at the orifice of the ductus
communis choledochus was a large papilloma, apparently simple in
character.

The head of the pancreas exhibited marked interstitial fibrosis.

Summary .—The principal features in this case may now be
recapitulated:

1. Two pathological conditions were present together in the
pia-arachnoid, one recent, the other of old standing.

Digitized by

Google

CLINICAL NOTES AND CASES.

773

1900.]

(a) A leucofibrinous exudation into the meshes of the pia-
arachnoid existed, distributed in an irregular manner. The
exudation contained diplococci agreeing in morphological
appearances, staining reactions,(*) and cultural characters with
Fraenkel’s Diplococcus pneumonia . Similar micro-organisms
were present in the lymph covering the ependyma of the
ventricles. The subjacent cerebral cortex appeared free from
gross change when stained by v. Giesen’s method.

( b ) The pia-arachnoid, on microscopical examination, was
found to be thickened and infiltrated with cells having abundant
cytoplasm, these changes being such as are commonly associ¬
ated with chronic brain atrophy and excess of fluid in the sub¬
arachnoid space and ventricles.

2. The leptomeningitis occurred in conjunction with suppura¬
tion of the liver substance. There was a papilloma at the
opening into the duodenum of the ductus communis chole-
dochus, which was dilated, as was also the gall-bladder, which
contained gall-stones. The head of the pancreas was the seat
of chronic pancreatitis. The foci of suppuration in the liver
contained diplococci resembling those present in the pia-arach¬
noid, and were probably the source of the infection of this
membrane.

3. During life any symptoms which may have been attribut¬
able to the condition of the pia-arachnoid were obscured by
those due to the abdominal lesions.

( J ) The same was observed in the preceding case. A portion of the pia-
arachnoid placed in alcohol at the time of the autopsy exhibited streptococci
staining by Gram’s method. After hardening in Orth’s fluid (six days) and
Muller’s fluid (ten weeks) the streptococci ceased to stain by Gram’s method,
though they still stained readily by Loeffler’s method.—( a ) Fortsch . der Med., Bd. v,
1887, 18 and 19.—(*) Journ. of Path, and Bacteriol., 1898, p. 147. Compare also
Bonome, Ziegler's Beitrage f. path. Anat., Bd. viii, Heft 3.— ( 4 ) Fraenkel’s Diplo¬
coccus pneumonia is the organism most commonly found in meningitis. Thus
Netter [“ Recherches sur les m^ningites suppur^es,” Archives gin. de Medecine ,
Paris, 1889] found out of forty-five cases collected from various sources, Fraenkel’s
diplococcus in twenty-seven cases, Weichselbaum’s Diplococcus intracellularis
meningitidis in ten, and Streptococcus pyogenes in six.—( fl ) Cf. p. 772.

Description of the Illustrations.

Fig. I—Case 1.—Frontal section of the right hemisphere through the anterior
portion of the temporo-sphenoidal lobes, in front of the optic chiasma. The
arachnoid is thickened generally, and the meshes of the pia-arachnoid are filled up
by inflammatory exudation, chiefly lying in the fissure of Sylvius (f.S.), and over
the anterior portion of the island of Reil, but also recognisable at the great
longitudinal fissure, and to some extent in most of the sulci, at least in their outer
part. Microscopical examination of the pia-arachnoid in these situations shows
the existence of numerous cellular elements, with or without streptococci.

Digitized by VjOOQle

774 CLINICAL NOTES AND CASES. [Oct,

anterior horn of the lateral ventricle; n.e. t nucleus caudatus; c.c. t corpus
callosum. Above the lateral ventricle is seen the main mass of the corpus
callosum lying behind the genu ; below is seen a narrower layer of this structure,
lying behind the rostrum, while connecting the two in the middle line is seen the
septum lucidum; opt. «., right optic nerve; ol.n. f right olfactory nerve, lying
in the olfactory sulcus ; t*. t anterior extremity of right temporo-sphenoidal lobe.

The section passes through the commencement of the Sylvian fissure, f.S. just
touching the operculum, and including the anterior part of the island of Reil.

Natural size.

Fig. II A.—Case i.—Section at the summit of the posterior end of the third left
frontal convolution in the neighbourhood of a focus of inflammation in the meshes
of the pia-arachnoid. A portion of the grey matter (a) of the convolution is
represented covered by the pia-arachnoid ( b ). The grey matter does not appear
much altered in aspect. Three of its layers are seen, the molecular layer, next the
pia ; the layer of small pyramidal cells in the middle ; and still deeper the layer of
large pyramidal cells. The pia-arachnoid is increased in thickness by the
presence, in very large numbers, of cells. The closeness with which these
are packed together varies in different levels. In some situations the cells do not
stain well; this feature is not well seen in the figure, though in other sections from
this case, where the pathological process is more advanced, it forms a prominent
feature. The pia-arachnoid exhibits some wavy strands of connective tissue
in the middle of its extent, and also at the surface of the grey matter; elsewhere
no connective tissue is recognisable under this magnification. Two blood-vessels
are seen in the pia-arachnoid, and also a fine twig descending in the cortex.

As already mentioned, the section is made at tne summit of a gyrus. Over the
sulci the thickening of the pia-arachoid is considerably greater, as is indicated in
the preceding figure.

v. Giesen’s stain, x 55.

Fig. II B.—Case x.—Section of a necrotic area lying in the inflammatory exuda¬
tion in the pia-arachnoid. Very little evidence of structure can be made out,
though here and there a nucleus can be recognised. Streptococci are seen in
moderate numbers, forming chains sometimes of considerable length.

Stained by Loeffler’s method, x 650.

Fig. III.—Case 2.—Frontal section of the brain through the anterior extremities
of the temporo-sphenoidal lobes, about half an inch in front of the optic chiasma.
The subarachnoid space is everywhere wide ; least so over the summits of the gyri,
and usually considerably distended over the sulci, especially the Sylvian fissures.
Inflammatory exudation is present in places in the meshes of the pia mater giving
it a dull opaque character and a putty-like aspect, thus completely changing the
normal appearance of this membrane, which is that of delicate threads or strands of
connective tissue supporting blood-vessels of varying size. This exudation is most
marked in the Sylvian fissures and over the third frontal convolutions. Accompany¬
ing the inflammatory exudation there is also fluid distension, which in some situa¬
tions, particularly over the upper frontal region, is equally marked with the former.
There is also some distension of the ventricles. A thin coating of lymph, which
on close observation was recognisable on the ependyma, is not shown in the figure.

T.S., tip of the temporo-sphenoidal lobe; Fi, F2, F3, first, second, and third
frontal convolutions; f.S. t outer part of .fissure of Sylvius; ol.t. t olfactory tracts,
lying in the olfactory grooves; anterior cornua of the lateral ventricles with
the septum lucidum lying between, and more externally, on each side the caudate
and lenticular nuclei, separated by the anterior portion of the internal capsule.
Outside the lenticular nuclei are seen the claustra.

Natural size.

Fig. IV.—Case 2. —Section at site of exudation into the pia-arachnoid. To the
right is seen the molecular layer of the cerebral cortex. This portion of the
cortex is unchanged in aspect; in particular it will be noted that the blood¬
vessels are not increased in size and there is no perivascular cell infiltration. To
the left lies the deeper portion of the pia-arachnoid membrane, separated, during
the preparation of the section, by a short interval from the molecular layer.
Owing to the greatly increased thickness of the pia-arachnoid, it is not possible to
represent the whole of it in the figure. This membrane exhibits three distinct
portions: next the molecular layer is a stratum consisting of a framework of

■Digitized by tjoosle

Digitized by

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1900.

Fig. 2b.

To illustrate Dr. Barratt’s paper.

Digitized by

Go<

Bale and Danielsson, Ltd .

Digitized by

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1900.

Fit;. 5.

To illustrate Dr. Bakkatt’s paper.

Digitized by

Hale and Danielson, Ltd.

CiOOgle

Digitized by

CLINICAL NOTES AND CASES.

77 5

1900.]

connective tissue, in the meshes of which are large numbers of cells of con¬
siderable size. The spaces in this layer are caused by tearing during the pre¬
paration of the sections. Next is seen a wedge-shaped area in which the meshes
of the connective tissue framework of the pia-arachnoid are occupied by a net¬
work of fibrin presenting a finely reticulate structure, in which are recognisable a
few cells. The rest of the section is occupied by a dense collection of small cells,
among which no strands of collagen are to be found.

v. Giesen’s stain, x 80.

Fig. V.—Case 2.—To the left and above is a collection of multinuclear leucocytes
embedded in a homogeneous material, apparently derived from the disintegration
of the other small cells, staining unevenly in different parts, and containing micro¬
organisms, varying slightly in size, and generally, but not invariably, arranged in
pairs. This sketch is made from a portion of the dense cell infiltration shown in
the preceding figure.

Below and to the right is represented, for the sake of comparison, one of the
large cells found in the deeper part of the pia-arachnoid, at the junction with the
molecular layer (see Fig. IV). It possesses a large nucleus and its cytoplasm i&
very abundant.

Loeffler’s method, x 1200.

An Angeioma of Broca's Convolution . By A. F. Shoyer*
M.B., Assistant Medical Officer and Pathologist, County
Asylum, Lancaster.

Angeiomata of the internal organs are not common and
have usually been found in the liver. Including the present
case I can find record of but seven instances of this tumour
occurring in the brain. For the purposes of comparison I have
examined the records of four previous cases, all that I could get
access to, and shall preface the account of my own case with a
short notice of each of these four cases.

The first case was one of a calcified angeioma in the centrum
ovale of a female suffering from melancholia. The notice of the
case is in the British Medical Journal for 1884, and is very
short, containing no details.

In the American Journal of Medical Sciences for Novem¬
ber, 1894, there is a record by Allen Starr and McCosh of an
operation in which a plexiform mass of veins in the pia mater
was removed from the parietal region. The patient suffered
from epilepsy subsequent to two falls on the head, and the
result of the operation was a cure. The brain substance be¬
neath this tumour was normal.

In the archives for neurology of the London County Council
Dr. Cecil F. Beadles describes a case of an angeioma in the
left frontal lobe, in which there was a peculiar varicose con-

Digitized by VjOOQle

776

CLINICAL NOTES AND CASES.

[Oct,

dition of the vessels of the pia mater, similar to what I shall
describe below in my own case. The patient was an epileptic
and became insane.

Dr. Ohlmacher describes a case in the Journal of Nervous
and Mental Diseases for July, 1899, in which there were mul¬
tiple cavernous angeiomata, one in the callosal gyrus, another
in the optic thalamus, and another in the cervical cord. In
the same case there were also a fibro-endothelioma of the
cerebral dura mater, an osteoma of the spinal arachnoid, and
a haematomyelia. The patient was aged forty-eight, and sub¬
ject to epileptic seizures, but was quite sane. He attributed
his disorder to a blow on the head which he received at
the age of twenty-five.

Dr. Ohlmacher considers that the angeiomata had started in
the pia mater, and invaded the brain substance.

The clinical history of my own case is incomplete, and her previous
history impossible to ascertain, as she was a friendless pauper.

E. H—, a female aged 61, was admitted to the County Asylum, Lan¬
caster, on the 5th of May, 1896. She was stated to have been insane two
months, and the predisposing cause given was paralysis.

On admission she was described as “ demented, restless, and fretful;
said her life is poisoned. She is feeble and aphasic; right side is
shrivelled and contracted from infantile paralysis.”

During the four years of her life in the asylum she was sometimes
maniacal, and twice had epileptiform seizures, once in August, 1896,
when the left limbs were convulsed, and again in July, 1897.

She died on February 4th, 1900, of colitis.

Autopsy.—External appearances .—Well-nourished ; varicose veins on
both legs, and pigmented scars on lower two thirds of each leg. Limbs
on right side are contracted and their muscles atrophied, but the bones
appear of equal length with those of the opposite side. Skull is thick
and dense. Dura mater thickened and adherent to vault of skull all over.

Pia-Arachnoid. —Thickened, and at site of Broca's convolution
adherent to tumour described below. The vessels in the pia mater over
both hemispheres were dilated in an irregular varicose manner, some
being as thick as a crowquill, and all being distended with clotted blood.
These dilated vessels lay in the sulci, which gaped to receive them, as
if from atrophy of the gyri. The dilated condition of the vessels was
most marked over the left hemisphere, but still the largest vessel was in
the right occipito-parietal sulcus. There was distinct flattening of the
left frontal and parietal lobes. At the site of Broca's convolution was a
somewhat bulging black tumour presenting a surface about an inch in
-diameter. The membranes over it were thick and adherent, and showed
indistinctly the outlines of the gyri. To inspection and touch it
appeared like a cyst full of coagulated blood. On horizontal section
through the centre of the tumour it was seen to be a fairly well demar-

1 Google

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1900.

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

To illustrate Dr Shoybr’s paper.

Digitized by

Goo

fQind Daniclsson , Ltd.

Digitized by

1900.]

CLINICAL NOTES AND CASES.

777

cated cavernous body, extending for about an inch in all directions, but
not encapsuled, consisting of a mass of sinuses full of clotted blood.
The left middle cerebral artery was very much thicker than the right,
and in the Sylvian fissure gave off a stout branch to the tumour, after
which it was of normal size. The white matter in the neighbourhood
of the tumour had a porous appearance, owing to the presence of numer¬
ous small spaces or lacunae in its substance. The left crus cerebri was
about half the size of the right; the left half of the pons was shrunken,
and also of the medulla, and the left pyramid small and dark in colour.
On section of the cord the right crossed pyramidal track stood out by
reason of its darker colour. There was extensive ulceration of the
whole of the large intestine, and of at least the last two feet of the small
intestine. Theaorta was slightly atheromatous, and the kidneys moderately
cirrhotic. The state of the other organs called for no note.

Histology. —1. The tumour itself is made up of spaces of varying size
full of blood-clot, whose walls are comparatively thin, and composed of
fibrous tissue, mostly lined with endothelium resembling that of a vein.

The substance between the sinuses occupies much less space than they
do, and is evidently altered nervous material proper to the situation.
There is a basis of connective tissue developed from the neuroglia, a very
few degenerated nerve-cells, and a fair number of beaded, degenerated
medullated fibres seen in sections prepared by Pal’s method. The
arteries have much-thickened walls, in which a hyaline change is taking
place, giving them a glazed appearance in contrast to the clearly stained
surrounding tissue. Around the arteries are dilated lymph spaces con¬
taining a few nuclei of cells, whose branching processes make up a fine
areolar network. The pia mater over the tumour is very thick and con¬
tains numerous nuclei. There are numbers of normal capillaries in the
matrix of the tumour.

2. The porous-looking white matter described above is seen to owe
its appearance to the existence of numerous lacunae of varying size, each
of which contains the section of one or more blood-vessels, supported in
a very loose network of areolar tissure, being probably the dilated peri¬
vascular lymphatic spaces.

3. The cortex in the near neighbourhood of the tumour shows marked
changes, the pyramidal cells being scanty, and the tangential fibres alto¬
gether absent.

4. Sections of the cortex of the ascending frontal convolution at some
distance from the tumour presented a fairly healthy appearance, the
pyramidal cells being numerous and their processes well formed, while
the tangential fibres are plentiful.

5. In the pons the left pyramidal fibres are largely replaced by con¬
nective tissue.

6. In the medulla there is old degeneration of the left pyramid, and
the right nucleus of the twelfth nerve is smaller than the left.

7. Sections at various levels of the cord show sclerosis of the right
crossed pyramidal track. The right anterior horn is in all sections con¬
siderably smaller than the left, but the cells are fairly healthy and more
free from pigmentary and other changes than is usual in the chronically
insane.

Digitized by VjOOQle

77 8

OCCASIONAL NOTES.

[Oct.,

Remarks .—The curious condition of the vessels of the pia
mater found in both this case and that of Dr. Beadles, and the
case of Starr and McCosh, when the membranes only were
affected, would seem to support Dr. Ohlmacher’s conclusion
that the condition originates in the soft membranes, but in
the present case, as in that of Dr. Beadles, the main blood-
supply was from the middle cerebral. Angeiomata of the
liver have been said to often arise from an injury, and it is
interesting to note that in several of these cases of angeiomata
of the brain there is a history of previous injury to the head,
just as in the present case there was previous hemiplegia, so
that possibly the condition starts at the site of an old haemor¬
rhage, and is due to disturbance in the circulation of the brain.

Discussion.

At the Annual Meeting of the Medico-Psychological Association, London, 1900.

Dr. Mickle. —I have never come across any case of the kind, and I should
think this one now described by Dr. Shoyer is almost unique. I did not hear any*
thing as to whether the functions of the third frontal showed impairment during
life, whether the case was right-handed or left-handed.

Dr. Shoyer. —The case is one of infantile hemiplegia. The patient was com¬
pletely aphasic.

Occasional Notes.

The Annual Meeting of the Medico-Psychological Association .

The old-time Annual Meetings when holden in London
were always voted successful and delightful, and so forth. At
least the country members always enjoyed them, and when
our dear old friend Dr. Paul negotiated a dinner at the “Ship”
every one carried away the most agreeable recollections of
Greenwich and its neighbourhood.

Annual meetings nowadays are different, in accordance with
the more strenuous spirit of the age. So when we record that
a second consecutive annual meeting has been held in London,
and has been most useful and successful, we do not mean
merely from a social point of view.

The 1900 meeting has shown many noticeable features, and
set out a fine record of work.

Digitized teyLjOOQlC—

1900.]

OCCASIONAL NOTES.

779

It has been the boast and the reproach of our speciality, its
glory and its shame, that we cover too large a field ; but if we
can always maintain as high a general level as that arrived at
on the occasion of the recent London meeting we need not be
ashamed of the extent of ground we cover.

The Presidential Address of Dr. Fletcher Beach was of
unusual merit and interest. Departing from the general
custom of presidents, he did not content himself with a mere
review of the year, or with generalities of any sort. In select¬
ing his subject he was happily able to deal with a topic on
which he can speak with special authority, and a topic which
none of our presidents appear to have made the subject of an
Annual Address during the last forty-five years. Dr. Fletcher
Beach’s address, therefore, had not only the advantage of its own
inherent interest and importance, but was also striking through
its perfect freshness—a quality very rare in similar discourses.

The majority of our speciality do not practise in the particu¬
lar branch in which Dr. Beach has risen to eminence, and are
perhaps too little acquainted with its history. Accordingly
they have heard or will read with interest his admirable account
of the progress which has been made during the last sixty
years in the treatment of certain defective classes of society,
such as idiots, imbeciles, the feeble-minded, the epileptic, and
juvenile delinquents. Though England and Scotland can claim
to have been early pioneers in the work of improving the condi¬
tion of the lunatic, and to have held the first place in this work
for many years, yet the same cannot be said with regard to the
care of idiots and the defective, wherein we have been neither
very early nor very advanced.

Let us hope that the interest which the President’s Address
will arouse in the minds of our members, and the example of the
useful, humane, and unostentatious work done by Dr. Beach, Dr.
Shuttleworth, and Dr. Warner of recent years may stimulate
some of our younger associates to devote themselves to this
field, which is still so full of opportunities.

Dr. Barratt’s paper on “Two Cases of Leptomeningitis” was
very valuable, and well deserved the complimentary remark of
the President that the demonstration of streptococcus in the brain
in these cases was one of the most advanced observations that
had recently been made.

Dr. Turner’s able paper on “ Some Alterations produced by

Digitized by VjOOQle

7 8o

OCCASIONAL NOTES.

[Oct.,

Disease in the Giant Nerve-cells of the Cortex” contained work
of the very first order. Many competent judges agree in the
opinion expressed at the meeting that Dr. Turner's prepara¬
tions were the best of the kind that ever have been shown at
the meeting of any society in this country.

Among the multifarious subjects which must engage the at¬
tention of alienist physicians, asylum construction will always
hold a place. So able an exponent of modem views on this
subject as the Treasurer to the Association described at the
Annual Meeting the plans of the New Sussex asylum, and a
lively discussion followed upon Dr. Hayes Newington's re¬
marks.

Among other interesting contributions we must notice one
from Dr. Wynn Westcott on alcoholism. Considering the
importance which this subject is now assuming, we are glad to
welcome at our meetings those who, though not belonging to
our Association, approach this question in a scientific and
humane spirit. Dr. Westcott's analysis was full and minute,
though not perhaps containing very much that was not to some
degree familiar to most of those who have our opportunities of
becoming acquainted with the subject. It gave rise to an
interesting discussion.

Other papers, such as those by Drs. Orr, Cowen, and Blair,
will commend themselves to our readers; and this remark might
well apply to the whole of the work which found a place on the
agenda paper.

On the whole the matter brought before the Annual Meeting
was varied and excellent

British Medical Association : the Section of Psychology at the
Annual Meeting .

The Section of Psychology at the Ipswich meeting was well
attended, and the list of papers read bears testimony to the
very considerable amount of work done. As will be seen in
Notes and News, we have to thank Dr. Whitwell for a
summary of the proceedings.

We congratulate the president of the section, Dr. Percy
Smith, upon his important and interesting address, which will
no doubt find attentive readers in the pages of the British

Digitized by VjOOQle

1900.]

OCCASIONAL NOTES.

78 l

Medical Journal . He presented his conclusions relative to the
prevention of insanity in a manner which should prove of
definite value, for he impressed upon the medical profession
the duty of advising against the marriages of persons strongly
predisposed to insanity, and indicated the legal provisions
which are necessary to limit the action of alcohol in the
production of insanity and of syphilis in general paralysis. It
is, indeed, of little avail to emphasise the apparent inefficacy of
medicine in the cure of insanity while the captious critics
refrain from attacking the evil at its source. Dr. Percy
Smith’s address cannot be too widely published, for until the
country recognises that insane heredity, alcoholism, and syphilis
are prime factors in the evolution of mental disorders, and
until it acts upon that conviction, we cannot expect a marked
alleviation of the burden which is so irksome to bear.

We need not refer to the other papers, important as some
of them are, for their aim and scope are indicated in Dr.
Whitwell’s rtsum^ and they will be found in detail in the
pages of the British Medical Journal .

We note that the members present adopted a resolution
recommending that the section should in future be called the
Section oj Psychiatry , and suppose that the intention is to make
psychology apply to normal conditions and psychiatry to
abnormal. There is a decided convenience in being able in a
word to discriminate between the two, and we are already
familiar with the term psychiatry , as it is used on the Continent,
although it has not met with entire approval among us. We
want more distinctive terms, just as we require a convenient
self-contained word to express that morbid condition charac¬
terised by fixed and limited delusions of a persistent type.
Paranoia is an unfortunate word, Psychiatry may be normal or
abnormal—there is nothing in either to denote the limitations
which we desire to convey. Here, then, are two more questions
for Notes and Queries.

Education and Psychology .

The Master of Downing College, Cambridge, Dr. Alexander
Hill, has recently delivered two lectures on Brain Tissue as the
Apparatus oj Thought . These lectures, before the distinguished

Digitized by VjOOQle

782

OCCASIONAL NOTES.

[Oct.,

•audience of the Royal Institution, contained much interesting
matter, skilfully arranged and characterised by originality of
view. What is of interest to our readers, however, is not
so much the contents of the lectures, but their significance.

That part of the English educational system which is
represented by those archaic establishments, the Universities of
Oxford and Cambridge, has hitherto so slightly recognised the
existence of psychology as an aid to teaching, and of the brain
as the fundamental fact of mental development, that the
phenomenon just reported is at once astonishing and of good
omen. That a Master of a College in Cambridge should
appear before the public as a teacher competent to direct
pedagogues in accordance with scientific methods opens vistas
of hope for the expansion of our educational system in
consonance with the dictates of modern psychology. The
deadly upas of mediaeval culture has too long spread its
baleful influence over those educational establishments; but
with Dr. Hill at Cambridge, and Dr. Burdon Sanderson at
Oxford, the pure light of science is already proving a revivify¬
ing antidote to the bacteria of scholasticism.

Neurologists and Alienists.

Specialism in medicine, as in other departments of know¬
ledge, has its special dangers in contracting the mental vision ;
but it has undoubtedly done much for scientific progress.
Medical specialism, in addition to scientific advantages, offers
a certain convenience to the public in enabling them to obtain
the advice of those who have intimate knowledge of particular
forms of disease, and who are therefore presumably best
qualified to treat them.

Medical specialists, as a rule, abide by their specialism, and
promptly relegate to other consultants any case which does
not appear appropriate to their limitations. For instance, we
should hardly expect that a patient who had strayed into the
rooms of a neurologist would be retained for an operation to
relieve him of a cataract.

It is, indeed, of frequent occurrence that one specialist in the
course of his medical duties finds it necessary to have further

Digitized by Google

1900.]

OCCASIONAL NOTES.

783

advice from another specialist. We have known a case of
detached retina, apparently suffering from visual hallucinations,
so obscure in local symptoms that the diagnosis could not be
absolute without the opinion of a skilful ophthalmic surgeon.

This reasonable division of labour, which cannot but be
productive of the best results for the patients affected, does not
apparently hold good in regard to cases of mental disease.
Herbert Spencer tells us that the labourer in the village ale¬
house says very positively what Parliament should do, and
there are not a few occasions when the plain man declares
himself a complete arbiter. Indeed, a learned judge placed
it on record that he considered himself or any other intelli¬
gent man capable of diagnosing insanity. We need not enter
on that discussion again, but would rather inquire how it is
that neurologists have come to treat mental disorders which
lie beyond the range of their ordinary practice.

This has arisen, no doubt, to a large extent owing to the cir¬
cumstance that the friends of insane patients are most unwilling
to recognise the fact of mental disorder. They prefer to consult
a neurologist rather than any physician whose name is asso¬
ciated with the treatment of insanity, just as they prefer to
speak of mania as hysteria and of gross delusions as mere
fancies.

There is no doubt that the records of asylums and the case¬
books of alienist physicians show that insane persons are
treated by neurologists in considerable numbers. Often these
patients have been under the care not of one, but of several
neurologists, a progress which has been described, perhaps
with undue levity, as the “ regular neurological round.”

Whether the neurologists are specially qualified to treat
mental disorders, or whether they should relegate them to the
alienists, is a question for neurologists individually to decide.
The alienist, however, to whom these patients usually come
sooner or later, after running the gauntlet of such a pharma¬
ceutical buffeting as is entailed by the regular round, is
compelled to recognise that such a course of preliminary
treatment, often combined with the stock prescription of travel,
has not unfrequently introduced an aetiological factor of no
small prognostic importance, and the moral is that the cobbler
should stick to his last.

XLVI. S3

Digitized by VjOOQle

784

OCCASIONAL NOTES.

[Oct,

Notes and Queries.

Dr. Mercier*s suggestion has not awakened that amount of
interest which we expected ; but we are favoured with these
replies, which may yet be followed by others.

As to the children of general paralytics begotten in the
early stages of the malady, Dr. Clouston can only recall one
case of idiocy.

Dr. Norman, in reference to the meaning of the word
degenerate, is unprepared to say very much, as he conceives
Dr. Mercier*s query is intended to draw some expression from
those who use the term degenerate with the looseness which
has become so common. “ Let the galled jade wince.” But
he thinks it may clear the ground for further discussion to
point out that Morel, from whom the moderns who talk of
degeneration profess to have derived their inspiration, thus
defines degeneracy or degeneration {la diginirescence ):—“ The
clearest idea which we can acquire of degeneracy of the human
species is by representing it to ourselves as a morbid deviation
from a primitive type.” Again, he speaks of what “ les itres
diginirh ” really are : “ a morbid deviation from the normal
type of humanity.” The vagueness of this has apparently
been the cause from whence sprang the quite unscientific,
modem use of the word, but it should be remembered that Morel
only implicitly sanctioned such usage, which he probably did
not foresee. In his book on degeneracy he deals almost
exclusively with very definite causes which tend to bring about
short-lived and morbid varieties of the race—alcohol, lead,
paludic poison, the essential factors of cretinism and of pellagra,
starvation, etc.

The word is commonly applied to any and every phase of
structure, conduct, mind, or appearance, normal or abnormal,
to which the user of it wishes to apply an abusive term with a
scientific flavour. A man is called a “ degenerate ” if he is a
thief or a murderer, a sexual pervert, or any other form of
criminal; if he is insane, or eccentric, or a genius, or clever, or
stupid, or commonplace; if he has a misshapen jaw, or ear, or

Digitized by

Google

1900.]

OCCASIONAL NOTES.

785

head, or nose, or hand, or foot; if he has a tattoo mark on his
arm, or a wen on his neck, or a cast in his eye, or a carious
tooth ; if he is solitary or social, benevolent or morose, a philan¬
thropist or a miser, married, single, or widowed, tall or short,
black-haired or red-haired. There is nothing that can be pre¬
dicated of man that may not be called a mark of degeneracy.

C. A. M.

Dr. Urquhart asks, What is the meaning of the word
neurotic ?

The word “ neurotic ” has much the same meaning as the
word “ degenerate.” The meaning commonly attached to it
would be best expressed by “ something the matter with the
nerves,” “the nerves” being understood in a popular and
ladylike sense. If a man has epilepsy, he is neurotic. If he
had chorea when a child, he is neurotic. If he starts on
hearing a noise, he is neurotic. If his grandfather was insane,
he is neurotic. If he does not sleep very well, he is neurotic.
If he suffers from migraine, if he has tic convulsif or tic
douloureux, if he has asthma or neuralgia, if his great-aunt
committed suicide, or his nephew is in Earlswood, if he is
addicted to drink, or is a fanatical teetotaler, if he is worried
by loss of money or elated by success, if he is dyspeptic, or
gouty, or diabetic; if, in short, we want to say of him
something that will comfort us with the assurance that we
know more than we do know about him, we call him neurotic ;
and we receive an access of complacency from the use of the
term. Neurotic is the Mesopotamia of neurologists. It is
such a comforting word ! C. A. M.

Dr. Clouston suggests for consideration the question, Is
there any record of murder having been committed by a
general paralytic while he was as yet in the early stage of the
malady ?

Digitized by

Google

786

REVIEWS.

[Oct.,

Part II.—Reviews.

The Grammar of Science. By Karl Pearson, M.A., F.R.S. Second
edition, revised and enlarged. London : A. and C. Black, 1900.
8vo, pp. 548, with 23 figures in the text. Price 7 s. 6 d. net.

That a second edition of this remarkable work should be required in
a comparatively short time is gratifying evidence of the lively and
wide-spread interest that is now taken in the fundamental problems
with which it deals. Of its very great value in helping us to define
and clarify our concepts of the fundamentals Space and Time, Matter and
Motion, Mechanism and Life, it is needless to speak; and if, in what
follows, the attitude assumed is mainly critical, it must be understood
that this attitude is not adopted out of any inclination to disparage
the great merits of the book, but rather to indicate that in spite of its
somewhat dogmatic tone, the last word has not yet been said upon the
questions of which Prof. Pearson treats.

The book is essentially psychological in its standpoint u We
are often told,” says Prof. Pearson, “ that the scientific method applies
only to the world of phenomena, and that the legitimate field of
science lies solely among immediate sense-impressions. The object
of the present work is to insist upon a directly contrary proposition,
namely, that science is in reality a classification and analysis of the
contents of the mind; .... in truth, the field of science is much
more consciousness than an external world.” This being so, it is to
be regretted that the author’s psychology is sometimes at fault, owing
no doubt to the fact that his life’s work has been done in another
field, into which we shall not attempt to follow him.

The distinction that he draws in his first chapter between the
4< accurate classification of facts and observation of their correlation
and sequence ” on the one hand, and “ the discovery of scientific
laws by aid of the creative imagination” on the other, is scarcely
valid. Classification of facts is but the discernment of likeness and
unlikeness among them, the grouping together of the like and the dis¬
crimination of the unlike; and the discovery of a scientific law is
neither more nor less than this. It is still the assimilation of likeness
and the discrimination of unlikeness. Classification presupposes a
principle under which the classification is made. The discovery of a
law is merely the discovery of a new principle of classification. The
processes are identical in nature, the only difference being that by the
discovery of a scientific law we usually mean the discernment of wider,
more recondite, more far-reaching similarities, and of nicer shades of
discrimination, than in what we are accustomed to call classification.

Professor Pearson assumes freely the licence which is customary
among psychologists of using old words in new senses, and of using
new words for meanings which established usage has attached to old
words. He follows Lloyd Morgan in calling a percept a " construct”—
a very unnecessary innovation ; and he gives to “ sensation ” a mean¬
ing that it has never had before. The passage in which this occurs is

DigitizecLby VjQQQlCL

1900.]

REVIEWS.

787

very important, and needs examination. “ Turn the problem round
and ponder over it as we may, beyond the sense-impression, beyond the
brain terminals of the sensory nerves, we cannot get. Of what is
beyond them, of ‘things—in themselves,’ as the metaphysicians term
them, we can know but one characteristic, and this we can only
describe as a capacity for producing sense-impressions, for sending
messages along the sensory nerves to the brain. This is the sole
scientific statement which can be made with regard to what lies beyond
sense-impressions. But even in this statement we must be careful to
analyse our meaning. The methods of classification and inference,
which hold for sense-impressions and for the conceptions based upon
them, cannot be projected outside our minds, away from the sphere
in which we know them to hold into a sphere which we have recog¬
nised as unknown and unknowable. The laws, if we can speak of
laws, of this sphere must be as unknown as its contents, and therefore
to talk of its contents as producing sense-impressions is an unwarranted
inference, for we are asserting cause and effect —a law of phenomena or
sense-impressions—to hold in a region beyond our experience. We
know ourselves, and we know around us an impenetrable wall of sense-
impressions. There is no necessity, nay, there is want of logic, in
the statement that behind sense-impressions there are ‘ things-in-them-
selves * producing sense-impressions. About this supersensuous sphere
we may philosophise and dogmatise unprofitably, but we can nevei
know usefully. It is indeed an unjustifiable extension of the term
knowledge to apply it to something which cannot be part of the mind’s
contents. What is behind or beyond sense-impressions may or may
not be of the same character as sense-impressions, we cannot say.
We feel the surface of a body to be hard, but its core may be hard or
soft, we cannot say; we can only legitimately call it a hard-surfaced
body. So it is with sense-impressions and what may be behind them ;
we can only say sense-impression-stuff, or, as we shall term it with a
somewhat divergent meaning from the customary, sensation . By sensa¬
tion we shall accordingly understand that of which the only knowable
side is sense-impression. Our object in using the word sensation
instead of sense-impression will be to express our ignorance, our abso¬
lute agnosticism, as to whether sense-impressions are ‘ produced ’ by
unknowable ‘ things-in-themselves,’ or whether behind them may not
be something of their own nature. The outer world is for science a
world of sensations, and sensation is known to us only as sense-
impression.”

The most striking and important characteristics of this curious passage
are the violent effort that Prof. Pearson makes to tear himself free from
the necessity of admitting that there is some thing-in-itself behind
sensory phenomena, and the ultimate and complete failure of his
attempt. He begins by postulating a noumenon; scared by the
Frankenstein monster that he has raised, he does his utmost to repudiate
and reject ir,

But ah, well-a-day! the devil, they say,

’Tis easier at all times to raise than to lay;

and he ends by taking it to his bosom under the extraordinary title of
“ sensation ”—a meaning of that word which, as he truly says, is “ some-

Digitized by

Google

788

REVIEWS.

[Oct,

what divergent from the customary ” ! Of “ things-in-themselves,” he
tells us, “ we can know but one characteristic, and this we can only
describe as a capacity for producing sense-impressions.” Here he defi¬
nitely and positively admits the existence of noumena; but the sea of
metaphysics is too cold, and he quickly withdraws his foot, and tells us
that “to talk of its contents as producing sense-impressions is an
unwarranted inference “ there is no necessity—nay, there is want of
logic—in the statement” But yet he cannot get away from the nou-
menon. He calls it first sense-impression-stuff, and then sensation; he
seeks to minimise it, to deny it; three times does he deny it, but then
the cock crows. It clings to him like the air in which he moves, and at
last he is fain to reinstate it completely. “ Our object in using the word
sensation .... will be to express our ignorance, our absolute agnosti¬
cism, as to whether sense-impressions are 1 produced * by unknowable
‘ things-in-themselves/ or whether behind them may not be some¬
thing of their own nature.” He will not allow it to be called a “ thing-
in-itself; ” he prefers to call it “ sensation ”—he can call it abracadabra
if he chooses,—but the admission is plain and loud that behind sense-
impression there is something . Whether this something is called the
noumenon, whether it is called the object, whether it is called the thing-
in-itself, or the sense-impression-stuff, or what it is called, does not matter
one straw. The important thing is that Professor Pearson, no more than
any one else, can do without it, or get rid of it, or conceive its absence.
To call it sensation is most unfortunate, for then we have the same word
with two utterly contradictory meanings. The ordinary meaning of
sensation is an affection of the mind—an affection which corresponds in
some way with, is complementary and opposed to, something outside the
mind. Professor Pearson would have it mean this something outside
the mind, and thus give it a signification the very opposite of that which
is its accepted meaning. By his previous avoidance of the term in its
ordinary sense, and his substitution of the term sense-impression, he
seems to try to avoid the necessity of admitting the existence of that
something beyond sensation to which sensation is due; but his effort is
fruitless. The very term sense-impression implies not only an impres¬
sion received, but an impression given; not only something which is
impressed, but something which impresses; and the same implication
lies patent or latent in every term that could be selected. Try as we
may to shut ourselves up in a world of “ sense-impressions,” we can no
more get away from the certainty that outside of sense-impression there
is something that impresses them, than the child can conquer its fear of
darkness by shutting its eyes. That we have no warrant for inferring,
no ground for speculating, what the nature of this noumenon may be, we
should admit as freely as Professor Pearson could desire ; but to deny
its existence is not merely unwarrantable, not merely groundless—it is
impossible; and this Professor Pearson admits, not only explicitly in
the passages we have quoted, but implicitly again and again when he is
most earnest in his denial. “ It is idle,” he says, “ to postulate shadowy
unknowables behind that real world of sense-impression in which we
live. So far as they affect us and our conduct they are sense-impressions;
what they may be beyond is phantasy, not fact; if, indeed, it be wise to
assume a beyond y to postulate that the surface of sense-impressions which

Digitized by

Google

1900.]

. REVIEWS.

789

shuts us in must of necessity shut something beyond out." “ So far as
they affect us ”—here Professor Pearson assumes their existence. Con¬
scious of this assumption, he proceeds to whittle them away; but he
cannot. He cannot conceive himself “ shut in ” without at the same
time conceiving a “ beyond.” An enclosure with nothing beyond the
enclosure is nothing, or is infinity. There can be no shutting in without
an outside; and even if he could abstractedly conceive such a possi¬
bility, he could not conceive it with respect to his own consciousness or
universe of sense-impressions. He makes an appointment on one day
to meet a certain man in a certain spot three days after. He then parts
from his friend, and sees him no more until the time appointed. During
that time he had no sense-impressions of his friend; yet he knew that his
friend existed, and when they met he knew that his friend had continued
to exist during the interval of his absence; and, try as he may, he
cannot conceive that in that interval the friend existed only as “ stored
sense-impressions ” in Professor Pearson’s own mind. He believes with
unshakable conviction that during that interval the friend existed
noumenally, and this belief he can no more shake off or whittle away
than he can do the same to the conviction of his own existence and of
his own sense-impressions. Matter and motion, as we are accustomed to
conceive them, may not exist; the ether may be but a figment of our
imagination ; space and time may be only modes of consciousness ; but
that, when we are face to face with one another, there exists something
outside of our own consciousness which corresponds in some way to the
sense-impressions that we experience, we cannot help being certain.
Again I say that, of the nature of this noumenon, ignoramus et ignora-
bimus ; but that it exists is a certainty as assured as the complementary
certainty that we ourselves exist.

Professor Pearson’s “ Canons of Legitimate Inference ” are the
weakest part of his book, and it is only fair to say that in them the
result of his own thought is least apparent. The first canon—that
where it is impossible to apply man’s reason, that is to criticise and
investigate at all, there it is not only unprofitable but anti-social to
believe—we may pass by as a harmless truism, merely remarking that to
those who do so believe the canon is useless, for they do not recognise
the limits of their powers of criticism and investigation; while, for those
who do not so believe, it is needless.

The second canon is open to more destructive criticism : “ We may

infer what we cannot verify by direct sense-impression only when the
inference is from known things to unknown things of the like nature in
similar surroundings.” The obvious defect in this canon is that it leaves
in obscurity the difference between known and unknown. If the “ un¬
known thing ” is known to be of like nature and in similar surroundings
it is not wholly unknown; and the whole gist of the validity of the
canon lies in how much of the “ unknown thing ” is known. Of like
nature? How nearly like? What is meant by nature? what by
surroundings? what by similarity of surroundings? Is it always a
legitimate inference that, since A. B. made a bull’s-eye by the last shot,
he will make another by his next ? As stated, the canon is worthless
for practical use.

The third canon seems to have been stated pour rire . “ We may

Digitized by VjOOQle

790

REVIEWS.

[Oct.,

infer the truth of tradition when its contents are of like character and
continuous with men’s present experience, and when there is reasonable
ground for supposing its source to lie in persons knowing the facts and
reporting what they knew.” The first observation that presents itself in
connection with this extraordinary canon is, why is it limited to tradi¬
tion ? In so far as it is valid at all, is it not valid for other and for all
kinds of testimony ? What exactly is meant by like character ? what by
continuous with men’s present experience ? and above all, what in the
name of reason is meant by reasonable ground ? The canon practically
amounts to this, that we may believe a statement if we have reason to
believe it.

The fourth canon says that, “ while it is reasonable in the minor
actions of life, where rapidity of decision is important, to infer on slight
evidence and believe on small balances of probability, it is opposed to
the true interests of society to take as a permanent standard of conduct
a belief based on inadequate testimony.” This canon seems to have been
transferred from the pages of Mr. Martin Tupper. If it contained a
definition of the adequacy of testimony it might be of value, but as it is
it has a somewhat platitudinous flavour. Taking it as it stands, how¬
ever, it appears that, according to Prof. Pearson, it is opposed to the true
interests of society to take, as a permanent standard of conduct, a belief
in a world external to consciousness, and yet this is what mankind has
been doing ever since mankind has existed, and this is what mankind
will continue to do as long as mankind exists; so that the true interests
of society seem to have a gloomy future.

The weakness of Prof. Pearson’s psychology is again exhibited in that
part of the chapter on scientific law which deals with the perceptive
“ faculty ” and the reflective “ faculty.” He treats the two “ faculties ”
as radically distinct, and speculates as to possible relations between
them. That psychology has long discarded the term “ faculty ” and the
notion that it implies of the complete separation of mental processes
that the process of perception is but a simple case of reasoning, and
that perception and reasoning are identical in nature, and, in so far as.
they differ, differ in content only; are views with which Prof. Pearson
does not appear to be familiar. Yet he sharply criticises Mr. Herbert
Spencer, and must therefore be familiar with the works in which these
views are propounded.

Two expressions occur constantly throughout Prof. Pearson’s book—
“the routine of perception,” and “resuming sense-impressions” or
phenomena. Neither of these expressions is familiar, the meaning of
neither is clear without explanation, and neither is defined or explained.
It appears that by a routine of perception is meant an experience of
unvarying sequence,—at least this is the meaning that seems to fit most
appropriately the many occasions upon which the expression is used ;
but in the absence of a definition it is difficult to be sure, and this
uncertainty of the meaning of a phrase that recurs on nearly every
page is a serious defect in the book. By “resumption” of sense-
impressions appears to be meant a summing up or brief description,
but it would be much better if the meaning of these continually recurring
phrases were strictly defined.

Prof. Pearson’s theories of space and time, of matter and motion.

Digitized by

Google

1900.]

REVIEWS.

791

and, indeed, his theory of the universe generally, depends entirely upon
the distinction that he draws between perception and conception, the
latter being, in his view, something different from inference. If we
allow him his premises, his conclusions are irrefragable, and in any
case his theories have much to commend them, and must be taken into
account in any future “ resumption ” of the universe. But it is evident
that if there is no such clear and absolute difference between perception
and conception as his theory demands, its foundations are undermined
and its fabric insecure. Now, while of course there are important
differences between perception and more formal reasoning, it is well
established that there is no such absolute difference as Prof. Pearson
assumes. By far the greater part of perception is, in fact, inference,
and when this is kept in view, very much of the reasoning of the Grammar
of Science is vitiated.

The chapters on Life and on Evolution are, as indeed is the rest of
the book, in spite of the defects that have been pointed out, of very high
value, and are still of very high value whether the theories they propound
are valid or no. Their value lies in the true scientific spirit that pervades
them, and in the truly scientific method that they follow. Not the least
of the services which the author renders us in these chapters is his clear
indication of the radical vices of Weismann’s methods, and the lack of
any real demonstration of the truth of his theories. At a time when
these theories are swallowed whole by the majority of biologists, a
searching exposure of their lack of proof was greatly needed, and will
be heartily welcomed by the remnant who have not yet bowed the knee
to the Baal of unsupported assertion.

In taking leave of the Grammar of Science it must be again asserted
that the reader must not infer, from the insistence here laid upon its
defects, that the general verdict is meant to be unfavourable. Prof.
Pearson has been handicapped by a lack of psychological knowledge*
which is the more to be regretted since it might so easily have been
attained; but in spite of this lack he has produced a psychological work
of very great importance, and one which, combining as it does original
and vigorous thinking in both psychology and the more general aspects
of biology, it behoves every student of insanity to study with diligence.

Chas. Mercier.

The Law of Inebriate Reformatories and Retreats , comprising the
Inebriates Acts , 1879 to 1898. By Wyatt Paine, Barrister-at-
Law. London: Sweet and Maxwell, Ltd., 1899, 8vo, pp. xxxvii,
226.

Mr. Paine has done useful work in arranging the various sections of
the Inebriates Acts, and in giving notes and references together with
an appendix containing the forms, rules, and regulations arising from
recent legislation in regard to habitual drunkards. His work is pre¬
faced by a slight sketch of the legal and medical aspects of inebriety.
This section should be treated more thoroughly in any subsequent
edition of the work, for the legal references are scanty and the medical
discussion is flimsy and imperfect. The author expresses the hope

Digitized by VjOOQle

REVIEWS.

[Oct,

that his book will be found useful to justices of the peace and
legal practitioners ; but medical men will do well to add it to
their working libraries, for they are constantly consulted by the
friends of habitual drunkards before justices or lawyers are called
upon to intervene. This legislation has largely resulted from long-
continued efforts of the medical profession, intimately brought into
contact with the evils of inebriety in all its forms. There is now some
tendency to forget these labours, and the law, engrossed as it is with
that battered old fetish, the liberty of the subject, has not even yet
come into line with medical opinion. We can only regard these Acts
as tardy instalments of a legislation which must yet be completed.

We cannot congratulate Mr. Paine on his quotation from the Medical
Times and Gazette of 1853, which gives a summary of gross changes
found post mortem in the stomach, liver, and kidneys of a chronic
alcoholic subject. It would not have been difficult for him to have ascer¬
tained the latest discoveries in the pathology of alcoholism, discoveries
which elucidate nervous degeneration and consequent mental deteriorar
tion. His psychology requires to be modernized no less than his medical
lore. Mr. Paine might as well have carried his legal references no
further than Coke upon Littleton.

Apart from these unfortunate shortcomings, and in spite of apparent
haste in preparation of details, the book will be useful to a wider circle
of readers than the author ventured to hope. He shows that the earlier
doctrine—that under no circumstances is drunkenness an excuse for
crime—must be modified; although he once more introduces that
ancient formula about the person knowing right from wrong, while the
real question is could he help it ? Mr. Paine recognises that legis¬
lation shows a tendency to regard the criminal habitual drunkard as
occupying an intermediate position between the ordinary criminal and
the criminal lunatic ; and that punishment, while continuing deterrent,
should be reformative rather than retributive. We abide in the hope
that all punishment will, in time, be reformative rather than retributive.

Mr. Paine puts it very mildly when he says that the absence of any
provision for enforced seclusion in the case of an unwilling drunkard is
perhaps to be deplored. Those who have had experience in dealing
with drunkards are very much more emphatic in the statement of their
opinion. It is indeed an omission which is at once an injustice and a
danger—far more of a danger than any interference with the sacro¬
sanct right of a drunkard to go to perdition in his own way, too often
dragging his family into the abyss after him.

We fully agree with Mr. Paine in his expression of regret that the
impecunious voluntary applicant for admission into a retreat is not
helped by these imperfect Acts of Parliament. The rich inebriate may,
perchance, be saved, but the impoverished drunkard must choose
between his hopeless struggle and the infringement of the law four
times within twelve months. Truly we are great in the gentle art of
compromising.

Passing from these matters of history to the Acts as arranged by
Mr. Paine, we can only express our thanks that he has set them forth so
that they can be readily referred to. Where there are apparent diffi¬
culties of application Mr. Paine gives explanatory comments, and, as

Digitized by VjOOQle

1900.] REVIEWS. 79£

on page 31, submits his opinion as to the probable intention of Parlia
ment. The relation of the Acts to Scotland and Ireland is fully dealt
with, and the schedules and rules framed for the working of retreats
and reformatories are given in detail—including that extraordinary regu¬
lation which provides that every officer of an inebriate reformatory shall
be a total abstainer from intoxicating liquors. Why limit these restric¬
tions to the officers? Why not enact that the Secretaries of State
shall also practically show this more excellent way ?

Mtdecine legale des Aliinis. Par R. von Krafft-Ebing. Edition
fran^aise, traduite par le Dr. A. R^mond. i er Fascicule; Partie
criminelle. Paris : Octave Doin, 1900, 8vo, pp. 544. Price (of
the complete work) 20 fr.

The first volume of the French edition of Krafft-Ebing’s Lehrbuch
der gerichtlichen Psychopathologie deals with the relation of insanity to
the criminal law.

Amongst the numerous works on this question the well-known
treatise of the Viennese Professor occupies a foremost place. The
clinical acumen and the mastery of lucid exposition which characterise
all the author's contributions to science would of themselves fully
explain this success; but it will nowise detract from our appreciation
of these qualities to admit that advantages of environment have
materially aided their expression in the present work. Forensic
psychiatry involves the application of medical science, which is positive
and of general validity, to legal institutions, which are conventional
and local. As an obvious result of the nature of these factors, a
reasoned method in this application is only attainable where the law,
in its principles and in its procedure, largely accepts the guidance of
science. In a great measure this condition is realised in Austria. The
Austrian code provides that where the sanity of an accused person is
called in question he shall be examined by two official experts, who
shall furnish to the Court a full report on his mental capacity, specify¬
ing in case of insanity the extent to which in their opinion the
diseased condition has influenced the individual’s ideas, impulses, and
acts. The problem is thus posed in a purely clinical form : the expert
is not required to base his diagnosis on the doctrines, or to formulate
it in the terms of an obsolete psychology. This enlightened attitude
of the law naturally facilitates the task of the writer on legal psycho¬
pathology.

The present translation has been made from the last German edition,
which, while retaining the original form of the book, embodies a large
amount of new matter. Notably neurasthenia, the psychic disorders of
menstruation, and the intoxications by morphia and cocaine come in for
fuller treatment; and the chapter on psychic degeneracy has been
largely re-written. The translator, Professor Remond of Toulouse, has
also interpolated notes on several points of detail, and has added a
number of interesting illustrative cases.

The first part of the book deals with the subject in its general
aspects. The author indicates that at present the criminal law rests on

Digitized by VjOOQle

794

REVIEWS.

[Oct.*

the assumption of a relative freedom of the will, “responsibility*
implying the existence in the individual of average motives and of
average interaction of these motives. The non-acquisition of this
relative freedom or its loss through mental diseases abolishes respon¬
sibility. The conception of responsibility is thus quite conventional*
and its conditions are fixed by reference to the normal standards of
the given social group. The application of these principles is shown
in the codes of the chief European states.

The following chapters deal with the functions of the alienist
expert; the general principles of diagnosis in mental disease; the
dissimulation and simulation of insanity. On the last point the author
agrees with the opinion that simulation of insanity is very uncommon,
and he leans to the view that simulators are rarely quite sane. The
capital importance for diagnostic purposes of a complete study of the
clinical evolution of the given case is emphasised.

The remainder of the volume is devoted to the examination of the
various clinical forms of mental" disease in their relation to criminal
acts. The classification followed—it is on the lines indicated by the
author in his Lehrbuch der Psyehiatrie —is perhaps rather minute for
the special objects of the book; it leads occasionally to some repeti¬
tion, and to the separation of conditions setiologically similar. This
is evident, for instance, in the case of psychic degeneracy, paranoia,
and alcoholism.

The most interesting questions raised in this portion of the work
refer to responsibility in “ borderland ” cases, discussed especially in
the chapters on degeneracy, impulsive insanity, and foiie morale . The
author’s conclusions are in the main in agreement with the views
which Maudsley has made current in this country. In some passages,
indeed, of the work, and in a few of the illustrative cases which he
cites, Krafft-Ebing seems to press this doctrine rather far, assuming for
the ethical and aesthetic ideas and emotions a development and a de¬
finiteness which their very relative and unstable nature hardly justifies.

Another chapter of special excellence is that dealing with criminal
acts in states of pathological unconsciousness.

Beside the numerous clinical observations which are recorded in
extenso, abundant references are furnished under each section to
analogous cases in medical literature. This feature of the work adds
greatly to its value, and should render it of practical utility even to
those medical witnesses who, in submitting their conclusions to the
superior wisdom of a British jury, have to present them in the psycho¬
logical terms of the judicial tests of 1843.

It is much to be regretted that the book is disfigured by a quite un¬
pardonable number of misprints. W. C. Sullivan.

The Psychology of the Cephalic Index (Centralblatt fur Anthropologic y
Heft 3, 1900). Ammon, Otto.

The alleged connection between mental characters and variations in
length and breadth of the head has been vigorously proclaimed by
Lapouge and other anthropo-sociologists, and still more vigorously*

_Digitized by CjOO^Ic _

REVIEWS.

795

1900.]

perhaps with better reason, denied by Manouvrier. While, however, it
is certainly in the highest degree hazardous to maintain that a brachy-
cephalic head by its mere shape involves one set of mental characters,
and a dolichocephalic head by its very triflingly different shape a
totally unlike set of mental characters, it is another thing to assert
that both sets of characteristics—cephalic and mental—are merely asso¬
ciated through bearing the marks of particular races. We know that
head-shape is an extraordinarily persistent mark of race. It is not impos¬
sible, though still somewhat doubtful, that certain mental characters
may cling to a race with equal persistence.

A Norwegian anthropologist, A. M. Hansen, has lately published a
very remarkable little book on the long-headed and broad-headed
population of his own country, and the mental qualities of each, and
his results have been set forth with approval by Ammon, the distin¬
guished German anthropologist. On account both of the importance
of the subject and of its interest to British readers — since the popu¬
lation of our islands in the past was certainly recruited to a consider¬
able extent from the Norwegian people—it may be worth while to state
Hansen’s conclusions briefly.

He regards the broad-heads as the more ancient of the two populations,
descended from the people of the old stone age, who left the relics of their
lives and ways in the Kjokkenmoddings; they occupied the extreme south
of Norway, the only portion then inhabitable, and lived largely by fishing.
When the glaciers receded grass-covered and wooded terraces began to
appear inland ; these were occupied by the long-headed people of the late
stone age (by the Germans usually called " Aryans,” in opposition to
Sergi and others), a people of high culture, possessing flocks and cul¬
tivating the ground. As they approached the coast they met and
subjugated the broad-heads and to some extent mixed with them, pro¬
ducing a crossed type. On the whole, however, the two populations
have remained in much the same relations down to the present day.
Now Hansen has produced two maps of Norway, each in various
shades, one to show the relative prevalence of the broad-heads, the
other to show the relative strength of the Conservative vote as shown
by the Storthing elections in 1897, and the remarkable fact is revealed
that these two maps almost exactly correspond in shade; where there
are most broad-heads, there the Conservative vote is also strongest.

The western broad-heads have dark hair and eyes, the more easterly
long-heads, fair hair and eyes. Hansen devotes chief attention, how¬
ever, to describing the psychic characters of the two races, both as they
exist now and as they have always been described in folk-tales and
legends. The character of the broad-heads is for the most part un¬
attractive. They are described in the old sagas as lacking in courage
and generosity of spirit, as easily moved to falsehood and hate, always
prone to be suspicious. The heroes of the sagas, on the contrary, are
cheerful, open, brave, fond of fighting, careless of the future, ready for
every undertaking and adventure, prone to argue and revengeful.
Hansen gives a number of opinions by latter-day observers confirming
these traits described in the sagas. The coast people of the west are
reserved, melancholy, very religious, not fond of fighting, easily terri¬
fied, not willing to undertake labour if its use is not very obvious, in-

Digitized by VjOOQle

796

REVIEWS.

[Oct.,

sincere, and unreliable; they are, however, bold sailors. The long¬
heads of the interior and east, on the other hand, are frank and cheer¬
ful, brave to recklessness, seldom losing their presence of mind and
self-possession. They are clean, fond of adornment, and like to
possess the best tools. Their freedom and love of independence is
very marked, and they are keenly alive to insult They are hospitable,
but dangerous when drunk. They are ndt religious. The proportion
of men furnished to the voluntary militia by the long-heads is three
times greater than that furnished by the broad-heads, while, on the other
hand, the latter furnish more than twice as much money per head to
foreign missionary work as compared with the former. The broad
headis, Hansen states, have a passion for equality, and are compara¬
tively indifferent to freedom; the long-heads have a passion for free¬
dom, and care nothing at all for equality.

It is scarcely necessary to add that mixture of races has to some
extent confused these characteristics. It might perhaps be said
that the character of the broad-heads is due to ancient conditions of
slavery; to this Hansen replies that slaves by no means necessarily or
always possess these characters. Nor are they the necessary result
of the conditions in which the people have wed the west coast of
Norway in the early stone age resembled Greenland now, yet the
Greenlanders are a cheerful and hospitable people. Hansen regards
the psychic character of the two races as very fundamental, and with¬
out asserting a direct relationship he points to the resemblance between
the broad-heads and the Mongolian people of Asia. He even seeks
to go deeper still, and to attempt a psycho-physical explanation of
the difference between the two races, of the melancholic character of
the broad-heads, the sanguine temperament of the long-heads ; he
thinks that the high, nervous tension of the long-head carries him
over difficulties which wholly absorb the broad-head, while the storms
of nervous energy which are only a pleasurable relief to the nervous
tension of the long-head would be accompanied by terror and anxiety
in the broad-head.

It appears that Hansen’s results have been questioned, and he has
consequently been induced to prepare similar maps of the whole of
Scandinavia, including Denmark ; the result has been that his conclu¬
sions have been confirmed. Havelock Ellis.

A Study of Lapses (Monograph Supplement, Psychological Review). By
H. Heath Bawden, A.M. New York : Macmillan and Co. 1900.
Pp. 122.

The happy thought has occurred to Mr. Bawden to study psychologi¬
cally the problem arising out of a consideration of lapses (lapsus lingua
and lapsus calami). The lapse is a very familiar phenomenon, and Mr.
Bawden presents a vast number, some obtained by experiment, but
most by observation of ordinary reading, writing, or conversation. It
may suffice to refer to “the ox and the ax,” “bass the pasket,” the
lady who wished “ to go into the corch to pool,” the clergyman who
referred to “ Jab and Dovid,” and he who prayed, “ O, Glod, we are

Digitized by VjOOQle

REVIEWS.

79 ?

1900.]

gad.” Mr. Bawden does not absolutely guarantee the statement of the
gentleman in church who nervously informed another that he was
“occupuing my pie,” nor the sorrowful lament of the college don to the
undergraduate who had “ actually tasted two werms;” but he warrants
so complex an error as “ She went into the ashothecary’s pop to get
a cint pup.” Such lapses usually arouse a smile, and are forgotten,
Mr. Bawden has little difficulty in showing that they deserve the most
serious study, since they not only carry us into the borderland between
sanity and insanity, but also involve some of the most difficult problems
in normal psychology. Being involuntary and automatic, lapses may
seem as “most useful and unerring guides in the understanding of
mental processes.” In this monograph the author sets forth the range of
the phenomena, and proposes the general lines of interpretation.

It is found that a lapse may usually be accounted for in one of three
ways—(1) lack of sufficient attention, due to thoughtlessness, hurry, or
nervousness; (2) w^r-attention; or (3) divided attention when two
objects are both striving for the focal point in consciousness, thus, e. g. r
producing modifications or transpositions of vowels or consonants. The
first class may be regarded as belonging to the general class of fatigue
phenomena, the second and third to what Stout has called conflict or com¬
petition. The mental process involved is thus by no means simple. Strictly
speaking, the proximate causes of these errors are exclusively neither
central nor peripheral, but partly both (the sensory and motor aspects
being regarded as two ends of the same organic circuit); and even when
artificially isolated in the laboratory a lapse forms a complex of pro¬
cesses. The specific occasions of error mentioned by the persons
making them are numerous; fourteen classes are enumerated. They
may, however, all be grouped according as they belong to the fatigue
phenomena or to the phenomena of conflict or competition, in which
latter case the functioning of the organism is altered or brought to
a deadlock by reason of opposing stimulations.

Ballet has remarked on the gradual stages which intervene between
functional verbal amnesia and aphasia; and Bawden points out that the
query arises whether lapses, both oral and graphic, may not—some
clearly and others less definitely—be due to an incipient aphasia or
agraphia. He considers that we may at least say that the lapses are
“due to a momentary malco-ordination in the corresponding cortical
areas;” and he adds, “ Certainly the frequency of errors in an individual
sometimes reaches a degree and a constancy which might well be called
a transitory or local aphasia or paraphasia ”—in other words, a functional
aphasia often due to temporary nervous exhaustion.

A large part of the study is devoted to an elaborate consideration of
lapses on the basis of association, the conception of English psycholo¬
gists, more especially Stout, being here followed. There is also a short
section on the relation of lapses to the psychology of the ludicrous, the
so-called deformity theory of the ludicrous receiving support. The
author considers that if alienists continue to make as much progress as
their past achievements warrant us in supposing, much light will be
thrown on the phenomena of lapses, and indirectly on economy in edu¬
cational methods. Although it cannot be claimed for Mr. Bawden (and
he would not himself claim) that he has reached any novel conclusions.

Digitized by VjOOQle

79** REVIEWS. [Oct.*

his monograph is an interesting example of the way in which a trivial
and neglected field of phenomena may be reduced to order and used
to illustrate and emphasise some of the most complex and fundamental
problems in psychology. Havelock Ellis.

The Soul of Man. By Dr. Paul Carus. Second edition. Chicago :
Open Court Pub. Co.; London: Kegan Paul. 1900. Pp. 482,
8vo. Price 3 s. 6 d.

Kant and Spencer. Same author and publishers. 1899. Pp. 105,
8vo. Price is.

Both these books appear in the Religion of Science Library, already
comprising forty-one volumes, not less than twelve of these being
by the author of the present volumes, who is the editor of the
series, and has also published half a dozen other books. Dr. Paul
Carus is a remarkable man. He is the editor of the Open Court ,
a monthly magazine devoted to “the religion of science and the
science of religion.” He is also the editor of the Monis /, a quarterly
journal of philosophy and science, which competes successfully with any
similar journal in existence, for Dr. Carus has succeeded in getting
around him as contributors many of the most distinguished men in
science, philosophy, and psychology to be found in Europe generally, as
well as in America. Binet, Ribot, Hering, Weismann, Mach, Nageli,
Topinard, are but a few of the distinguished writers whom Dr. Carus has
made well known in America. Moreover the books he has himself
written testify to the most varied ability and erudition. He has pub¬
lished several laborious works on Buddhism, he has edited Lao-tze in
Chinese, he has written a number of extremely interesting and valuable
studies of the evolution of religious conceptions ; his spare moments
he spends, apparently, in preparing lengthy primers and handbooks of
philosophy, science, and ethics. He is a convinced monist, with
<a philosophy which he calls positivistic, in the sense that it is based, as
he claims, on empirical facts, but it is in no sense the positivism of
Comte or Spencer. Dr. Carus wishes to co-ordinate all the facts of
science with metaphysical and religious dogmas into a whole which
may be called objective and positive. The spirit of some mediaeval
schoolman seems to be re-incamated in him, and, like an ancient doctor
universalis , he courageously attempts to unite the visible and invisible
worlds into a great knowable whole. Moreover this remarkable pheno¬
menon manifests itself in Chicago, in the chief centre of the modern
materialistic world, and seems, indeed, to flourish there exceedingly.

The Soul of Man is not the most important or the most original of
Dr. Carus’s works, but it is perhaps one of the most characteristic. The
title itself is significant Here we have what is mainly a fairly full
and copiously illustrated popular account of the anatomy and physiology
of the nervous system in men and animals, passing on, through a study
of fecundation, to consideration of such complex psychological subjects
as hypnotism and double personality; and thence, by what the author
feels to be no abrupt transition, to free will, death, immortality, and
od. The author clearly believes that a positivist philosopher may

Digitized by VjOOQle

REVIEWS.

799

1900.]

confidently sweep all things—“from God to foam-balls dancing down
a stream,” as the poet has it—into his vast net. It must be noted
that the exposition of cerebral anatomy and physiology is clearly and
ably done, though the author sometimes relies on authorities (like
Meynert) who are now a little out of date, and ignores altogether the
recent advances in cerebral histology. The specialist, to whom indeed
the book is not addressed, may pass it with a smile, but still it is
quite a remarkable feat by an intellectual athlete.

Kant and Spencer is a much slighter production, but it may interest
those who will not be attracted to the more ambitious performance.
Spencer has always shown a marked antipathy to Kant, and, as he
has himself admitted, has never made himself familiar with his
writings; Dr. Cams, while identifying himself neither with Kant nor
with Spencer, considers that the latter has been guilty of injustice and
misinterpretation towards a much greater thinker than himself. The
book is a reprint of articles that appeared some years ago in the Open
Court\ and is to some extent a controversy between Dr. Cams and Mr.
Spencer; the latter took, however, but a small part in the contest, and
it must be admitted that both in argument and in knowledge of Kant
Dr. Caras has the best of it. Apart from this controversial section
the book consists of three papers. The first is on “ The Ethics of Kant,”
and it is here argued that Kant’s ought does not stand in opposition to
the must of natural law. The second is a very interesting discussion of
Kant’s views on evolution, the author showing how radically Kant
held to the idea of evolution and the mutability of species. The
third paper is a criticism of “ Mr. Spencer’s Agnosticism ” from the
standpoint of the author’s own very different “ positivism.”

The Development of Colour Perception and Colour Preference in the
Child (Archives of Ophthalmology , vol. xxix, No. 3, 1900). Holden
and Bosse.

The evolution of the colour sense has been dealt with by many
experimental psychologists both in Europe and America, the most
important investigation (apparently unknown to the present writers)
being that of Garbini. A well-recognised difficulty in such investiga¬
tions is the varying luminosity of colours; an infant when attracted by a
bright colour may only see the brightness, not the colour. Holden and
Bosse have made an ingenious attempt to neutralise this fallacy. This
they have done by using as a background graduated sheets of grey
paper, light grey at one end and dark grey at the other. On this
were placed squares of coloured tissue-paper, the experimenter with
eyelids half closed finding the spot where the luminosity of the coloured
square equalled that of the background. The infants, when wide
awake and in good humour, were then urged to pick up the coloured
squares. With precocious infants of six months and average infants
of seven or eight months a prompt reaction was usually obtained to
red, orange, and yellow; in a few there was a sluggish and uncertain
reaction to green and violet, and very seldom to blue. Between ten
and twelve months there was often prompt reaction to all colours.

xlvi. 54

Digitized by VjOOQle

8oo

REVIEWS.

[Oct.,

These experiments indicate a much earlier development of colour
perception than is shown by Garbini and others; whether this is due
to imperfect elimination of luminosity or to defect in the earlier experi¬
ments is not yet clear.

To determine colour preferences coloured ribbons were used, and
the order in which these were selected was noted in all cases in
which evident choice was exerted. Up to twenty-four months of age
the order of choice was that of the spectrum, beginning at the red end.
In the years following, up to thirteen, an interesting evolution was
observed. While during the first two years of life there was a marked
preference for the red end of the spectrum, there comes a period of
uncertainty, then a preference for the violet end of the spectrum,
which is very decided at the age of eight, and is still well marked
when the series ends. During the last year investigated, yellow and
orange tend to be chosen last of all, while red tends to rise in
favour. Had the authors continued their investigation into adult age
they would have found, especially among women, a tendency to
return to the earlier infantile preference for red (see, e . g. y summary of the
earlier observations, H. Ellis, Popular Science Monthly , August, 1900).

This careful and important study, which was extended to over
200 children, while bringing out no very novel points, does much to
give precision and cohesion to the more fragmentary results of earlier
and often less competent investigators. Havelock Ellis.

The Criminal\ his Personnel and Environment: a Scientific Study .

By August Drahms. New York: The Macmillan Co., 1900.

Pp. 402, 8vo.

This work can scarcely be termed a “ scientific study,” notwithstand¬
ing the claim made on the title-page. It is written by the resident
chaplain of the San Quentin State Prison, the chief prison in Cali¬
fornia, and is a somewhat pretentious attempt to cover the whole extent
of criminal anthropology and criminal sociology. But the author makes
very little use of the information which he must have acquired in the
exercise of his own functions, while his knowledge of the literature of
his subject is mostly second-hand. He constantly misspells the names
of the authorities he refers to; he is often unable to appreciate the
relative value of their opinions, and he cannot express his own opinions
in clear and correct English. Fortunately his standpoint is that of an
average common-sense person, and on most important questions no
very serious exception can be taken to his main conclusions; as regards
the treatment of criminals, he advocates an unrestricted indeterminate
sentence.

While it cannot be said that this work replaces any previous study
of the criminal, or even that it brings the subject up to date, the book
contains a few novel facts which may be noted. It is interesting to
find that the inmates of San Quentin in all the measurements recorded
according to the Bertillon system correspond very closely to the inmates
of Elmira on the other side of the American continent; the average
variations are seldom over an inch, while both groups are inferior

Digitized by VjOOQle

J 9 °°-]

REVIEWS.

801

(except in length of arm) to the Amhurst College students who are of
about the same age. Classified according to class of offence, it is
found at San Quentin that thieves have slightly the widest heads,
“erotics” slightly the narrowest and longest heads, murderers short
and moderately wide heads; so that the cephalic index of erotics is
79, of thieves 80*5, of murderers 83*5. This tendency of several
offenders to be dolichocephalic harmonises curiously with the tendency
noted in many parts of Europe for sexual offences to be associated
with fair hair and blue eyes.

It might be expected that the author would show some freshness in
dealing with the religious aspects of the criminal temperament The only
novelty in his brief discussion of this point is, however, contained in the
remark that less than half per cent, of the inmates of San Quentin were
real members of any Protestant church when their crimes were com¬
mitted.

The book is preceded by a brief and too laudatory introduction by
Professor Lombroso, and is followed by a bibliography of English
criminological works which may be found useful.

Le Probbmc de la MSmotre-Essai de psycho-mechanique . Par le Dr. Paul
Sollier. Paris: Ancienne Librairie, Germer Bailliere et Cie,
F£lix Alcan, editeur, 1900, 218 pp. Price 3 fr. 75 c.

In this work Dr. Sollier endeavours to show the analogies which may
be established between the various phenomena constituting an act of
memory and certain others of a purely physical order and produced by
simple transformations of forces. Reviewing the observations and
speculations of former writers on the subject of memory, it appears clear
that they are agreed in admitting that as a result of stimulation of the
cells of the cortex determining a sensation, a perception, some per¬
manent modification takes place which allows the reproduction of this
perception at a given moment. But considerable difference of opinion
exists concerning these two points : how or in what form does this
imprint exist, and in what region of the brain does it take place ? The
view that the vibration itself produced by the initial stimulus is prolonged
indefinitely—more or less enfeebled—is almost unanimously rejected
nowadays; but some hold that there is a modification of the molecular
condition of the cell and the creation of dynamical associations
between the centres involved; others that this modification is only
a tendency, a disposition to reproduce the impressions already received,
on account of a functional differentiation. It is difficult to see how
these hypotheses can be confirmed or upset. With regard to the second
point, the seat of localisation, there are two views or opinions: either
the images of memory are reproduced in the centres of perception them¬
selves, or their seat is not in these centres but in some other region of
the brain—in the aperception centre (frontal lobe) or in association
centres interposed between the perceptive centres or centres of projec¬
tion, the latter being the more commonly accepted view. Clinical
knowledge and pathological anatomy throw light on this question, but

Digitized by VjOOQle

802

REVIEWS.

[Oct.,

in its elucidation Sollier appeals especially to what he calls experimental
psycho-pathology. At the outset he shows that the doctrine of partial
memories arose from a confusion of terms and an erroneous interpreta¬
tion of clinical facts. In analysing a complete act of memory—the
mnesic act—six operations are considered : penetration or fixation, con¬
servation, evocation, reproduction, recognition, and localisation; and
these are successively studied with the conditions necessary or favourable
to their performance. Thus we find that the conditions for fixation are
the anatomical and physiological integrity of the cell; that the circula¬
tion and nutrition of the brain should be normal; that the intensity of
fixation is not proportional to the intensity of stimulus, and that the
latter must not exceed certain limits, etc. etc. In discussing conservation
and evocation, much help is obtained from the study of disorders of
speech: we know, for instance, that there is independence between the
word and the representation of the object which it denotes. Our
present knowledge tends to the assumption of the existence of a
centre of ideation—a psychical centre in which the conservation and
evocation of recollections take place. Moreover the observation of
cases of amnesic aphasia—a subject ably handled quite recently by
Prof. Pitres—leads to the conclusion that the evocation of words takes
place in other centres than the motor and sensorial centres for speech.
To explain certain modes of evocation of recollections, such as the
evocation by determined emotional or cenaesthetic states, and also by
voluntary attention and effort, the author suggests the presence of an
increase of potential in the cerebral centres due to their functioning.
To those who have read the author’s work ‘Genese et Nature de
FHyst6rie,’ it would appear probable that the experimental psycho¬
pathology to which he refers at the beginning of the present book would
be of the kind extensively illustrated there, and so it is. In discussing
the reproduction of memory, and especially in the chapters on the theory
of memory, reference is frequently made to experiments on hysterical
subjects. Without impugning the accuracy of the observations, in view of
the startling conclusions to which they seem to point, one must feel
very sceptical as to these experiments. Among other deductions, Sollier
advances that the brain is to be considered like any other organ,
endowed with a sensibility of its own, the loss or return of which is
accompanied by special reactions of a psychical kind, and by sensory
reactions identical to those observed when other organs lose and recover
their sensibility. Again, the return of activity in the frontal lobe, an
evidence of which is shown by sensibility in the frontal region of the
skull, brings about the evocation of recollections.

If we assume that the phenomena described are unmistakably
objective, and that, as Sollier advances, suggestion and deception are
excluded (they are provoked by “ purely mechanical means, without
any psychical intervention, even indirect”), we must congratulate
ourselves on a signal advance in our knowledge of cerebral locali¬
sation, for thus: “ If, therefore, I observe some isolated functional
disorder with at the same time a patch of cranial anaesthesia, I shall be
able to conclude that the function in question has its centre in the
cerebral convolution subjacent to the anaesthetic patch; and I shall
come to the same conclusion if, at the same time that some functional

Digitized, by

G< ogle

NOTES AND NEWS.

1900.]

803

<lisorder disappears, I see a patch of sensation reappear on an anaesthetic
skull.”

In this way Sollier concludes that memory has its seat in the pre¬
frontal centres, that it is here that takes place the evocation of recol¬
lections, etc.

Whatever other claims may be made in favour of this book, it does
not lack originality, and it contains a fair rcsumk of numerous contribu¬
tions to the subject of memory.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

Annual Meeting.

The fifty-ninth annual meeting of the Medico-Psychological Association of Great
Britain and Ireland was held at 11, Chandos Street, Cavendish Square, London,
on July 26th and 27th, 1900. Dr. J. Beveridge Spence presided on the opening
of the proceedings. The following members were present: J. B. Spence (Presi¬
dent;, Fletcher Beach (President elect), E. W. White, W. R. Dawson, R. L.
Langdon-Down, J. C. Johnstone, T. S. Tuke, W. J. Mickle, A. R. Turnbull, O. T.
Woods, R. H. Cole, C. Clapham, J. Chambers, H. G. Hill, D. Bower, C. K.
Hitchcock, A. F. Shoyer, A. D. O'C. Finegan, C. S. Morrison, C. Caldecott,
A. R. Urquhart, W. Douglas, A. N. Boycott, T. S. Sheldon, T. O. Wood,

J. Stewart, C. Norman, J. A. B. Mackeown, G. A. Watson, A. W. Campbell,

K. O. Graham, T. M. Moody, F. A. Elkins, J. S. Bolton, G. S. Elliot, H. Rayner,
D. Rice, J. F. Briscoe, E. France, T. W. McDowall, R. C. Stewart, A. S. L.
Newington, J. H. Macmillan, J. A. Oakshott, C. A. Mercier, R. R. Rutherford,

L. A. Weattierly, G. E. Shuttleworth, J. Turner, R. R. Leeper, M. Crqjjg,
A. Miller, T. S. Clouston, G. F. Blandford, G. Hungerford, L. R. Oswald, R. P.
Smith, W. E. Jones, F. S. Gramshaw, T. Drapes, H. T. S. Aveline, D. Blair, A.
Helen A. Boyle, C. F. Beadles, A. E. Macdonald, P. W. Macdonald, W. G. Ellis,
W. C. Sullivan, H. A. Benham, W. H. Kesteven, H. Stilwell, G. H. Savage,
A. N. Davis, G. H. Johnston, J. Middlemass, G. A. Welsh, J. Warnock, H. Hayes
Newington (Treasurer), Robert Jones (General Secretary), and others.

Visitors: Drs. T. Martin, Heywood Smith, E. E. Norton, C. Pirquet, F. E.
Newberry, F. H. Greenaway, C. O. Laid, J. W. Barrett, B. Hollander, E. B.
Forman, L.C.C., and Reed, Messrs Knipe and Lister.

Apologies for non-attendance were received from the following members:
D. M. Cassidy, J. G. Soutar, M. J. Nolan, and Evan Powell.

The minutes of the previous Annual Meeting were taken as read and confirmed,
and signed by the President.

The President. — I wish to take this opportunity of congratulating Dr. Moody
on his recovery from his recent serious accident, and to express how glad we all are
to see him again amongst us, and how much we regret that he has been unable
to be present at our meetings as regularly as we know he would have desired.

Dr. Moody. — I beg to thank you very much for your kind words regarding
myself.

Digitized by VjOOQle

804

NOTES AND NEWS.

[Oct,

Election op Officers and Council.

President .

President Elect .

Ex-President .

Treasurer .

Editors of Journal

Auditors ......

Divisional Secretary for —
South-Eastern Division
South- Western Division
Northern and Midland Division .

Scotland .

Ireland .

General Secretary . . ,

Secretary of Educational Committee .
Registrar .

Fletcher Beach, M.B.

Oscar T. Woods, M.D.

. B. Spence, M.D.

i. Hayes Newington, F.R.C.P.Ed.

Henry Rayner, M.D.

< A. R. Urquhart, M.D.

.Conolly Norman, F.R.C.P.I.
David Bower, M.D.

\ Ernest W. White, M.D.

A. N. Boycott, M.D.

P. W. Macdonald, M.D.

W. Crochlby Clapham, M.D.

A. R. Turnbull, M.B.

A. D. O’C. Finegan, L.R.C.P.I.
Robert Jones, M.D., B.S., F.R.C.S.
C. A. Mercier, M.B.

H. A. Benham, M.D.

G. H. Savage, M.D. 1898

J. Carlyle Johnstone, M.D. „
A. W. Campbell, M.D. „

*T. S. Sheldon, M.B. „

James Chambers, M.D. „

Oscar T. Woods, M.D. „

G. Stanley Elliot, M.R.C.P. 1899
R. Percy Smith, M.D. „

D. M. Cassidy, M.D. „

Members of Council.

R. D. Hotchkis, M.D.

H. T. S. Aveline, M.R.C.S.
W. R. Dawson, M.D.

H. Gardiner Hill, M.R.C.S.
Alfred Miller, M.B.

C. H. Bond, M.D.

F. P. Hearder, M.D.

J. G. Havelock, M.D.

L. A. Weatherly, M.D.

189

1900

* Dr. Sheldon, who had not attended a meeting of the Council during the year
on account of ill-health, was re-elected at the Council in May, Z900.

Examiners.

Examiners for the Certificate in Psychological Medicine .

England: J. Kennedy Will, M.B., Theo. B. Hyslop, M.D. Scotland : John
Kbay, M.B., G. M. Robertson, M.B. Ireland: C. E. Hetherington, M.B.
M. J. Nolan, L.R.C.P.I.

Examiners for the Nursing Certificate of the Association.

R. Percy Smith, M.D., J. B. Spence, M.D., A. Campbell Clark, M.D.

Election of Honorary Members.

Dr. Urquhart said the following gentlemen have been proposed as Honorary
Members, in accordance with the rules of the Association :

G. Alder Blumbr, M.D., appointed Assistant Physician to the Utica State
Hospital, U.S.A. in 1880, succeeded Dr. J. P. Gray as Medical Superintendent in
1887, elected Medical Superintendent of the Butler Hospital for the Insane at
Providence, New Jersey, in 1899. Dr. Blumer is an Englishman who took
his medical degree in America, and spent some months in 1884 studying
psychiatry in Europe. He has been an ordinary member of the Association since
• 1890. During his tenure of office in the Utica Asylum Dr. Blumer brought the
industrial pursuits of the patients to a high pitch of perfection, having established
knitting, spinning, weaving, shoe-making, brush-making, printing, bookbinding,
and farm colonies on a business footing. For a time ne was sole editor, and
latterly has been joint editor of the American Journal of Insanity, and in addition
to the ordinary duties of editorship has found time to write valuable papers
on subjects relating to insanity—on the care and commitment of the insane, on
employment of the insane, on music, etc.

Dr. Johannes Bresler, M.D., was educated at Breslau, Munich, and Leipzig,
having taken his medical degree at the University of Leipzig. Having served ra

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

805

Dr. Kahlbaum’s Asylum at Gorlitz, at Breslau Asylum, at Koston Asylum,
after a period of military service, Dr. Bresler was appointed to the Asylum
of Freiburg, in Silesia, where he remains. He is an honorary member of
the Medico-Psychological Society ef Paris, and is the founder and editor of
the Psychiatrishen Wochenschrift. Dr. Bresler has made many and valuable
contributions to the literature of insanity, a list of which I lay on the table. He
has been a corresponding member of this Association since 1896.

Dr. Ant. Ritti, M.D., Laur£at of the Academy of Medicine of Paris, z88o,
General Secretary of the Medico-Psychological Association of Paris, Editor-in-
Chief of the Annales Mtdico-Psychologique, Physician to the Charenton Asylum
since 1879, and Medical Inspector of the Insane in the Department of Seine since
1881. Dr. Ritti’s distinguished career has been marked by many well-known and
highly appreciated works, a list of which I lay on the table. He is now Secretary
for the Section of Psychiatry in the International Medical Congress, and has given
a courteous and pressing invitation to those of our members who may find
it convenient to go to Paris at this time.

The President. —It is well that you should know something about the gentlemen
for whom you are called upon to vote, and Dr. Urquharthas taken so much interest
in the matter that I think you will agree that his statement has been quite
satisfactory, and declare Drs. Blumer, Bresler, and Ritti duly elected honorary
members.

Election of Ordinary Members.

The following candidates were declared duly elected members:—Anderson, John
Charles, M.D.Durham, Assistant Medical Officer, Darenth Asylum, Dartford,
Kent (proposed by F. R. P. Taylor, Edwin H. Beresford, and Robert Jones);
Ellis, Henry Reginald, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, County
Asylum, Morpeth, Northumberland (proposed by T. W. McDowall, J. T. Calcott,
and Robert Jones); Fleck, David, M.B., Ch.B., B.A.O.Ireland, Assistant Medical
Officer, Metropolitan Asylum, Caterham, Surrey (proposed by G. Stanley Elliot,
P. E. Campbell, and Robert Jones); Laing, Charles Frederick, M.B., C.M.Glasg,,
Assistant Medical Officer, County Asylum, Parkside, Macclesfield, Cheshire
(proposed by T. S. Sheldon, Crochley Clapham, and Robert Jones) [proposed
through Secretary of Northern and Midland Division] ; Lambert, Ernest Charles,
M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer, Darenth Asylum,
Dartford, Kent (proposed by F. R. P. Taylor, Edwyn H. Beresford, and Robert
Jones) ; Murphy, Jerome J., M.R.C.S.Eng., F.R.C.S.Lond., Assistant Medical
Officer, Darenth Asylum, Dartford, Kent (proposed by F. R. P. Taylor, Edwyn
H. Beresford, and Robert Jones) ; Wilson, Tames, Patterson, M.B., Ch.B.Glasg.,
Assistant Medical Officer, Metropolitan Asylum, Caterham, Surrey (proposed by
G. Stanley Elliot, P. E. Campbell, and Robert Jones).

The Treasurer laid the balance-sheet for 1899 before the meeting (see p. 806).

Auditor’s Report.

Dr. Outterson Wood.—I have to state that we have examined the accounts,
and vouchers, and checked the items of receipt and expenditure, and have certified
the same and the balance-sheet to be correct. We are pleased to be able to report
an increasing roll of members, and that the finances of the Association are in a very
satisfactory condition.

Treasurer’s Report.

The Treasurer moved the adoption of the Report, as printed on the following
page, and Dr. Conolly Norman seconded the motion.

Dr. Mercier drew attention to the fact that the total income from the sale
of the Journal and Handbook and from the advertisements had undergone a
serious diminution. He also called attention to the amount of ^134 expended
upon Annual, General, and Divisional Meetings. He considered that the assist¬
ance of reporters at Divisional Meetings was not necessary, and, indeed, was not
allowed according to rule. He suggested that some such arrangement as that
which obtained at the British Medical Association Meetings could be introduced,
and concluded by moving that the Treasurer be surcharged with whatever
expenses had been incurred in reporting the proceedings of Divisional Meetings.
This was seconded by Dr. Conolly Norman.

Digitized by VjOOQle

1900.] NOTES AND NEWS. 807

Dr. Oscar Woods thought the question was one whieh might be very fairly
brought forward and considered.

Dr. Macdonald hoped that the members of the Association would be loth to do
anything which would curtail the usefulness of the Divisions. He considered that
this question, which was continually being brought up, of the amount expended
by way of secretarial help to those who really do the fagging work of the Asso¬
ciation, was not worthy of consideration at an annual meeting.

Dr. Outtkrson Wood, as one of the Auditors, pointed out that he was bound
•to say that the expenses of the Divisional Meetings were very moderate. He
thought that the Association ought to be very thanlrful that there were men who
were working as the Divisional Secretaries were working. They did an enormous
amount of good work at a very moderate expense.

Dr. Clouston said that reporters had been employed for many years by
Divisional Secretaries, but if any item of expenditure seemed to be on the in¬
crease, it was quite right to have it debated. He congratulated the Treasurer and
the Association on the healthy state of the finances.

The Treasurer, in reply to Dr. Mercier, said he thought a reporter was
undoubtedly useful where there were minutes of the Association and debates being
carried on. He maintained that such work ought to be done by the reporter. He
thought that Dr. Mercier was carrying the question in the wrong direction when
he referred to the Divisional Meetings, at which the reporting expenditure was,
as a rule, very moderate. In the case of the Annual Meeting, when two days were
devoted to scientific work, there would naturally be some expense; and here he
thought with Dr. Mercier that speakers on scientific subjects might well be asked
to jot down their remarks. He had tried to find out why there should be a
diminution in the sales of the Journal, etc., but could obtain no explanation. As
to advertisements there was a most satisfactory increase, £30 17s. this year as
against £ig or £20 last year. With regard to the Journal, he had taken out the
figures for the Editors at their request, and he found that the Journal was carried
on very economically considering its value.

Dr. Mercier then withdrew his motion, and the Treasurer’s report was received
and adopted.

Statement of the Payments made and received by the
Treasurer on account of the Gaskell Memorial Fund*

1898. Dr.

£ s. d.

Aug. 3. Examiners* Fees (Dr.

Percy Smith, Dr.

Mercier) . 440

Dec. 31. Balance.46 1$ 9

1898. Cr.

£ s . J.

July ax. Balance ... ... ... 50 19 9

£$o 19 9

£io 19 9

1899.

£ t. d.

Not. so. Transferred to Deposit

Account .93 10 xi

1899.

£ d.

Jan. 1. Balance. 46 15 9

„ Diridends.S3 7 1

July 1. Diridends.aj j 1

Dec. 51. Balance . 010

£93 xo II

£9$ 10 IX

1900.

£ *• d.

Jan. 1. Balance.. ... oxo

Aug. a8. Dr. Maurice Craig

(Prize).35 0 0

Sept. Examiners* Fees (Dr.

Percy Smith, Dr.

Kennedy Will) ... 440

Sept. Balance. 71s

1900.

£ /. d.

Tan. x. Diridends. ij ; 1

July x. Diridends.aa 19 1

M 6 a

£46 6 a

H. HAYES NEWINGTON, trtMwrtr.

Digitized by VjOOQle

8o8

NOTES AND NEWS.

[Oct

Complimentary Motion.

The President, in proposing a vote of thanks to the officers of the Association
said:—When I mention our friend Dr. Hayes Newington, who is, perhaps, the
Association’s oldest and busiest officer, I am sure that you will agree with me that
a better Treasurer could not be found. The Secretary, Dr. Jones, has an enormous
amount of work to do, and it is wonderful how he manages to get through it. I
speak with great gratitude of Dr. Jones, for he has been indefatigable in his
efforts to induce members to give demonstrations and to read papers. You will
all admit that our quarterly meetings have been very successful. The Editors do
much and good work for us, and I think that later on, when we arrange to give them
some little assistance, you will feel that we are only doing what is right and proper
in recognition of the work upon which they are engaged. The Divisional Secretaries
are also doing admirable work, and it is surprising how they are bringing in new
members. Every time one receives a notice of a meeting, one sees a list of new
names, and that reflects great credit on the Secretaries. We all know what an
onerous post the Registrar occupies, and I was not surprised to receive from him
this morning a letter telling me that he was overworked. It is almost too much
for a man who has to manage a large asylum. If it were not for the assistance given
by some of those who are associated with us in asylums, it would not be possible
to cope with the work. We owe the Registrar a deep debt of gratitude for the
time and attention he has given to his duties. I propose, therefore, that the
thanks of the Association be given to the officers of the Association for the work
they have done during the year. The motion was carried unanimously amid great
applause.

Dr. Benham.— On behalf of the Officers I beg to thank you for the cordial vote
of thanks you have accorded to us. As the President has said, the duties entail
much hard work. In my own case, unless I had been assisted by others connected
with the asylum I could not possibly have carried out the Registrar’s duties. No
doubt some other arrangement will have to be adopted, but that will be a matter
for consideration in the future.

Report of the Parliamentary Committee.

Dr. Hayes Newington read the report of the Parliamentary Committee and
moved its adoption.

During the past year the Parliamentary Committee has met four times. It
authorised its Chairman to seek an interview with the Parliamentary Committee
of the County Councils Association. This interview took place, but had no
result, the Lunacy Bill having appeared without a pension clause, and the latter
association not being prepared to propose one. But in anticipation of this inter¬
view the Chairman procured valuable information from all county and borough
asylums, and the Committee takes this opportunity of thanking the various super¬
intendents for supplying it. The information was embodied in a memorandum
which after discussion and approval by the Committee was printed and circulated.
Thus comprehensive statistics bringing important considerations up to date are
preserved ready for use on further occasion.

The Joint Committee of this and the British Medical Associations met as in
former years, and besides continuing its previous criticisms was fortunate enough
to obtain Dr. Farqiiharson's undertaking to move a pension clause on a favourable
opportunity arising. The Committee are of opinion that the best thanks of this
Association are due both to Dr. Farquharson and Sir John Batty Tuke for the
ready way in which they proffered their best services in its interests.

The Lunacy Bill has once again come and gone, bearing on its face all the
shortcomings to which objection has been raised by this Association; but it is
right to acknowledge with satisfaction the reappearance of the clause permitting
the treatment of incipient insanity in a less cumbrous manner than obtains now,
and further, the insertion of an entirely new clause providing for the combination
of counties for the purpose of founding and carrying on joint institutions for patho¬
logical research.

Your Committee has lent what aid it could to the Irish Division when it was
seeking to obtain authorisation for carrying out a proposal similar to that last
mentioned. (Signed on behalf of the Committee.)

H. Hayes Newington.

Digitized by

Google

1900.] NOTES AND NEWS. 809.

Dr. Macdonald seconded the adoption of the report and it wa^ carried
unanimously.

Dr. Urquhart intimated that he wished to retire from the Parliamentary Com¬
mittee, and proposed the election of Dr. Carlyle Johnstone in his place.

Dr. Hayes Newington proposed the addition of Drs. Oscar Woods, Finegan,.
and Conolly Norman.

The President declared these motions carried, and the Parliamentary Com¬
mittee now stands as follows :

Parliamentary Committee.

Fletcher Beach, H. Benham, G. F. Blandford, D. M. Cassidy, T. S. Cl oust on,
E. M. Cooke, H. Gardiner Hill, Robert Jones, H. Rooke Ley, D. G. Thompson,
E. B. Whitcombe, Ernest White, J. Wiglesworth, D. Yellowlees, A. D. O’C.
Finegan, Conolly Norman, Oscar Woods, J. G. McDowall, C. Mercier, H. Hayes.
Newington, Evan Powell, H. Rayner, G. H. Savage, R. Percy Smith, J. B. Spence^
A. H. Stocker, David Bower, C. K. Hitchcock, and J. Carlyle Johnstone.

Report of the Educational Committee.

Dr. Mercier. —The Educational Committee have had a great many meetings,
and done a great deal of work during the past year. Amongst other matters, the
Committee has had before it for a considerable time the difficult subject of the
granting of its Certificate in Nursing to candidates in the asylums of the Colonies
and Dependencies of the Empire, and begs to submit its report thereupon.

It was felt that if a practicable scheme could be devised by which attendants on
the insane in the Colonies and Dependencies of the Empire could be afforded the
opportunity of obtaining the Nursing Certificate, and thus becoming affiliated to
the Association, it would be highly desirable that this should be done. The scheme
of training and examination has been found in this country so beneficial alike to
the insane, to the attendants themselves, and to their employers, that when
application was made by members of this Association having charge of large
asylums in the Colonies to extend these benefits to the attendants serving there,
the Committee was anxious that the request should be granted.

It was found upon examination of the regulations, that the obstacles of distance,
and of the consequent delay in communicating, would render it impracticable to
apply to the Colonies the scheme in force in this country unless some elasticity
were introduced into its details. The Committee therefore endeavoured to devise
a plan by which, while the efficiency of the training and the stringency of the ex¬
aminations should be strictly safeguarded, such elasticity might be introduced into
the system as should obviate the manifest difficulties of the situation, and to this
end they recommend the adoption by the Association of the following addition to
the Regulations:

1. That power be given to the Council to make such modifications in the

details of the examinations as may, without impairing their thorough¬
ness or stringency, save time or increase convenience in holding them.

2 . That power be given to the Council to modify in special cases the condi¬

tions under which Coadjutors are appointed.

3. That power be given to the Council to appoint, on the recommendation

of the Division of the Association in any Colony or Dependency in
which a Division may have at the time been formed, a Deputy Registrar,
who may exercise in that Colony or Dependency such duties of the
Registrar as the Council may determine.

With respect to the recognition of institutions for the purpose of the Nursing
Regulations, the Committee recommend :

1. That in England the following institutions should be fully recognised:

County asylums, borough asylums, Leavesden and Caterham Asylums,
registered hospitals, Broadmoor Criminal Lunatic Asylum;
and that with respect to licensed houses, each of these institutions should, if
it desires to be recognised, apply to the Council for recognition.

2 . That in Scotland the following institutions be fully recognised : Royal

asylums, district asylums;

and that institutions in the position of licensed houses should apply,
individually for recognition.

Digitized by tjOOQle

8io

NOTES AND NEWS.

[Oct.,

3 * That in Ireland the following institutions be fully recognised: District
asylums, St. Patrick’s Asylum, the Stewart Institution, Dundrum
Criminal Lunatic Asylum;

and that institutions in the position of licensed houses should apply
individually for recognition. (Signed on behalf of the Committee)

Charles Mercier.

Dr. Mercier proposed that the report of the Educational Committee be adopted,
and Dr. Percy Smith seconded the motion.

Dr. Clouston said he thought that some explanation was due to the Association
os to how they stood in regard to the Certificates in Psychological Medicine. At
one time they had a large number of candidates, to the financial benefit of the
Association, but lately candidates had greatly diminished in numbers. The reason
of the falling off might be owing to the fact that the teaching of mental diseases
was now compulsory on every medical student before he took his degree. He con¬
sidered that the matter should now be looked at in the light of the new medical
ordinance, and that they should ask themselves whether instead of having a pass
examination in Psychological Medicine they should not make it an honours ex¬
amination, a higher qualification in Psychiatry, which gentlemen who desired
such a qualification should be encouraged to take. The experience of all colleges
and universities had been that when a difficult examination was set, it had
revivified examinations in a wonderful degree. As an example, the Royal College
of Physicians in Edinburgh had taken a new lease of life since the examinations
had been made more difficult. They had followed the example of London in this
matter, and he thought that the Association might look forward to a period of
increased usefulness in regard to its Certificate if it were put on the footing of an
honours examination.

Dr. Percy Smith pointed out that, although attendance at lectures and at
clinical instruction in asylums was compulsory, there was not necessarily any
examination in psychiatry by the examining bodies before qualification. Some
never asked a single question on psychiatry in any of their papers, and there was
certainly no special examination on the subject. He thought that it would be a
great pity to do away with their “ pass examination.” He thought that one of
the reasons why so few candidates entered for the ordinary pass examination for
the certificate was that assistant medical officers in asylums were not sufficiently
encouraged. In fact, he had heard it stated that certain superintendents had
asked junior assistant medical officers what good it would be to them to go in for
such an examination. He maintained that it was an exceedingly good thing for
assistant medical officers to show that they had really worked on the subject. The
Gaskell Prize constituted,an honours examination, but he thought if that were the
only one, the candidates might be fewer than at present. If medical superintendents
would encourage their assistant medical officers, more candidates would present
themselves for the certificate and also for the Gaskell Prize.

Dr. Conolly Norman said that attendance at clinical lectures and instruction
for three months was not a sufficient preparation for an honours examination. In
Ireland examinations in this subject were held, and the papers set were very
difficult and suitable for an honours examination. If the Association made the
examination an honours one, they must exact more than the Licensing Bodies and
require a longer curriculum than three months.

Dr. Douglas suggested that the difficulty might be met by making a pass
and an honours examination, and thought that the falling off in the number of
candidates might be due to lack of publicity.

Dr. Clouston said that he was anxious to hear the opinions of the members of
the Association, and proposed that the matter should be referred to the Educational
Committee for report at the next Annual Meeting. This was seconded by Dr.
Conolly Norman, and the following motion was agreed to:—“ That the question
of the certificate given to medical men by the Medico-Psychological Association
ehould be referred to the Educational Committee for report.”

Dr. Mercier proposed the reappointment of the Education Committee, seconded
by Dr. Percy Smith.

Dr. Urquhart said he thought that the Educational Committee might be
modified in some degree. That Committee did a great deal of work, and they

Digitized by tjOOQle

1900.]

NOTES AND NEWS.

8ll

were much indebted to Dr. Mercier for his labours upon it during so many years.
He considered that it was too large, and would therefore move that the names of
those members who had not attended a single meeting should be deleted, of course
with the exception of teachers of psychological medicine, who were ex officio-
members of the Committee. Now that the nursing examinations bulked so
largely, those who took special interest in that work should be adequately repre¬
sented. Dr. Carlyle Johnstone seconded the motion, which was strongly
opposed by Dr. Macdonald. The motion was lost, and Dr. Carlyle Johnstone.
proposed that the name of Dr. Havelock be added to the Committee. This was
seconded by Dr. Clouston. The Educational Committee is composed as
follows:

Educational Committee.

T. S. Adair, G. J. Blandford, H. A. Benham, A. Campbell Clark, T. S. Clouston*
A. D. O’C. Finegan, W. Graham, J. G. Havelock, T. B. Hyslop, J. Carlyle

J ohnstone, W. S. Kay, P. W. Macdonald, T. Maloney, W. F. Menzies, W. F.
fickle, C. A. Mercier (Secretary), G. W. Mould, H. Hayes Newington, Conolly
Norman, J. Rorie, H. Rayner, W. Reid, C. Rogers, G. H. Savage, T. Claye
Shaw, R. Percy Smith (Chairman), J. B. Spence, A. R. Turnbull, L. A. Weatherly,
E. B. Whitcombe, Ernest White, J. R. Whitwell, T. W. McDowall, J. Wigleswortn*
J. Kennedy Will, Oscar Woods, and D. Yellowlees.

Report of the Council.

The report of the Council was read by Dr. Percy Smith in the absence of the^
General Secretary.

The number of members of this Association for 1899—1900 are as follows :—
Ordinary, 550; honorary, 36; corresponding, 12 ; total, 598.

At the Annual Meeting of last year the membership was—ordinary, 540 ; hon¬
orary, 38; corresponding, 12; total, 590. Whilst in 1898 the membership was—
ordinary, 524; honorary, 38; corresponding, 12; total, 574.

There has been a gradual growth in the number of ordinary members of the
Association during the past three years.

The Council acknowledge with thanks the bequest of ^100 by the late Dr. Paul.
It now appears in the accounts.

Drs. Meyer and Godding, honorary members, and Dr. R. H. Nicholson, ordinary
member, have died, and five members have resigned.

Meetings.

The Annual Meeting during the past year was held in London, in July, and was.
most successful. The President, in his address, referred to the prevention of
phthisis in asylums. This was followed by a paper read by Dr. France at the
November General Meeting, at which Sir William Broadbent, Sir James Crichton
Browne, and Professor Clifford Allbutt attended. A Committee to consider the
question was appointed, and the following were elected members:—Drs. Cassidy*
Elkins, France, Mr. Hine, Drs. Mott, Conolly Norman, Percy Smith, Spence,
Weatherly, Whitwell, and Wiglesworth. The Committee has already commenced
to work.

The members greatly appreciated the kind hospitality of Mrs. Langdon-Down
during the Annual Meeting.

Three General Meetings were held, the one already referred to in London
in November; one in February this year, through the courtesy of Dr. Kidd, at
the West Chichester Asylum; and another last May in London, at which a valuable
and interesting communication was made by Dr. Maudsley, and also by Dr. Koenig,
one of the medical officers of the Berlin Municipal Asylum at Dalldorff. We
note especially the growing tendency there has been to appreciate the value of
practical work, such as microscopical and other demonstrations. The discussions,
have been interesting and stimulating.

Divisions .

The Divisions each held two meetings during the year.

Sixty-three new members have been elected during the year.

Digitized by tjOOQle

8 I 2

NOTES AND NEWS.

[Oct,

The prosperity of the Association much depends upon the prosperity of its
different Branches, and the Council would be pleased to see increased interest in
this direction in some of the Branches.

Committees .

Much work has been done by the Standing Committees, by the Educational in
regard to the Nursing Examination, and the new arrangements for the admission
of Colonials, and by the Parliamentary Committee in relation to lunacy bills and
pensions.

The Council have to emphasize the great support received from the Chairman
of the Parliamentary Committee in regard to the best interests of the Association,
and the Association is under much obligation to him in his position of Treasurer.
The other Committees have also done valuable work, and the Association is
indebted to the officers for their continued services.

The Journal,

Dr. Rayner having reported to the last meeting of Council that additional
assistance was required in the editing of the Journal, it was remitted to Dr.
Rayner and the Treasurer to ascertain whether aid could be got from some of
the younger members of the Association, and thus obviate expenditure of funds.
They ascertained that Dr. James Chambers was willing to help, and that help was
accepted by the Editors temporarily, the July number of the Journal having
been brought out with Dr. Chambers’ kind co-operation. On the same lines
Dr. John R. Lord had undertaken the production of a specific part of the
Journal quarter by quarter.

The Council further appointed a Committee to consider the general arrange¬
ments in connection with the editing of the Journal. That Committee met on
the 25th of July. Present:—Dr. Rayner in the Chair, the Treasurer, and other
Editors.

It was resolved to recommend to the Council that the Editors should remain
as at present, that the two named members, Dr. J. Chambers and Dr. J. R. Lord,
should be given the position of Assistant Editors, to act under the direction of
the present Editors. That the recommendation should carry with it the insertion
of the names of the Assistant Editors on the title page of the Journal, although
the Committee is not of opinion that they should thereby be entitled to seats on
the Council. That the selection and appointment of Assistant Editors should
rest with the Editors of the Journal, who are annually appointed by the
Association.

The Council, having considered that report, together with a statement of the
Journal accounts for the last five years, prepared by the Treasurer, adopted it
unanimously.

The report of the Council was received and adopted.

Nursing of Insane in Irish Workhouses.

The President. —It will be within the memory of many present that on the
initiative of Dr. Finegan, the Council were instructed by the Annual Meeting to
inquire into the question of the advisability of sending a letter to the Local
Government Boards as to the nursing of insane patients in workhouses. The
matter was discussed at the various Divisions of the Association, with the result
that it was unanimously agreed that in their opinion it was advisable that some
such memorandum as we have in the agenda to-day should be sent, as an ex¬
pression of the opinion of this Association. It is now for this Annual Meeting
to say definitely whether we shall send it or not. I propose that this Annual
Meeting direct the Secretary to send a copy of the Resolution to the Local
Government Boards as follows: —“ It is the unanimous recommendation of the
Medico-Psychological Association of Great Britain and Ireland, that in union
workhouses in which insane people are detained, a properly qualified and trained
mental nurse should be employed in the insane wards.” This was unanimously
•approved, and the General Secretary has carried out the instruction.

This concluded the proceedings of the morning meeting.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

813

Afternoon Meeting.

Dr. Spence. —The first business for the afternoon is to introduce to you the
President for the ensuing year. Of all the gentlemen who have occupied the posi¬
tion of President of this Association, few have required less introduction than Dr.
Beach. He is thoroughly well known to every member of the Association ;
he has served us well and faithfully for many years in the past, and I hope that in
the future there are many years of useful work for him still to do. He commends
himself to us by his urbanity, genial nature, and the good fellowship which he has
displayed to every member of this Association. When he retired from the
position of Secretary, I remember how very heartily we thanked him for his good
services, and how sorry we were to lose him. We are very pleased to have him
in the position of President, which is a distinguished and important office, and I
am sure no one whom we could have elected would do honour to it more than
our friend Dr. Beach. I have known him for a great many years, and I feel
it a personal privilege that it becomes my duty at the close of the year of my
presidency to introduce him as my successor, and to ask him to take the chair
which I now vacate.

Dr. Blandford. —Before we listen to Dr. Beach’s adddress, I have to propose
that this Association records its unanimous and grateful thanks to Dr. Spence for
the excellent way in which he has performed the duties of President during the
last year. I need not enumerate his virtues to you, because you all are quite
as well acquainted with them as I am. You have all seen him often, because he
has been so assiduous in attending the meetings of the Association during the year
of his presidency. You all know how excellently he has conducted the business,
and with what kindness and cordiality he has received all the members of
the Association, and I feel certain that you will join with me in expressing
our warm thanks to him for the way in which he has discharged his duties.

Dr. Clouston. —I have the greatest pleasure in seconding the proposal of
a vote of thanks to our retiring President. We all know that in Dr. Spence the
Association has had an ideal President in physique, in mind, and in morals. The
way in which he has conducted our meetings convinces us that he is one of
the best Presidents we have ever had. I trust that we shall have a great many
more like him. This motion was carried with acclamation.

Dr. Spence. —I am very much obliged to Dr. Blandford and Dr. Clouston for
the kind remarks they have made. I suppose I feel as many men have felt
at the end of their period of office, that if one had to go through it again one
would do much better. I can assure you that the duties of President have been
very much lightened by the assistance received from the officers of the Association,
more especially from our excellent Secretary. The kindness I have shown is
nothing to what I have received from the officers and members of the Association,
and I regret giving up the post, not so much for the honour of it, but for the
pleasure it has afforded me in bringing me in contact with my brethren in the
profession.

Dr. Beach then read his Presidential Address, and the further proceedings are
given in detail in Part I of this number of the Journal.

Second Day.

The President. —Before closing this meeting I think it is only right and
proper that I should propose a vote of thanks to our excellent Treasurer and our
excellent Secretary. The dinner was a brilliant success, and that is entirely
due to our Treasurer. We could not get a better Secretary than we have. His
time and attention are devoted to getting a sufficient number of papers, and the
unqualified success of this meeting in that respect is largely due to his unstinted
efforts.

Dr. Stewart (Clifton).—I have much pleasure in secondingthis vote of thanks.
After thirty-two years’ membership I have been surprised by the very conspicuous
success, both as regards the character of the papers and the intense interest
shown in them. I do not remember to have been at a dinner at which there was
such a unanimous expression of thanks to those who have arranged it.

Dr. Hayes Newington thanked the President and Dr. Stewart for their kind
remarks, but said that he should be sorry to see the dinner exalted unduly. The

Digitized by

Google

814

NOTES AND NEWS.

[Oct.,

real work of the meeting had fallen upon Dr. Jones, and he felt sure that everybody
would be satisfied that enough had been heard of insanity within the last forty-
eight hours to consider for some time to come.

Dr. Jones having also expressed his thanks, Dr. Urquhart said, I beg to propose
a vote of thanks to our President for his services in the chair, and must add a
hearty word of thanks to the gentlemen who have read papers. We know that
Dr. Jones has had a great deal of correspondence and a very great deal of trouble,
but the meeting would hardly have been a complete success without the active
co-operation of those whom he has induced to oblige us on this occasion.
Another point I would specially notice is that a great deal of the work has been
done by younger members of the Association, and those of us who have been
in attendance here for some years have every confidence in their carrying on the
business and the scientific interests of our Society just as well as in the past, and,
perhaps, with increasingly greater effect. There is difficulty in adequately dis¬
cussing some of the papers which have been read; for instance, when we have had
an opportunity of quietly perusing Dr. Edridge-Green’s paper in the Journal no
doubt we shall be more competent to appreciate it. The authors, who have given
us of their best, must be content to let what they have said fructify in our
minds until we have an opportunity of expressing our ideas. We are under deep
obligations to our President, and we are very glad, after all he has done in various
capacities for this Association, to see him in the position he now holds.

The President. — I am much obliged to Dr. Urquhart for proposing a vote
of thanks to myself, and for the kind manner in which you have expressed
yourselves to-day. The papers have been of such interest that one’s mind has
been constantly occupied with thoughts which will fructify later on. I do hope
that during my presidency the younger members will come to the front. We
have now a large number of them who are working hard, and it is only right and
proper that they should give us the result of their researches. I can assure them
of a hearty welcome at this Association.

Council and Committees.

In connection with the Annual Meeting there were meetings of the Educational,
Parliamentary, Editorial, and Tuberculosis Committees. The Council met on
the 26th July, the following members being present: J. B. Spence (President),
Fletcher Beach (President elect), R. Percy Smith, J. Carlyle Johnstone, A. R.
Turnbull, H. Hayes Newington (Treasurer), Conolly Norman, Crochley Clapham,
James Chambers, T. Steele Sheldon, W. R. Dawson, G. Stanley Elliot, C. A.
Mercier, Oscar T. Woods, A. R. Urquhart, H. Rayner, Harry A. Benham, David
Bower, Arthur D. O’C. Finegan, A. W. Campbell, James M. Moody, P. W.
Macdonald, and T. Outterson Wood.

Letters of apology were received from Drs. D. M. Cassidy and J. G. Soutar.

It was reported that the Gaskell Prize had been gained by Dr. Maurice Craig,
and that the Bronze Medal had been awarded to Dr. C. C. Easterbrook for his
essay on “ Organotherapy.”

It was resolved that the Tuberculosis Committee should have permission to
replace any members by others thought suitable by the Committee; that the
Committee should have power to add to its numbers to the extent of three;
and that Mr. Clifford Smith be invited to assist the Committee in an advisory
capacity.

The Registrar reported that 521 candidates entered for the May examination
for the Nursing Certificate, 438 having been successful.

There were three candidates for the Certificate in Psychological Medicine, and
all were successful.

IRISH MEETING.

The quarterly meeting of the members of the Irish Division of the Medico-
Psychological Association was held at the Second Asylum for the Richmond
District, Portrane, Co. Dublin, on Thursday, June 28th. The following were in
attendance: Dr. Patton (in the chair), Dr. Conolly Norman, Dr. Rambaut

Digitized by VjOOQle

NOTES AND NEWS.

1900.]

S i 5

Dr. J. O’C. Donelan, Dr. Henry Eustace, Dr. Leeper, Dr. Nolan, Dr. Lawless,
Dr. Dawson, and Dr. Arthur Finegan (Hon. Secretary).

Letters of apology for non-attendance were read from Dr. B. Harvey, Dr.
Strangman, Dr. Hetherington, Dr. O’Neill, Dr. Graham, Dr. Bernard, Dr.
Revington, Dr. Fitzgerald, Dr. O’Meara.

A paper, " Notes to serve for the study of Fracture of the Ribs,” by Drs. Conolly
Norman and Rambaut, was read by the former.

Dr. Richard Leeper read a communication entitled “ Remarks on our usual
Methods of Investigating Cerebral Disease, with some Suggestions for future
Original Research.”

Dr. Conolly Norman moved that the paper on “ A Case of Sensory Aphasia,”
by Dr. Rambaut, be taken as read, as he and Dr. Rambaut had already occupied
a good deal of the time of the meeting, and there was an interesting paper to be
read by Dr. Donelan. Dr. Dawson seconded the proposition, which was passed.

Dr. Donelan then read his paper: “ Some Notes on Portrane.”

At the conclusion of the meeting the members were entertained by Dr. Donelan.

BRITISH MEDICAL ASSOCIATION.

Annual Meeting, Ipswich, 1900.

Section of Psychology.

Reported by J. R. Whitwell, M.B.

President: R. Percy Smith, M.D. Vice-Presidents: E. L. Rows, L.R.C.P.;
W. Aldren Turner, M.D. Honorary Secretaries: Cecil A. P. Osbourne,
F.R.C.S.Ed.; J. R. Whitwell, M.B.

The section was well attended, and the papers read were fully discussed.

President’s Address.

Dr. Percy Smith, in his address on the subject of the Prevention of Insanity,
referred to the increase in the number of the insane (as shown by the Commis¬
sioners’ Report of last year), and the continued burden thus caused to the rate¬
payers. Speaking of the enormous importance of hereditary defect as an element
in causation, he pointed out that little or no effort was made in the human species
to guard against the breeding from bad stock, and detailed glaring instances from
his own experience of bad results from this cause. Alcoholic excess in the indi¬
vidual and its results in offspring were referred to, and attention was called to the
further need for legislation for the non-criminal inebriate, and the inefficacy of the
present Inebriates Act. Syphilis, both acquired and hereditary, as a potent element
in the production of general paralysis he recognised as absolutely established, and
supported the view that syphilis should be a notifiable disease, reviewing the
beneficial effect of this action in Finland and other countries.

Sexual Functions and Insanity.

Dr. Macnaughton Jones opened a discussion on “ The Bearing of Sexual
Function and Disease of the Sexual Organs on Insanity and Crime.”

The following were the conclusions that the speaker placed before the section :

1. Functional disorders of ovulation are frequently attended by mental aberra¬
tion, and in a proportion of cases originate the mental disturbance.

2. The same remark applies to disorders of ovulation which have a pathological
cause.

3. In the great majority of such cases the nervous disturbance is of the neuras¬
thenic character, and is associated with various visceral or other neuroses. In
only a small proportion does the alienation assume so grave a type as melancholia,
mania, or dementia.

4. Where in an insane person ovulation and its external manifestation, the
menstrual discharge, are absent or erratic, the erraticism or absence may be a
consequence of the general and insane condition, and not a causal factor in its
production ; but under any circumstances such abnormal menstruation appears to
nave an aggravating effect on the insanity, and there is sufficient evidence to

xlvi. 5 5

Digitized by VjOOQle

8i6

NOTES AND NEWS.

[Oct.,

strengthen the belief that when such irregularity—especially if it be due to a
pathological cause—exists, it should be treated therapeutically or by operative
measures.

5. The question of a gynaecological examination of an insane woman must be a
matter for the discretion of the psychologist, influenced by the gynaecological
view as to its expediency from the signs and symptoms present in the sexual
organs. For many reasons, as a universal practice, with our present knowledge
it is not warrantable.

6. Sufficient evidence is now advanced to justify the removal of the adnexa or
tumours of the uterus in insane women, when there are gross lesions of the former
or tumours of the latter, it being remembered that dementia has not uncommonly
followed upon the development of uterine myoma. Here, again, such operation
must be advised according to the psychological condition of the patient and the
type of her insanity.

7. From a mass of evidence, including some of the largest experiences in
Europe, Canada, and America, it does not appear that there is in healthfully-
minded women, who suffer from diseases of the genitalia, any special risk of post¬
operative insanity. On the other hand, if there be a psychopathic predisposition,
which has existed prior to and independently of the sexual disease, there is in
such cases a larger percentage of post-operative mental disturbance than follows
other operations. In such women the prudence of a radical operation may have
to be carefully discussed. The post-operative mental effect does not appear
generally to be of a serious or permanent nature.

8. It may be generally affirmed that when mental disease of a graver type
follows upon sexual disorder, there has been in the woman affected an underlying
and often unrecognised psychopathic predisposition ; the disorder of menstruation
or the disease in the genitalia completing the chain of the vicious circle needful
for the final manifestation of the mental condition.

9. The relation of aberrant sexual function or a disorder of menstruation to any
criminal act ought to be taken into consideration in determining the responsibility
of the woman.

Epilepsy.

Dr. Pasmore read a paper on the subject of Epilepsv, describing the usual
mode of incidence of the mental symptoms. He referred especially to the cases
in which periodic maniacal outbursts occur, alternating with or replacing con¬
vulsive seizures, which he termed psycho-epilepsy. He maintained that many
cases of so-called recurrent mania were really to be classed under this heading,
and quoted numerous instances in support of this view.

Peripheral Neuritis and Mental Disease.

Dr. Percy Smith read a paper “ On the Association of Peripheral Neuritis
with Mental Disease,' 1 in which he pointed out the fact that the association of
peripheral neuritis with a specific form of mental disease, described by Korsakoff
and others as “ polyneuritic psychosis," had received but little recognition
in this country. He had met with peripheral neuritis in twenty cases in
sixteen years out of some 3600 acute cases of, mental disease which had passed
under his care. Of these four were males, sixteen females; and of the four males
three were alcoholic in origin, and in one the neuritis was secondary to typhoid
fever, though alcohol could not be definitely included. Of the sixteen female
patients eleven were certainly alcoholic, four others came into the category on
closer investigation, and the remaining one was of diabetic origin. In 50 per cent,
of all the cases there was a family history of both alcohol and insanity. The
mental condition in the alcoholic cases agreed in the main with the groupings
described by Korsakoff, but did not do so in the cases following typhoid fever
and diabetes. Seven of the twenty patients recovered, two died, and the remainder
were permanently damaged either physically or mentally. From his observations
Dr. Percy Smith concludes that there should be considerable doubt in accepting
as proven a characteristic polyneuritic psychosis apart from alcoholism, etc.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

817

The Colony Treatment of Epilepsy.

W. Aldren Turner introduced a discussion “On the Colony Treatment of
Epileptics, especially with reference to the Chalfont Home for Epileptics.” He
discussed the matter chiefly under the following heads:

1. Education of epileptic children. —These children should be educated apart
from the healthy or imbeciles.

2. The management of adult epileptics (sane). —He said that medicinal treat¬
ment was not greatly of importance; but institution life with suitable employ¬
ment, etc., was of much greater importance. In such cases the average fre¬
quency of the fits is reduced, and the physical and mental state improved.

He claims that the colony treatment affords a means of disposal of the unfor¬
tunate class referred to with benefit to themselves, and the plan may be made a
financial success.

Referring to the possibility of curing epilepsy, he pointed out the necessity for
care in deciding when recovery has been established.

The Pathological Histology of Acute Delirious Insanity.

Dr. John Turner (Essex) assumed three clinical varieties of Acute Delirious
Insanity: —1, alcoholic; 2, septic (puerperal, etc.); 3, idiopathic (probably auto¬
toxic). After describing in detail the symptoms, both mental and physical,
usually met with in these cases, he reviewed the literature of the subject with
special reference to the experimental work of Nissl, Marinesco, and others,
pointing out the inconstancy of the results.

Making use of pressure preparations and sublimate hardened sections, with
toluidin blue as a staining agent, he notes the following changes:

(1) Excess of pigmentation in giant-cells of the frontal convolution.

(2) Certain cells stain very densely, masking the stichocrome appearance.

(3) Occasionally a shrunken condition of the cells and crumbling of Nissl
bodies.

(4) Ready fracture of cell processes during fixation.

(5) Excessive number of free nuclei in perivascular and pericellular spaces.

(6) Sometimes extreme fatty degeneration of the cells of the second layer.

(7) The liver in all the cases examined showed evidence of marked fatty
degeneration of the cells.

The implication of the nerve-cells in the above way is in very scattered areas,
and partial.

Many of these conditions were shown by means of the lantern.

Blood-pressure in Mental Disease.

Dr. Craig read a paper “ On Blood-pressure in Mental Disease.” He consi¬
dered it proven that a high blood-pressure was definitely associated with melan¬
cholic conditions, and low blood-pressure with maniacal conditions. He suggested
that it may be that the lowered blood-pressure was due to cholin poisoning, the
result of katabolic processes. He referred to the comparison that may be made
between mania, and sleep, and dreams. He suggested the correlation that appears
to exist between melancholia agitata and mania, and fully endorsed the suggestion
that saline infusion may be the correct treatment in many of these cases.

Insanity in Male Lead-workers.

Dr. Robert Jones read a very detailed paper “On Insanity in Male Lead-
workers.” Recognising the importance of lead poisoning as a cause of mental
disease, he reviewed the various methods by which lead may find its way into the
body, e.g. in enamellers, file-cutters, etc., especially pointing out that workers in
the crude ore, i. e. miners, are rarely affected. The predisposing effect of gout,
rheumatism, and sex were fully discussed.

The researches of Lugaro on the pathology of the disease were briefly referred
to; also the theory that symptoms were due to altered elimination. Whether the
lesion is peripheral or central in its primary condition nothing in his experience
had given him the power to decide. As regards symptomatology, he discussed
fully and in great detail the various symptoms, and would classify the cases
under three headings :

Digitized by

Google

818

NOTES AND NEWS.

[Oct,

(x) Toxaemic cases, which are favorable in prognosis.

(а) Hallucinatory, in the main favorable in prognosis.

(3) Those resembling general paralysis of the insane, frequently favorable.

The Relation of the Lunacy Laws to Neuro-psychological
Disease.

Dr. McCormac brought forward certain points which he considered required
remedying in connection with the relation of the existing lunacy laws to neuro¬
psychological disease—(1) in the direction of protecting the certifying medical
man against legal action taken by discharged patients, especially laying stress on
the danger of the dictum of Mr. Justice Field (Tooeood v. Wilkes) that the onus
of proving the absence of mala fidex lies with the defending medical man; (2) in
the direction of establishing hospitals (as distinguished from asylums) 11 in which
special attention should be paid to the treatment of diseases of the nervous system'*
in which mental cases may be treated by restrictions without limiting the liberty
of the patient. The result of this, he maintains, would be (but does not bring
any evidence to show the basis of this belief) that there could be but few cases of
failure, and this small percentage of failures would be dealt with as the law
directs.

He agreed with most alienist physicians in urging the extreme importance of
mental cases being brought under early treatment, instancing cases in which lives
had been wrecked by the unfortunate tendency to keep patients at home, or give
them change of scene and air, etc.

Cardio-psychical Association.

Dr. Whitwell suggested for consideration and examination certain morbid
cardiac states which appeared to have some association with mental symptoms,
illustrating some of them under the following classification :

(x) Mental associations of acute cardiac disease.

(2) Conditions of imbecility associated with cardio-vascular hypoplasia.

(3) Conditions of mental immaturity associated with early heart disease, con¬
genital or acquired.

(4) Mental variation in an abnormal direction associated with valvular disease
of the heart in the adult.

(5) Heart delirium associated with uncompensated lesions.

(б) Mental changes associated with acute cardiac asthenia.

(7) Mental changes associated with the cardiac asthenia and erethism of fibroid
degeneration in senility.

(8) Pathological eupathy occurring in late heart disease.

Organo-thbraprutics in Mental Disease.

Dr. Eastbrbrook (Morningside) read a paper founded upon an exhaustive
examination of the use of various animal extracts in various forms of mental
disease extending over a considerable period of time. Of 130 cases of insanity
treated with thyroid extract twelve patients recovered, twenty-nine were im¬
proved, and eighty-nine remained unimproved. Those who recovered included
cases of myxoedema, stupor, puerperal and lactational melancholia, and simple
and climacteric melancholia. Parathyroid and thymus extracts gave negative
results. Ovarin was given in thirty-six cases, with temporary improvement only
in four cases, and none in the rest. The total results of organo-therapeutic
treatment were not very favorable except in myxoedematous and stuporous
states.

PARLIAMENTARY NEWS.

Imbeciles Training Institutions Bill.— May 2nd .

Mr. Tomlinson (Preston) moved the second reading of this Bill to exempt
certain institutions from rating. Five philanthropic institutions were affected.

Digitized by tjOOQle

NOTES AND NEWS.

1900.]

819

Mr. T. W. Russell promised that they would be included with hospitals in a
reference to a Select Committee. The Bill was withdrawn.

Youthful Offenders Bill. —May 21 st

Sir M. White-Ridley moved the second reading of this Bill to diminish im¬
prisonment among offenders under the age of sixteen, and to extend the power of
whipping. In his reply on the discussion, Sir M. White-Ridley recognised that
there was a sharp division of opinion, and the debate stood adjourned by the
rules of the House.

Edinburgh District Lunacy Board Bill.— June 2$th .

This Bill was reported for third reading.

Lunacy Regulation (Ireland) Bill. —June 25 th.

This Bill was read a second time. Lord Ashbourne said that it was to intro¬
duce useful provisions now in operation in England, and to permit of the con¬
ditional discharge of criminal lunatics.

The St. Pancras Scandals. —June 26th.

Lord Russell of Killowen called attention to this matter, and asked what
proceedings were to be taken.

The Lord Chancellor said that his attention had been called to the case by
the Lunacy Commissioners, who had sent him a draft clause for insertion in the
Lunacy Bill, which had not yet passed into law. He had also received a com¬
munication from the Local Government Board, and a circular letter to Boards of
Guardians was to be sent out.

June 28th.

Mr. J. Burns having made inquiries in reference to this matter, Mr. Chaplain
said that he had directed an immediate investigation by the Local Government
Board, and a communication to be made to Metropolitan Boards of Guardians.

The Case of Private Weir.— July 10 th.

In reply to Mr. P. O’Brien and others, Mr. Wyndham said that Private Weir
had been invalided home from South Africa as a lunatic; his insanity not being the
result of his army service no pension could be given him.

Lunacy Bill (England). —July 1 6th .

This Bill was withdrawn.

Lunacy Board (Scotland) Salaries Bill. —July 19 th.

This Bill was read a third time.

Proposed Exemption of Hospitals from Local Rates.

Evidence was taken by the Select Committee on June 22nd and subsequent
dates. A claim has been made for exemption by various institutions for the
feeble-minded and epileptic.

RECENT MEDICO-LEGAL CASES.

Reported by Dr. Mercier.

[The editors request that members will oblige by sending full newspaper reports of
all cases of interest as published by the local press at the time of the assizes.]

Reg. v. O’Hara .

Denis O’Hara, 39, labourer, was indicted for murder of his daughter, aged six,
May 21st. Prisoner had left work for about a fortnight before the murder, and
•during that time had been drinking. On the morning of the 21st May he started

Digitized by VjOOQle

820

NOTES AND NEWS.

[Oct,

drinking early, and up to noon had had five pints of beer. About half past four
in the afternoon he took his little girl home, stood her on a chair, tied a rope
round her neck, fastened her up, and took the chair away. He then went to the
police station, and laying on the counter a door key, he said, “ If you will take it f
and go to my house, 18, George Street, you will find a child dead. I have done
it. If you go there you will find her in a rocking chair wrapped up in a coat.”
The body was found as described. Shortly after the prisoner was placed in a
cell his wife came, and he said, “ That is my wife crying; I heard her mention
Mary Agnes, my child’s name. Mary Agnes, I loved her; she was the prettiest
child in Burnley.” He then described how he committed the murder, and went
on, ** They have wrung ray heart, and I have wrung theirs. It does not matter
what you do. I do not care how soon I am out of it. I gave her a halfpenny,
and they made her give it back; she took it off me. They wrung my heart, and
I have wrung theirs.”

Evidence was given that at noon the prisoner was ” half off, neither drunk nor
sober.” At five p.m. he was in a stupefied condition, and under the influence of
drink. When he made the statement in his cell he was excited from drink.
Dr. Ley, of Prestwich, deposed that he first saw the prisoner on May 28th, and
that prisoner was of unsound mind at that time. He was confused, depressed
and melancholy, and it was difficult to get any coherent answer out of him.
He appeared to be just recovering from an attack of acute mania—delirious
mania,—and in witness’s judgment he would be suffering from that attack on May
21st. He thought that on May 21st he would have a very confused idea of right
and wrong—be hardly capable of appreciating the nature and quality of the act
he was committing. On the 28th and 29th of June he examined the prisoner at
the request of the Treasury, and he thought the man was of sound mind.
He learned that the man had been drinking heavily, and it had culminated in an
attack of delirious mania. Dr. Edwards, of Strangeways Prison, said that he first
saw the prisoner on May 26th. He was much depressed and confused, listless,
and quite lost. He was not at that time of sound mind, and he should think
probably of unsound mind on the 21st May. He could not say that on May 21st
he was incapable of distinguishing between right and wrong. The judge said the
man might be in some degree insane, and yet be quite responsible for his actions.
To render him not responsible he must be suffering from mental disease which
impaired his judgment. They must not consider a man mad because of the
unusually shocking nature of his crime; if that was done any man who wanted to-
commit a murder had only to do it in a mad kind of way. Guilty, but insane.—
Mr. Justice Channel .—Manchester Guardian , July 18th.

Another of the numerous cases in which crime is committed during drunken¬
ness. Whether the drunkenness renders the criminal irresponsible depends upon
the duration of the drinking. In this case the drinking bout had lasted only
a fortnight, but the resulting insanity was sufficiently marked to exonerate the
criminal.

Reg. v. Bit ties.

John Birtles, 50, window cleaner, was charged with the murder of his wife.
Prisoner had been an inmate of Prestwich Asylum for four years many years
before. There had been frequent quarrels between him and the deceased, and the
son had had to protect his mother from violence. On the 8th May, when the son
came home at night, the prisoner opened the door to him, and said, “ I have
murdered your mother.” The son went for assistance, and on his return found
the door barricaded. It was forced, and the prisoner threatened the incomers
with a poker, and threw hot water over one of them. The woman was found
dead, with marks of very great violence. When arrested, the prisoner said
he would tell the truth to the magistrate. Dr. Scott, who was called in at the
time, said the prisoner seemed dazed, and in answer to a remark said, “ I did it.”
Witness did not see any signs of drink about him. Dr. Edwards, of Strangways
Prison, said that while the prisoner had been in prison he had seen nothing wrong
with his mind, nothing noticeable except excitement and garrulousness. Dr. Ley
said he examined the prisoner on the 28th May, and thought him of sound mind.
He ^ad been an inmate of Prestwich Asylum from 1881-1885, and was then
subject to numerous delusions and hallucinations—that he had committed some-

Digitized by tjOOQle

NOTES AND NEWS.

821

19OO.J

great crime—he did not know what it was,—and that everybody was making fun
of him. He was of opinion that injuries so extensive as those found on the
deceased had been caused by a man in a frenzy. The judge here asked witness
to define the word frenzy, which he did by saying that he meant “ the effects of
ungovernable passion.” The prisoner then gave evidence. He said that on May 8th
he had had four pints of beer; his wife was very abusive, and said “ it only wanted
a bit a paper to get him back to the asylum.” She then began to kick him with her
clogs, and pull his face about with her hands, and she seemed to be about to get
hold of the poker and tongs, which she had used before to strike him, when all of
a sudden a feeling came across him which he could not resist, and he got hold of
the crowbar and hit her with it. It was dusk at the time, and although he kept
striking about him with a crowbar, he did not know he was hitting his wife.
When he found out that this was the case, he fell down and shouted out,“ Oh my t
oh, dear, what have I done P ” Cross-examined: the crowbar was in the coal-hole.
He could not say why he did not give this account at the inquest. The judge
pointed out that the prisoner never mentioned the provocation until that day; but
even admitting the provocation, if he went out of the room for the crowbar, then
it was murder, and not manslaughter. It was difficult to see what there was in
the evidence to reduce the case to manslaughter, and still less to make the
prisoner not responsible for his actions. Guilty, but recommended to mercy.—
Manchester Assizes, Mr. Justice Channell.— Manchester Guardian , July 18th.

Justice seems to have been fairly met in this case. The jury could bring
no other verdict on the evidence, but took the previous insanity of the prisoner
into account in their recommendation to mercy. The sentence of death was
subsequently commuted on the same ground.

Reg. v. Holt .

Gertrude Holt, 25, knitter, was indicted for the murder of her new-born child.
Prisoner was confined on a Sunday, and when first seen by a doctor on the
following Tuesday, pointed, in answer to a question, to the top of a wardrobe,
where the body was found covered with wounds, inflicted apparently by scissors.
The defence was one of insanity, but no particulars are given. The judge said he
could see nothing in this case that could lead to a verdict of manslaughter; as to
irresponsibility, that there had been no evidence of insanity in the ordinary sense.
The existence of no fewer than seventy-seven wounds on the body indicated in all
probability that at the time she caused them the prisoner was in a condition of
frenzy, and if the jury thought she was in such a condition they might come to
the conclusion that she had not any sound judgment and knowledge of what she
was doing, and they would return a special verdict to that effect. Guilty, but
insane.—Manchester Assizes, Mr. Justice Channell .—Manchester Guardian ,
July 17th.

This case is remarkable when taken in relation to the previous one. It will be
observed that the learned judge himself had no hesitation in this case in using the
term “frenzy ” without defining to the jury its meaning, and that the existence of
frenzy was sufficient exoneration of the prisoner. But in the case of the man on
the following day the word possessed no such virtue, and the prisoner was
convicted in spite of his frenzy; so that extreme violence used by the man upon
his wife was no indication of insanity, but the extreme violence used by the girl
upon her child pointed clearly to insanity in her. It seems clear that either the
man should have been found insane, or the girl should have been found guilty of
murder. The latter was a good looking young woman; she was dejected ; she
cried and trembled in the dock; and the jury would have been more or less than
men if they had convicted her. Had the jury been one of women the verdict
might have been different. The man seems to have been an uninteresting person,
and in his case dry law took its course. But it is hard he should not have had
the benefit of his “ frenzy.”

Reg. v. Grosvenor.

Alfred Grosvenor, 27, French polisher, was indicted for wounding Alfred
Grosvenor the younger. The prisoner cut his son’s throat slightly, and then
his own severely. When the child's outcries summoned the landlord, the prisoner
said, “ I have done it myself. It is all through trouble; my wife has left me.

Digitized by VjOOQle

822

NOTES AND NEWS.

[Oct,

How is the boy P If he is done I will do it again.” When he was discharged
from hospital he said, " I knew nothing about it until it was done.” In defence
the prisoner said “ he did not know how he came to do it. His daughter died,
and the intense grief which he felt at her death caused him to fly to drink. He
was under the influence of drink when he cut his son’s throat.” Guilty of
unlawful wounding, and recommended to mercy. The judge said that he agreed
with the recommendation to mercy. He thought that what the prisoner did was
partly because of affliction in his family, and was not wholly traceable to his
having taken to drink, though, no doubt, that had something to do with it. He
should inflict no punishment, but bind the prisoner over in his own recognisances
in £10, to come up for judgment if called upon.—Mr. Justice Ridley.— Times ,
June 29th.

With the verdict and sentence we cannot fail to agree, but it is noticeable that
^*.pns° ner on his discharge from the hospital said that he knew nothing about it
until it was done, although at the time of the act be explained why he did it. It
is a very a common device of criminals to pretend that they know nothing of
what they were doing when their crime was committed, and such a statement
should always be received with great caution.

Reg, v. Smith,

Thomas Smith was arraigned for the murder of the Rev. J. W. Hudson.
Prisoner had asked deceased to intercede for him with his landlord; he had done
so, but unsuccessfully. Prisoner asked him to intercede again, and he was told
he had better go by himself; he then pulled out a revolver and shot deceased,
who died shortly afterwards. It was allowed to be proved that the mother of the
prisoner had several attacks of insanity during her married life, that the prisoner
during the last year had suffered from insomnia, that he had been addicted
to drink, and that for a long time he had been in the habit of firing off a gun and
a revolver pretty much at random, and often threatening people. Dr. O’Neill, of
the Limerick Asylum, stated that he examined the prisoner shortly after the
murder, and formed the opinion that the man was perfectly sane, and knew what
he was doing; he could discover no trace of mental infirmity. Dr. Gibson, the
prison surgeon, gave evidence to the same effect. The judge told the jury that
they were really thrown back on the state of the man’s mind for the past year and
a half. It was not enough to say the man had been bordering on delirium
tremens, because he may have got over it, and it would be for the jury to say
whether that condition was carried down to the very evening of the crime.
Guilty, but insane.—Limerick Assizes, Mr. Justice Kenny .—Dublin Express ,
July 9th.

The prisoner appears to have been sane enough to have been trusted with the
use of firearms for years before the murder, although it was known that he was a
crank and a drunkard; and a murder was the natural result. The favourable
verdict was evidently very largely due to the merciful liberality of the judge in not
merely allowing evidence to be given of the state of the prisoner’s mind many
months before the crime, but in directing the attention of the jury to this point.
The conduct of the police in allowing the prisoner the use of firearms was strongly
and justly commented on by his lordship.

Dowling v. Dod,

Plaintiff, a professional nurse, sued defendant for libel. The libel was contained
in a certificate addressed to the relieving officer for Paddington. Defendant
pleaded justification. It appeared from the evidence that while the defendant
was in the house of Dr. Farrer the plaintiff came in and had an altercation with
the latter, in which she struck him, knocked a lamp over, and was at last put out
of the house. Dr. Farrer and defendent upon this made inquiries among her
friends; in the result the libel was written. The plaintiff admitted that she had
written abusive letters to a lady with whom she had lived, complaining the lady
had taken possession of her mind, had read her thoughts, and had thrown her
down in the street by means of a “ thought-bodpr ” when she was a long way off.
Dr. Farrer deposed to the violence of the plaintiff during the interview in the
house. For the defence it was first submitted that the document was privileged

Digitized by tjOOQle

NOTES AND NEWS.

823

X900.]

under Section 13 of the Lunacy Act, 1890, which provides that every constable,
relieving officer, and overseer, who has knowledge that a person within his district
or parish who is not a pauper, and not wandering at large, is deemed to be a
lunatic, and not under proper care and control, shall give information thereof to a
Justice; and counsel contended that defendant was protected under that section
if he acted bond fide. He also contended that the occasion was privileged on the
ground that at common law any one of the public, if they saw a person who was
fiuriosus had the right to set the law in motion to get the prisoner put under
restraint. On the other hand, it was argued that Section 13 protected constables,
relieving officers, and overseers only, and not members of the public. It was
admitted that Section 13 might protect a member of the public if he acted with
reasonable care, and in good faith; but in this case he submitted that the
defendant had acted recklessly and wantonly. Mr. Justice Darling ruled that if
the relieving officer had expressed the opinion that the plaintiff was insane the
statement would have been privileged. It was impossible to suppose that the
relieving officer was intended to act only in cases which came under his own
observation. The policy of the Act required that information should be supplied
to him by members of the public who had seen the behaviour of supposed lunatics.
He was therefore of opinion that the defendant acted on a privileged occasion.
But he was also of opinion that there was evidence of malice. The judge left
to the jury the questions, first, whether the statements in the documents were
true; second, whether the defendant acted bond fide and without malice, third
whether he acted in good faith, and with reasonable care. The document stated
that the plaintiff had hallucinations. In support of that statement letters had
been read in which plaintiff had accused Miss Ashby of being in league with the
•devil. The jury had seen her, and could judge for themselves. If she was not a
witch the defendant would be justified in saying that the plaintiff suffered from
hallucination. Having thus given the jury a plain lead in favour of the defendant
the judge then went on to put the case as strongly as possible the other way.
He raked up the old trials of witches referred to by Sir Matthew Hale, and told
the jury how witchcraft was recognised by the laws of England, believed in
by members of Parliament, judges, and scientific men (save the mark), and finally
succeeded in inducing the jury to find a verdict for the plaintiff, with j£ioo
damages. It is difficult to believe that Mr. Justice Darling in thus addressing the
jury was speaking seriously, but, as a matter of fact, when the jury found for the
plaintiff he refused a stay of execution. The jury went further than the judge
however. The judge told them that the plaintiff’s letter accusing Miss Ashby
of being in league with the devil was tantamount to saying that Miss Ashby was a
witch, and the question for them was whether this statement was an indication of
insanity. But the jury said it was untrue that the plaintiff said she was bewitched.
They further said that it was untrue that if the plaintiff in her present state of
mind acted as a dispenser she would be a danger to the community.—Q. B. D.,
June 18th, 19th, and 20th .—Times following days.

The real reason for damages, etc., seems to have been that the jury considered
that whether the plaintiff was sane or insane it was not the defendant's business
to act in the matter. He did not know her, and he was not in the room at the
time of her attack upon Dr. Farrer, and in acting in friendship towards the latter
he was acting officiously, and interfering in a matter that did not concern him.

Moreover, the letter to the relieving officer was written incautiously, without
reticence, and with insufficient appreciation of the force of the words used—a very
common fault in certificates of lunacy. It stated that the plaintiff had sent
several threatening letters to various people, but letters to only one person were
produced. It stated that some of the people to whom the letters were sent went
in terror of their lives, but this was not proved even of the one recipient. It
stated that Mr. Dods had interviewed several people, who all agreed as to the
plaintiff’s insanity, but more than one of the people whom he interviewed gave
•evidence, and said that they had seen no evidence of insanity in the plaintiff.
Under these circumstances the verdict for the plaintiff on these points was
unavoidable; but there- seems no ground whatever for the finding that the
-defendant’s statement was untrue when he said that to the best of his knowledge
•and ability the plaintiff was of unsound mind, and it is scarcely likely that, if the

Digitized by VjOOQle

824

NOTES AND NEWS.

[Oct„

jury really took this view, they would have limited the damages to jfioo. This
particular finding seems to have had its origin in the resentment that juries are
apt to exhibit towards any medical man who certifies that a person is insane.

Soper v. Gibson and Young.

This was an action brought by Mr. William Soper, a coachman, against Dr. I.
Hill Gibson and Dr. W. M. Young, medical practitioners, in partnership atMaiaa
Vale, to recover damages for professional negligence and false imprisonment.

Mr. Moyses and Mr. Sidney Clark appeared for the plaintiff; Mr. Jelf, Q.C.,.
and Mr. Lambert Bond for the defendants.

The plaintiff’s case was that on January 8th, 1900, he consulted the defendant, Dr.
Gibson, being medical officer of a club of which the plaintiff is a member. He was, he
said, suffering from some ailment of a transitory character or was run down or
worried, and he alleged that the defendants negligently pronounced him to be
insane and a lunatic requiring to be put under restraint, and signed an order or
caused him, on or about January 14th, 1900, to be removed as a lunatic to Pad¬
dington Workhouse Infirmary for three days.

The defence was that the plaintiff was in fact insane and dangerous at the time,
or that the defendants had reasonable cause to believe that he was, and had acted
bond fide and without malice or negligence.

His Lordship, in summing up to the jury, said that, even if the plaintiff showed
that he was sane and not dangerous, that was not enough. He had to show that
the defendants, acting on the knowledge and information they possessed, did not
act reasonably. The plaintiff’s wife had made certain statements to them. Were
they not entitled to consider them P On all that the defendants saw and heard
from the plaintiff’s wife, were they negligent in thinking that the plaintiff should
be put under treatment ?

The jury returned a verdict for the defendants, and his Lordship gave judgment
for them accordingly, with costs—Mr. Justice Phillimore and a Common Jury.—
Times , June 20th.

Style v. Owen and Another.

The learned judge gave judgment this morning in this case, which was heard
before his lordship last term. The action was brought by the plaintiff, Mr. Robert
George Style, a surgeon residing in Cambridge Road, Bethnal Green, to recover
damages from the defendants, Dr. William Owen, of Shore Road, Hackney, and
J. R. Marriott, the relieving officer of the Hackney Union, for imprisoning the
plaintiff’s wife, and depriving him of her society. The defendant, Dr. Owen,
denied that he had detained or imprisoned the plaintiff’s wife. The other de¬
fendant, Marriott, said that whatever he did in the matter was in accordance with
his duty as relieving officer.

The circumstances of the case were of an extraordinary character. The plaintiff
and the defendant were medical gentlemen who resided and practised in the same
district, and who had been on terms of friendship for many years. The plaintiff’s
wife was mentally afflicted, and had been confined in an asylum. She had, how¬
ever, recovered and returned home, but in May last her malady reappeared, and
took the form of violent animosity to her husband. On the night of May 12th she
ran away from her home to the house of a neighbour, Dr. Fairbrother. She was
brought back to her husband’s house, and the next night she again ran away from
her home about 11 p.m., and was traced to the house of the defendant, Dr. Owen.
Dr. Fairbrother was sent to his house to induce Mrs. Style to return home, but,
according to plaintiffs case, Dr. Owen refused to allow her to go. The following
day Dr. Owen sent Mrs. Style to the Hackney Union—not as being insane, but as
being a destitute person. When Mr. Style went to ask for his wife at Dr. Owen’s,
house, he received information to this effect from Dr. Owen. Mr. Style at the
time was intending to remove his wife to a private lunatic asylum. He was
extremely indignant with Dr. Owen, and, having gone to the Hackney Workhouse,
he found his wife there, and had her removed to the Bethnal House Home. The
relieving officer had signed the admission order for Mrs. Style to the workhouse,
and the case against him was that he did not examine into the circumstances of
Mrs. Style's case, and make the necessary inquiries with regard to her which it waa.

Digitized by VjOOQle

NOTES AND NEWS.

825

1900.]

his duty to do before receiving her at the union. The defendant, Dr. Owen, said
that Mrs. Style went to the workhouse at her own suggestion and of her own free
will. She absolutely declined to return to her own home, and in his opinion she
was not insane. He and his daughters carefully tended her while she was in his
house, and her husband never came to fetch his wife tiH the third day after she
had run away. The hearing of the case was originally* commenced before his
lordship and a jury on March 9th, but, in consequence of the illness of Dr. Owen,
one of the defendants, the matter was adjourned, and the hearing was resumed
before his lordship only on March 31st, when Mr. Reed, Q.C., said that the record
as against the second defendant, J. R. Marriott, would be withdrawn, since the
plaintiff no longer imputed blame to him in the matter.

A great number of witnesses were called on behalf of the defendant to prove
that Mrs. Style went of her own free will to the union, having declined to remain
with her husband any longer; that she was sent into the infirmary because she
would have better treatment in that department; and that she could have applied
for a discharge at any moment if she had cared to do so, and would not have been
obliged to give notice of her intention of doing so.

Mr. Dickens, on behalf of Dr. Owen, submitted that there was no imprisonment
of the plaintiff’s wife by him. The only part he took in the matter was to send to
the relieving officer and ask him to come to the house, and the relieving officer
took his instructions from Mrs. Style.

Mr. Justice Ridley, in giving judgment this morning, after reviewing in detail
all the circumstances of the case, said that, though it was difficult to say what the
motives of Dr. Owen were in doing what he did, he had come to the conclusion that,
although mistaken in the course he had taken, Dr. Owen did act from motives of
humanity to the plaintiff’s wife. There would therefore be judgment for the
defendant, but without costs.—High Court of Justice, Mr. Justice Ridley.— Times>
May 1st.

In the Goods of Emma Alder son Shaw, presumed Deceased.

This was an application for leave to swear the death of Mrs. Shaw in the
following circumstances.

Mr. Willock said that Mrs. Shaw, whose maiden name was Wistar, was married
to Mr. John Shaw on April 23rd, 1889, and there had been issue two children,
born in 1890 and 1894. After the birth of each child Mrs. Shaw had a serious
illness and suffered from hysteria, and in consequence of her state of health she
went to Wiesbaden in November, 1897. She was on perfectly friendly terms with
her husband, as appeared from the correspondence, and returned to England in
June, 1898. On August 19th of that year she was staying at an hotel in Ken¬
sington, her husband being at the time at their home in Derbyshire. On August
20th she sent her husband an affectionate letter, dated August 19th, which clearly
showed her intention to commit suicide, and contained the following expressions :
— u I crave for death, for the death I have so longed for, so craved with passionate
hope of peace. If it is not peace, a sleep and a forgetting. How interesting it will
be 1 I do not need to say that the bugbear of Hades and the gridiron does not
affright me. If there is a God at all, I refuse, like Lord Sherbrooke, to believe He
is infinitely worse than I am myself. One would not torture poor souls, would
one P . . . I shall leave nothing compromising about me, nothing in the way

of luggage, etc. on the boat, and to slip very quietly over the side in the dead of a
moonless night ought to be easy and safe. It seems to me the most refined way
—there cannot be an inquest, unless the gulls hold one 1 Oh, 1 the healing of the
sea’ that will soon heal all my misery. ... I have wired to my solicitor to
destroy my will in his charge. I do hope that he will do so, and that all will fall
to you to keep for the children.” Mr. Shaw at once hastened to London and dis¬
covered that on the day in question Mrs. Shaw had telegraphed to her solicitor to
destroy her will, but that gentleman had not done so. She had also written to
one of the children telling them to buy a doll, and had driven from Kensington to
a hospital in Fitzroy Square with the object of consulting one of the resident
medical men. He was not, however, at home, and after making inquiries as to
where she could dine, she drove to Charing Cross Station, where every trace of
her had been lost. Advertisements had been inserted in the Times and other
newspapers, and inquiries had been made at Dover, Calais, Folkestone, Boulogne

Digitized by VjOOQle

826

NOTES AND NEWS.

[Oct.,

and on the Continent, as well as in the United States and New Zealand—but with*
out result. The lady was possessed of a banking account, but the last cheque
which had been cashed was on August 19th, 1898.

Mr. Justice Gorell Barnes, after perusing the affidavits in support of the motion,

f ive leave to swear the death on or since August 19th, 1898.—Mr. Justice Gorell
arnes.

Shields v. Shields and another.

This was an action by John Shields against the trustees under a settlement of
his father, deceased, Mr. Shields, senior. The testator had made during his
lifetime a settlement of his estate, and modified the same by will. The pursuer
was entitled to a fifth of his father's property, but in the will it was provided that
the defenders were “ to manage the same for him in such way as they think best,
and so long as they shall deem advisable, absolute discretion being hereby
conferred upon them, both as regards management and the length of time
to retain his share.” The reason for this unusual provision was that the pursuer
had been for some years a patient in Gartnavel Asylum. He was, however,
discharged in 1895, and it appeared that he had now recovered. Lord Low held
that the testator intended to give to the trustees power to manage the estate of the
pursuer so long only as he remained in a condition of mental incapacity, and that
there was nothing to show that pursuer was not to have the full use of his share
If, as had occurred, he should be restored to health. He therefore gave judgment
or, in Scots terms, gave decree of declarator, in favour of the pursuer. Another
instance of how in law words may mean the opposite of what they appear
to mean.

ASYLUMS NEWS.

Nurses’ Home, Gartloch.

A separate building, to accommodate the nurses and servants, has recently
been opened. It is of red sandstone, on the same architectural lines as the main
building, and while structurally distinct, is very accessible from both asylum and
hospital. It accommodates seventy in all, and is in three storys, being roughly
divided into six sections, each of which has public rooms and bedrooms, witn
bath-room, lavatories, and scullery. On the ground floor, in addition, are visitors*
and home sisters' rooms, with a library and kitchen, from the latter of which small
lifts run to the sculleries on the upper floors. Box and bicycle rooms are placed
in the basement. The two sections on the top flat are for nurses and servants,
the quarters of the latter being reached by a separate staircase, and those of the
former being arranged to insure quiet during the day. The lighting is electric,
and the heating by low pressure hot water, the steam being brought from the
main boilers. The total cost of the building furnished is about £ 14,000.

NEW DEPARTMENT, CHARING CROSS HOSPITAL.

Charing Cross Hospital has followed the example of St Thomas’s and some
provincial hospitals where there have been for a long time out-patient depart*
ments for mental disorders, and a similar department has been instituted there,
under the charge of Dr. Percy Smith, the late Resident Physician to Bethlem
Hospital. Although the out-patient treatment of mental cases has limitations, yet
there is at present very little opportunity for patients of the poorer classes and
their relatives to obtain advice in the early stages of any mental disorder, while
from the point of view of the student there are few opportunities for clinical
teaching on such cases as may be at present met with at general hospitals. In
fact they are as a rule dismissed as being something quite apart from ordinary
disease, and often considered hardly worth investigation. Such departments
supply a real want at general hospitals, and we hope to see others follow suit.

Digitized by VjOOQle

1900.]

NOTES AND NEWS.

827

THE INTERNATIONAL SOCIETY OF THE PSYCHICAL INSTITUTE,

PARIS.

A number of distinguished men have made a proposal to found a Society for
scientific experimental study of psychical phenomena. The objects of the Associa¬
tion are:—(1) The installation of laboratories equipped with suitable apparatus
(biometers, magnetometers, spectroscopes, registering instruments, photographic
apparatus, etc.); (2) the finding and payment of “ subjects ”; (3) the creation of a
periodical which shall publish accounts of the experiments made in the labora¬
tories, and their results, and the writings of collaborators interested in psychical
studies. The General Secretary of the new Institute is Dr. Emile Legrand, 14,
Rue d'Amsterdam, Paris.

Full information can be obtained from Mr. O. Murray, The Nook, Ormanda
Road, Branksome Park, Bournemouth.

We notice among the names of those who have already intimated their support,
Dr. Pierre Janet, Professor Baldwin, Professor Lodge, Professor Stout, Professor
Charles Richet, and many others.

THE ASYLUM WORKERS’ ASSOCIATION.

We regret that, owing to the pressure on our space, we cannot enter into details
as to the gratifying success which has attended the Asylum Workers’ Association
during the past year. We hope to give some account of the proceedings of the
Annual Meeting in our next number.

INSANITY IN THE CITY OF LONDON.

There recently appeared in the lay press the statement that the City possessed
“ an unenviable notoriety so far as its statistics of lunacy are concerned.” The
returns made by the Medical Officer of Health for the City were referred to as.
then justifying the conclusion u that one in every twenty-five persons actually
resident in the City, from a legal point of view, is at the present time an inmate
of a workhouse, or an infirmary, or a lunatic asylum.” As this statement may
be misleading, we think it well to give the facts regarding the relative propor¬
tion of insane to total population in the City.

There are 350 insane patients belonging to the City Union and Corporation,
and the resident population (night) of the City is about 35,000—thus giving the
proportion as 1 in 100. The day population in the City is nearly a million.

HEREDITY AND INEBRIETY.

The Society for the Study of Inebriety has appointed a Committee of medical
men to inquire into the relation of heredity to the production of inebriety. The
President is Dr. Wynn Westcott, Coroner for North-East London, and the
Committee includes the names of Mr. Victor Horsley, Professor Sims Wood-
head, Drs. Archdall Reid, Heywood Smith, and Harry Campbell, with Dr.
Thomas Morton as Secretary. Much progress has already been made with the
investigation, and the medical profession is now asked to supply evidence on the
following subject:—“ The Committee are fully satisfied that drunken parents tend
to have children who become drunkards; but they earnestly desire to obtain
evidence bearing upon the question whether a parent who himself inherits no
special tendency to inebriety can, as the result of mere intemperate habits, entail
upon his children a potential inebriety.” Communications will be gratefully
received by the President or Secretary, and may be addressed to 396, Camden
Road, London, N.

Digitized by VjOOQle

828

NOTES AND NEWS.

[Oct,

PLASMON.

This preparation has now been tried in several asylums, and we hear that
good results have been gained by its use. It is, essentially, the separated casein
of milk, and is presented as a ary powder which forms a gelatinous mass with
water. Professor Virchow has made experiments showing that plasmon retains
powerful nourishing qualities, while it remains practically tasteless and colour¬
less. From independent chemical analysis it is a substance of distinct value, and
we hope to present our readers with some account of the beneficial results of
administering it to the insane.

CORRESPONDENCE.

From Dr. Beveridge Spence.

In reply to your question, in eight of my new dormitories—accommodating
about 160 persons—I have electric push buttons placed and marked M To com¬
municate with the night attendant push this button,” and the bell connected with
the push is placed at the station where the night attendant or nurse sits when not
walking about, and this station is so situated that a bell ringing at night must be
heard by the night attendant or nurse at any point of his or her round. 1 may
say that although I have had these pushes provided in some of the dormitories for
about six years I have never heard that they have been used—or abused.

Burntwood Asylum.

August 315/, 1900.

From Dr. Moody*

Having been struck by the isolation of patients between the hours 8—
10.30 p.m. in dormitories which are only visited periodically by the night
attendants, I brought the matter under the notice of the Committee at the end
of 1895, and obtained sanction for the provision of an electric alarm.

In every dormitory where there is no stationary night attendant a push button
is provided. This, when used, rings a bell in the entrance hall and indicates in
which ward attention is required. The bed nearest the button is occupied by the
most sensible patient in the dormitory, who not only gives an alarm when neces¬
sary, but prevents the bell being rung without reason.

The alarm has on several occasions been of service in cases of sudden illness or
disturbances, and has quite justified the outlay involved.

After 10.30 p.m. the attendants' rooms, which adjoin dormitories and which have
windows in the division walls, are occupied, and the electric alarm not being
required is disconnected for the remainder of the night.

London County Asylum, Canbhill;

September 15/A, 1900.

From Dr. Cecil F. Beadles.

There is a general opinion amongst the Jewish community that insanity is
abnormally prevalent in the race. This idea seems to have been derived from
Prussian statistics. But is this so for Jews in this country P

With a view of obtaining an answer to this interesting, and I venture to think
important, question, I have sought information at certain asylums as to the
number of Jewish inmates therein, on the two dates December 31st, 1898, and
June 30th, 1900. The former date is chosen as one on which a comparison may
be made with the non-Jewish insane of the country; the latter as the number of
Jewish insane existing at the present time.

Knowing that the Jews in this country, are almost entirely located in a few
of the larger towns, it seemed useless to ask these questions of many of the
provincial asylums. But as it is possible that some institutions where Jewish
patients are received have been overlooked, I shall be glad if the Superintendents
of these will communicate with me on the subject, to enable me to obtain as com¬
plete returns as possible.

Digitized by

Google

1900 .] NOTES AND NEWS. 829

Perhaps I may be allowed this opportunity to thank all who have assisted me
in this inquiry.

Copy of Circular Letter.

Will you kindly give me your assistance in an attempt to find out the amount
of insanity that exists amongst the Jewish population of this country ?

As no figures appear to exist, the only available means is to obtain a return
of the number of Jewish patients, received into each asylum for the insane,
throughout the Kingdom.

I trust you will help me in this matter by returning the annexed form after
filling in the figures asked.

(1) The number of patients in the- Asylum on June 30th, 1900.

Total Insane. Jewish Insane.

Pauper. Private. Pauper. Private.

Males

Females

(2) As there are only comparative figures obtainable at present for the year
1898, both as regards the estimated Jewish population of England, and the amount
of insanity in the country, I should be glad, if it is possible, to have the number
of Hebrews present in the Asylum on December 31st, 1898.

Pauper. Private.

J ews
ewesses

Colney Hatch Asylum,

September 4th, 1900.

OBITUARY.

William Henry Lowe, F.R.S.

Dr. W. H. Lowe, F.R.S., died at Wimbledon on the 26th August, in his 86th
year. He was educated at the University of Edinburgh, at which he graduated in
1840. In that year he was admitted to the membership of the Royal College of
Physicians, Edinburgh, having previously taken the membership of the Royal
College of Surgeons of England. Dr. Lowe held several professional appointments
in Edinburgh, among others those of President of the Royal Medical Society, and
President of the Royal Botanic Society. He was elected a Fellow of the Royal
College of Physicians of Edinburgh in 1846, and President in 1873. At the meeting
of the British Medical Association in Edinburgh in 1875, he gave the opening address
in the section of Psychology, over which he presided. Dr. Lowe was for many years
associated with the late Dr. John Smith in the management of Saughton Hall
Private Asylum, near Edinburgh, residing at Balgreen, the garden and grounds
of which show permanent evidences of his skill and taste as a botanist. He was
also a keen entomologist and amassed a large and interesting collection of the
Lepidoptera of the district. In 1875 he settled at Wimbledon Park. He was the
author of‘Jaundice from Non-elimination, together with remarks on the Patho¬
logical Condition and Chemical Nature of the Bile.’ Dr. Lowe was twice married,
and is survived by a widow and family.

Landon Carter Gray, M.D.

Dr. Landon Carter Gray, who died in the May of this year, was born at New
York in 1850. Soon after he graduated he devoted special attention to neurology
and psychiatry, and at a comparatively early age he attained a leading position
in his profession. He was elected President of the American Neurological Asso¬
ciation, of the New York Neurological Society, and of several other learned
societies. For a number of years he was Chairman of the Executive Committee
of the Congress of American Physicians and Surgeons. He was the author of a
treatise on mental and nervous diseases and of many valuable contributions to
medical literature. Dr. Gray took a deep interest in the study of medica.
jurisprudence and, as a medico-legal expert, he is said to have been described by
a distinguished judge as the very model of what a medical witness ought to be.

Digitized by VjOOQle

830

NOTES AND NEWS

[Oct.,

NOTICES BY THE LIBRARIAN.

Received per Dr. Urquhart—I. Table to illustrate Dr. Conford's paper
published in the Journal for April, 1900. 2. Photographs to illustrate “ Acro¬
megaly,” by Dr. Blair, paper published in the Journal for April, 1899. Face
ana hands of a case of acromegaly, face and hands of a case of myxcedema,
normal hand, and hand affected by rheumatoid arthritis, which may be illustrative
of Marid’s pulmonary hypertrophic osteo-arthropathy; also a skiagraph of acro¬
megalic hand. 3. Mental Affections of Children , by W. W. Ireland, M.D.

NOTICES BY THE REGISTRAR.

The following gentlemen were successful at the examination for the Certificate
in Psychological Medicine, held on July 19th, 1900:

Examined at the Royal Asylum , Aberdeen. —Alexander William Overbeck
Wright.

Examined at the Royal Asylum, Edinburgh. —Walter S. Patton, J. Fraser Orr.

The following is a list of the questions which appeared on the paper:

I. What forms of insanity may occur in old age, and what is the prognosis in
each P What conditions would make you recommend removal to an asylum in a
case of senile dementia ? 2. Define an obsession, and classify and describe the
chief varieties of obsessions. 3. What are the causes of refusal of food by insane ~
patients P When does this symptom unfavorably affect the prognosis P 4. D»i
scribe a case of acute delirious mania, giving symptoms, treatment, and pojgi
mortem appearances, and stating how you would distinguish between it andacL
of mania a potu. 5. What is the pathology of hcematoma auris, what treatir^nt
would you recommend, and what is the prognosis P 6. Discuss generally £he
criteria of insanity.

The Gaskell Prize has been awarded to Dr. Maurice Craig, Assistant Phys^an,
Bethlem Hospital, London; and the Bronze Medal has been awarded t 0 o r *
Charles C. Easterbrook, Assistant Physician, Royal Asylum, Morningside, Rd-a-
burgh.

The next examination for the Certificate of Proficiency in Nursing will be l^ld
on Monday, November 5th, 1900, and candidates are earnestly requested to se.» A
in their schedules, duly filled up, to the Registrar of the Association, not latei
than Monday, October 8th, as that will be the last day upon which, under the \
rules, applications for the examination can be received.

The New Regulations (given in detail in the October numbers of the Journal
for last year and this year) will be in force at this examination. For full parti¬
culars respecting the various examinations of the Association apply to the
Registrar, Dr. Benham, City Asylum, Fishponds, Bristol.

The following candidates have passed the Special Examination for the Nursing
Certificate, held in South Africa:

Valkenburg Asylum. — Males: William Fowler Booth, Robert Smith, John
Cochrane. Females : Bridget O’Reilly, May Littlejohn.

Grahamstown Asylum. — Female: Ellen Bickell.

Fort Beaufort Asylum.—Female : Alice Hayward.

There will be no Examination for the Medico-Psychological Professional Certi¬
ficate in December.

ERRATUM.

Page 620. Omitted Royal Asylum , Edinburgh.—Female: Emily Cartlidge.

NOTICES OF MEETINGS.

Medico-psychological Association.

General Meeting. —The next General Meeting will be held in the rooms of the
Association, n, Chandos Street, London, W., on Wednesday, 21st November,
1900. Papers will be read by Sir Dyce Duckworth, Dr. G. H. Savage, and Dr.
Lewis Jones.

Digitized by VjOOQle

NOTES AND NEWS.

831

1900.]

South-Western Division. —The Autumn Meeting will be held at Broadmoor
Asylum on Tuesday, 30th October, 1900. Papers will be read by Dr. Brayn,
Dr. Alfred Turner, and Dr. John Baker.

Northern Division. —The Autumn Meeting will be held at Gosforth Asylum,
Newcastle, on Wednesday, 3rd October, 1900.

South-Eastern Division. —The Autumn Meeting will be held at Ticehurst,
on Wednesday, 10th October, 1900. The Honorary Secretary will be glad to
hear from any member who wishes to read a paper at the Spring Meeting to be
held in April, 1901, and to receive the names of candidates for election to the
membership of the Association.

Scottish Division. —The next meeting will be held in Edinburgh, on Friday,
23rd November, 1900.

Irish Division. —The next meeting will probably be held at the Royal College
of Physicians, Dublin, early in April, 1901.

APPOINTMENTS.

Dr. J. F. Flashman, M.D., appointed Pathologist in the Lunacy Department,
New South Wales.

Mr. R. A. Fox, M.B., appointed Junior Medical Officer in the Lunacy Depart¬
ment, New South Wales.

Mr. Wheeler Haines, B.Sc.Lond., M.R.C.S.Eng., L.R.C.P.Lond., L.S.A.Lond.,
appointed Senior Medical Officer at the North Riding Asylum, Clifton, York.

Mr. David Hunter, M.A., M.B., B.C.Cantab., L.S.A.Lond., appointed Medical
Superintendent of the new West Ham Borough Asylum at Chaawell Heath.

Mr. A. M. Rattray, M.B., C.M.Edin., appointed Senior Assistant Medical
Officer to the Newcastle City Asylum, Gosforth, vice Mr. D. Hunter, M.B.,
B.C.Cantab., resigned.

Mr. Archibald Stevenson, M.B.Glasgow, appointed Junior Assistant Medical
Officer to Hawkhead Asylum, Crookston.

XLVI.

Digitized by VjOOQle

INDEX TO VOL. XLVI

Past I.—GENERAL INDEX.

Acromegaly, 170

Adamson, hwmorrhage into ventricles of brain, 872
iEtiology of insanity, 862, 567
After-care Association (Germany), 177,895
After-images, 384

Alcohol, influence on mental work, 180
„ the strife with, 526
Alcoholic drink, abuse of, 177
„ epilepsy, 369

„ homicide, 787

,, neuritis, 587

,, responsibility, 179

Alcoholism and suicide, 260

,, from medico-legal aspect, 180

„ its nature, influence, and distribution, 648
,, psycho motor hallucinations in, 866

Ameline, heredity in general paralysis, 568
American retrospect, 172
Amnesic aphasia, 371
Anesthesia in the insane, 195
Analysis of one thousand admissions, 478
Angeioma of Broca’s convolution, 775

Angel and Thompson, organic processes and consciousness, 856

Anglade, Dr., systematised insanity, 174

Annual Meeting of the Medico-Psychological Association, 778

Anomia and paranomia, 871

Antheaume and Leroy, morphino-dipsomania, 867

Anthropology, 844, 558

Anti-alcoholic serum, 400

Aphasia and will-making, 820

Art and literature in the mentally abnormal, 859

Asphyzial problem in convulsions, 593

Association of verbal images in children, 584

Astasia abasia, 372

Asylum accommodation deficient in Lancashire, 898
„ architecture, evolution of, 87

„ attendants, hours of duly, 393

„ construction, 880, 401

„ for East Sussex, plans of, 678
„ news, 892, 826

„ remodelling, 457

„ reports, 188, 378, 558

,, retrospects, 551

„ self-supporting, at Pan, 444
„ Workers Association, 608, 827

Asylums, cost of, 892

„ Irish, pathological work of, 487

Digitized by VjOooLe

834

INDEX.

Attendants, training of, syllabus of work, 383
Auditory peripheric hallucinations, 864
Axial nerve-fibres of brain, 346

Babinski’s sign, 580
Ballet, Dr., polyneuritic psychosis, 175
Bannister, Dr., American retrospect, 172
Baths, treatment of insanity by, 497 , 596
Beach, Dr. Fletcher, Presidential address, 623
Beadles, Dr., lesions of snpra-renals in insane, 375
„ prevalence of insanity among Jews, 828
Beevor, Dr., myopathy, 372
Belgian retrospect, 179
Beri-beri, 586

Bernheim, Dr., verbal images and aphasia in children, 584

Berthelot, Dr., the rdle of science, 378

Bichet, Dr., biological conditions in general paralysis, 567

Biervliet, Dr., right-sidedness and left-sidedness, 853

Biffi, Serafino, obituary, 624

Bill, lunacy, 312

Binet-Sangl6, Dr., hierology, 361

Binocular illusions, 361

Black, Dr., suggestion and anrasthesia, 860

Bleuler, Dr., treatment of herpes zoster, 377

Bloodletting, the practice of, 598

Blood-pressure in mental disease, 817

Blood-supply in mental pleasure and pain, 566

Bodily disease and insanity, 283

Boeck, Dr., responsibility of the alcoholic, 179

Bouchereau, Dr., death of, 407 , 626

Bouman, Dr., folie-k-trois, 370

Bourneville, Dr., and Chapotin, eosinate of sodium in epilepsy, 878
„ idiocy from nodular scleroses, 576

Brabazon Society, 190

Bradbury, Dr., sleep, sleeplessness, and hypnotics, 693
Brain, anatomy and psychology, 359
„ axial fibres, 563
„ bankruptcy, 369
,, cells, structure of, 562
„ ecchinococcus of, 685
,, heaviest, 347

„ weight and peripheral nerve-fibres, 349
Brandt, Dr., brain weight, etc., 849
Bratz., Dr., alcoholic epilepsy, 369

„ lesions of hippocampus in epilepsy, 349
Bresadola and Cobelli, pellagrous insanity, 573
Bresler, Dr., German retrospect, 177
Bright’s disease, nervous symptoms in, 576
Briscoe, Dr., asphyxial problem in convulsions, 593
British Medical Association : Section of Psychology, 780—815
Broadbent, Sir W. H., sleeplessness, 694
Broca’s convolution, angeioma of, 775
Bromalin and bromidin as hypnotics, 504
Bronchi, foreign bodies in, 515
Browning, Dr., isolated finger paralysis, 687
Bruce, Dr., cerebellar tumour, 351

„ traumatism of cauda equina, 587
Brunet, Dr., cerebral atrophy in general paralysis, 592
Bruns and Stfllting, optic nerve in multiple sclerosis, 579
Brunton, Dr. L., headaches, 595
Burgess, Dr., ephemeral mania, 364

Digitized by VjOOQle

INDEX*

835

Burr, Dr., presentation to, 210

Burr and McCarthy, pachymeningitis, 688

Ccenseethesia, 288

Campbell Thompson, see Thompson

Cardio-psychical Association, 818

Case-taking, systematic, 265

Cephalic index, 568

Cerebellar tumours, localisation, 861

Cerebellum, function of, 564

Cerebro-spinal fluid, spontaneous escape from nose, 348
Cerebral cortex, function cells in, 666
Cestran, R., and Le Sourd, Babinski's sign, 580
Chagnon, Dr., auditory peripheric hallucinations, 864
„ mal perforant buccal, 689

Charing Cross Hospital, new department, 826
Child, nervous system of, 541
Childhood, mental troubles of, 342

Children, association of verbal images and aphasia in, 684
n feeble-minded, instruction of, 688

,, over-excitability, etc., in, 664

„ psychology of, 413

Chloral idiosyncrasy, 309
Chorea, Huntingdon's (hereditary), 684
Christian, Dr., early dementia of puberty, 175
Classification of mental disease, 677
Clinical neurology and psychiatry, 868, 669
,, position of melancholia, 868
Clouston, Dr., states of over-excitability, etc., in children, 364
Cololian, Dr. P., psychomotor hallucinations in alcoholism, 366
Communicated insanity, 109
Comparative lunacy laws, 42
Comte, Auguste, mental state of, 80

„ the ideation of genius, 838

Consciousness, 367

Continuity of work under altered conditions, 469
Correlation between sexual function, insanity, and crime, 318
Correspondence, 208, 828

Courmont and Bonne, Drs., Landry's paralysis, 860
Cowan, Dr., Dutch retrospect, 182
Cranial forms, 828
Craniometric observations, 560
Crichton Royal Institution, 551
Crime and mental disease, 188
„ treatment of, 151
Criminal, simulation of insanity by a, 599
„ statistics, 155, 548
Criminality in Rome, 600
Criminals, 637

„ irresponsibility in, 281

„ mental condition of, 377

Crook u. Crook and Horrocks, 518
Cross-education, 355
Cullerre, Dr., serous transfusion, 876

Dana, Dr., paralysis agitans and sarcoma, 350

Danish retrospect, 184

Davis, Dr., cross-education, 355

Dawson, Dr., blood-supply in mental pleasure and pain, 366
Deafness, nerve, 583

Dees, Dr., pathology of general paralysis, 592

Digitized by VjOooLe

INDEX.

Degeneracy and insanity, 628
Degenerate, meaning of, 784

Degenerate, meaning of, 784
Delirium tremens, 874
Deniker, Dr., cephalic index, 568
Dercnm, Dr., tumour of oblongata, 852
Disinfection, 208

Discard, Dr., binocular illusions, 861
Doctors and justices, 164
„ „ literature, 164

Donaldson, Dr., self-indicating locks, 209
Dormiol, 601

Dormitories, electric communication, 828
Dreams in epilepsy, 868
Drugs, dangers ox fashionable, 191
Drunkenness, criminal, 817

Duoostd, Dr., dreams related to attacks in epilepsy, 868
Dundee Royal Asylum, statistics, 205
Dutch retrospect, 182

Echinococcus of brain, etc., 685

Editorial comment, 822

Education and psychology, 781

Electric push buttons in dormitories, 828

Ellis, Dr. W. G., syphilis and general paralysis, 208

Elzhols, Dr., recovery from insanity after operation on uterus, 368

Emotions, pathology of, 841

Emphysema in case of stuporous melancholia, 617

Employment of the insane, 206

Enjoyment, physiology of, 184

Eosinate of sodium in epilepsy, 876

Epilepsy, 816

„ after ovariotomy, 866

„ and hysteria, 581

„ associated with insanity, 78

„ colony treatment of, 817

„ followed by chorea, with puerperal insanity, 114

„ hysteria and idiocy, 158

„ in children, 157

„ lesions of hippocampus in, 849

„ pathology of, with new treatment, 595
Epileptic attacks and mental excitement and depression, 576
,, „ abortive, causation, 586

„ speech, 242

Epileptics, care and treatment of, 546, 641
„ dreams related to attacks in, 868
Experimental psychology, 860

Faraarier, M., acromegaly in an epileptic, 176

- Fatigue and energy, 164

- „ muscular, 166

Feeding the insane, 499
Feelings, the, 219

Fenayron, post-operative mental confusion, 866

Fer6, Dr. C., hysterical breast, etc., 588

Fisher, Dr., sensory disturbances in epilepsy and hysteria, 581

Fixed idea, 366

Fleury, Dr., mental excitement and depression in epilepsy, 676
„ nervous symptoms in Bright's disease, 676
Folie k trois, 370

Foreign bodies in both bronchi, 616
Fraenkel, J., sensori-motor palsies of face, 880

Digitized by

Google

INDEX.

837

Fraenkel, J., symptomatology of intra-cranial disease, 586

French retrospect, 174

Friis, Dr., Danish retrospect, 184

Fry, Dr., interesting hysterical phenomena, 681

Gardinier, H. C., pathology of paralysis agitans, 851
Gamier, Dr., simulation of insanity by a criminal, 599
Gastric tetany, 589

Gaumpertx, general paralysis in childhood, 569

Geill, Dr. C., mental diseases, 187

General paralysis, atheromatous, pseudo-, 865

,, ,, biological condition of families of, 667

,, ,, cerebral atrophy in, 691

„ ,, changes in cortical nerve-cells in, 714

„ „ heredity in, 568

„ ,, in childhood, 569,670

„ „ morbid anatomy and pathology, 688

„ „ pathogenesis or delusional state, 660

,, „ pathological anatomy of, 590,691

„ „ ratio of, 555,556

„ „ statistics of, 569

„ ,, suicide in, 671

„ „ with hallucinations, 176

„ „ with syphilis,"*657

Genius, ideation of, 588
German retrospect, 177
Gibb-Dunn, post-epileptic hemiplegia, 871
Giddings, Miss Mary, obituary, 617
Glioma of corpus callosum, 612
Glycosuria, influence of psychoses on, 749
Godding, Dr. W. W„ obituary, 404, 628
Golgi, Prof., structure of nerve-cells of spinal ganglia, 845
Grant, D., nerve deafness, 483
Gray, Dr. L. C., obituary, 829

Habitual drunkenness, 896
Hsemorrhage into ventricles of brain, 872
Handwriting experiments, 885
Hausemann, the brain of Helmholz, 569
Hawkins, Rev. H., retirement of, 617
Headaches and their treatment, 695
Hemicrania, mental disorder in, 578
Hemiplegia and hemianesthesia, 373
„ post-epileptic, 371
Heredity and inebriety, 827
„ and insanity, 188, 862
Herpes zoster, treatment of, 377
Herrick, J. B„ Kernig’s sign in meningitis, 878
Hertoghe, R., chronic thyroidal fibrosis, 870
Hierology, psychology of, 361
Hill, C. J., pathology of epilepsy, 895
Hinsdale, G., purulent encephalitis in new-born, 589
Holland, psychology in, 182
Horsley, V., injuries to peripheral nerves, 371
Hrdlecka, A., art and literature in mentally abnormal, 359
Hughes, C. H., brain bankruptcy of busy men, 869
Human species and varieties, 328
Hunter, W. R., gastric tetany, 689
Hydrotherapy and balueotherapy, 696
Hypnotics in insanity, 500
Hypnotism, 360, 361

Digitized by VjOOQle

838

INDEX.

Hysteria and its relation to insanity, 88
„ genesis and nature of, 161

„ sensory disturbances in, 581

Hysterical breast, 688
,, phenomena, 581

Idiocy from nodular sclerosis, 675

Idiot children, pupillary anomalies in, 427

Idiots, imbeciles, feeble-minded, etc., treatment of, 6

Imbecile children in London, 894

Imbeciles’ Training Institutions Bill, 818

Increase of insanity, 134

Index, psychological, 587

Inebriates Act in Scotland, 888

„ Acts Board Bill (Lane.), 897
„ anti-alcoholic serum for, 400
„ homes for, 888

„ in France, 899

„ legislation for, 614

„ reformation in Ireland, 899

„ State reformatories, 202
Inebriety, its cause and cure, 658
Injuries, chronic hereditary, 870
„ to peripheral nerves, 871
Insane, rarer skin diseases affecting, 60
Insanity and bodily disease, 288
,, communicated, 109

,, in Herman and American law, 699

„ in male lead workers, 817
„ in the City of London, 827
„ physical signs of, 48

„ prevention of, 815

„ recurrent, 868

„ syphilitic, 307

International Medical Congress of 1900, 409
Intoxicating liquors, sale of, 124
Intra-cranial disease, symptomatology, 586
Irish district asylums, 192
Irresponsibility in criminals, 281

Isolation and open-air treatment of phthisical insane, 215

Jew, prevalence of insanity in, 828
„ the insane, 781
Judicial statistics, 155
Juvenile delinquents, treatment of, 646
„ general paralysis, 570

„ organic psychoses with syphilis, 670

„ paralysis and epilepsy, 176

„ tabes, 670

Kahlbaum, Dr. Karl, death of, 178

Kaplan and Meyer, juvenile organic psychoses, 670

Keraval, P., fixed idea, 366

Kerr, H., recurrent insanity, 363

Kiernan, J. G., senile dementia and marriage, 671

Kleppel, atheromatous pseudo-general paralysis, 365

Knee-jerk, loss of, in lesions of brain, 681

Kornfeld, H., insanity in German and American law, 599

Kraepelin, clinical position of melancholia, 363

Kraft-Ebbing, mental disorder in hemicrania, 678

„ neuralgia and transitory psychoses, 363

Digitized by VjOOQle

INDEX.

839

Kruger, echinococcus of brain, etc., 685
Kntner, juvenile tabes, 670

Laboratory of tbe Scottish asylums, 314, 388

„ pathological, at Claybury, demonstrations, 712
Lalande, delusional state in general paralysis, 560
Lancashire asylum board rate, 394

„ „ deficient accommodation, 393

,, Inebriates Acts Board Bill, 897
Landry's paralysis, 360
Langdon, F. W., facial paralysis, 689
Lantern demonstrations, 712, 714
Laughter, 339

„ in animals, 344

Lentz, Dr n alcoholism from medico-legal point of view, 180

Leptomeningitis, 763

Librarian, notices by, 829

Lloyd, J. H., tumour at base of brain, 689

Lobulus parietalis inferior, anatomy and pathology of, 347

Locomotor ataxia, diagnosis, 373

,, „ relation of pain Bense, 581

a „ treatment, 377

London lunacy, 126
Lord, J. R., pineal gland, 351
Love and jealousy, 166
Lovell-Gulland, G., sulphonal poisoning, 376
Lowe, Dr. W. H., obituary, 829.

Lunacy Bill, 312, 388, 603
a law, comparative, 42

a ,, in relation to neuro-psychological disease, 818
Lunatic, trusteeship of, 199
Lyman, H. M., anterior polio-myelitis, 362

Mai perforant buccal, 689
Malaria, psychical disorders in, 577
Mania, acute delirious, 364

,t a treated without sedatives, 80
» ephemeral, 364

Mann, F. J., acute delirious mania, 364
Marcet, Dr. W., obituary, 617
Marchand, L., epilepsy after ovariotomy, 365
„ juvenile general paralysis, 570

„ masturbation in schools, 130

McCarthey, D. J., narcolepsy or pathology of sleep, 679
McDougal, W., improvement in psychological method, 357
Meals and mental capacity, 335
Mechanical excitability of nerves in the insane, 583
Medical Graduates College and Polyclinic, 528
Medico-legal cases, Bedford v. Jackson, 391

„ Charleston v. Steward, 390, 612

„ Crook v. Crook and Horrocks, 518

„ Dowling t>. Dod, 822

„ Eady c. Elsden, 611

,, Hope v. Board of Guardians of Cbertsoy, 613

„ Reg. v . Beddoe, 389

„ „ case of homicide, 182

„ „ Birtles, 820

„ „ Flower, 389

„ „ Greaves, 614

„ „ Grosvenor, 821

„ „ Harmer, 203

Holt, 821

Digitized by VjOOQle

840 INDEX.

Medico-legal cases, Reg. r. Jennings, 890
»i >» H., 203

„ „ O'Hara, 819

„ • „ Smith, 822

„ „ White, 202

„ Soper v. Gibson and Young, 824

„ Style v. Owen and Another, 824

„ Shaw, Emma Alderson, goods of, 826

„ Shields v. Shields and Another, 826

Medico-Psychological Association meetings, 198,198, 199, 200, 878, 882, 601, 602:

—604,607, 808

,, „ Educational Committee, 809

,, „ Parliamentary Committee, 808

„ „ Presidential Address, 623

Meige, H., trophced&me, hlrdditaire, 370
Melancholia, clinical position of, 368

„ mania, etc., physical conditions of nervous system in, 606
„ physical changes in, 726
Meni&re’s disuse and crime, 203
Meningitis, Kernig’s sign in, 373
„ suppurative, 374

Mental confusion and infectious disease, 676
„ disease in relation to crime, 133
,, dissolution, 672
„ torticollis, 373
Meralgia paraesthetica, 682
Methylene blue as an hypnotic, 876
Metropolitan Asyluhis Board and medical officers, 816
„ lunacy scandals, 629
Meyer, Prof. Ludwig, obituary, 406, 624
Microscopical demonstration of histology of mesoglia cells, 724
Mill, C. K., anomia and paranomia, 871
Milne-Bramwell, post-hypnotic appreciation of time, 360
Mitchell, J. K., periodic paralysis, 872
Monakow, lobulus parietalis inferior, 347
Monostier, suicide in general paralysis, 671
Mongolian imbecility in infants, 369
Mongour and Gentes, hemiplegia with hemiansesthesia, 373
Moody, Dr., electric push buttons in dormitories, 828
Morel, Dr, J.. Belgian retrospect, 179
Morphinism associated with theft, 600
Morphino-dipsomania, 367
Motor mentaiisation, 360

Muskens, L. J. I., pain sense in locomotor ataxy, 581
Mosser and Sailer, meralgia parsesthetica, 682
Myelitis, acute ascending anterior, 350
Myopathy, 372

Narcolepsy, 679

Nerve-cells, pathological changes in, 714, 716
Nervous diseases, 169

„ system, anatomy of, 336
Neuralgia and transitory psychoses, 363
Neurologists and alienists, 782
Neurology, 345, 661
Neuron and cellular memory, 362
Neuropathology, progress of, 561
Neurotic, meaning of, 785
New South Wales Bill, 396
Nichols, H., the psychomotor problem, 358
Night supervision, 530

Digitized by VjOOQle

INDEX.

84*

Norman, Dr. C., clinical features of beri-beri, 686
Noques and Seril, mental torticollis, 378
Notes and queries, 531, 784
Nurses, home, Gartloch, 826

„ position of, in Scotland, 382
Nursing in Irish asylums, 198—200, 812

Obituary notices—Bouchereau, Dr., 407; 'Giddings, Miss M. R., 617; Godding,
Dr. W. W., 404; Gray, Dr. L. C., 829; Lowe, Dr. W. H., 829; Marcet, Dr*.
W., 617; Meyer, Prof. Ludwig, 406; Southey, Dr. R., 210, 626
O'Ferrall, L. M., syringomyelia, 589
Offence against morals, 377

Onuf, B., arrangement and function of cells of spinal cord, 668
Operations on insane in asylums, 394
„ on the insane, 112

Organo-therapeutics in mental disease, 818

Pachymeningitis with pseudo-bulbar palsy, 688
Palsies of face and ocular palsies of tabes, 680
Paralysis agitans and sarcoma, 350

„ ,, pathology of, 361

„ asthenic bnlbar, 687
„ facial, 589

,, isolated finger, 587

„ of serratus magnus, 374

,, periodic, 372, 575
„ StrumpelTs, 372
Paraplegia from acute spinal caries, 587
Parish councils and Scottish asylums, 616
Parliamentary news, 202, 388, 608, 818
Passow, A., axial nerve-fibres of brain, 346
Pathological anatomy of general paralysis, 590

„ histology of acute delirious iusanity, 817
„ of the emotions, 841

„ work of Irish asylums, 487

Pathology of insanity, 374, 590
Paton, S., brain anatomy and psychology, 359
Pan, asylum at, 444
Paul, Dir., portrait of, 210
Pellagrous insanity, 572

,, „ with criminality, 578

Pensions, 124

Peripheral nenritis and mental disease, 816
Phthisical insane, isolation of, 1

„ „ „ and open-air treatment, 215

Physical conditions of nervous system in mania, melancholia, etc., 505
„ signs of insanity, 48
Physiological psychology, 853, 566
Pineal gland, 361

Pineles, F., function of the cerebellum, 564
Pituitary body, tumour of, 852
Plasmon, 828

Platinum method for microscopical sections, 200, 352

Polio-myelitis, 352

Polyneuritic psychoses, 176

Poor, treatment of, 128

Post-operative mental confusion, 366

Pregnancy, spurious, 113

Presidential address (Dr. Fletcher Beach), 623

Private class of insane, 393

Prize dissertation, 408

Digitized by VjOOQle

& 42

INDEX.

Psychical Institute, Paris, 827

Psychology, the new, 411

Psychomotor problem, 858

Psychophysical perception, 756

Psychophysics, 417

Puberty, early dementia of, 175

Publican’s responsibility in criminal drunkenness, 817

Puerperal insanity with chorea and epilepsy, 114

Pupillary anomalies in idiot children, 427

Purulent encephalitis in new-born, 589

Putman, J. J., family periodic paralysis, 575

Baces of Europe, 881
Reaction at a distance, 716

Recovery from insanity after operation on’uterus, 368
Becurrent insanity, 368
Bemodelling of an old asylum, 457
Benaut, J., neuron and cellular memory, 862
Besponsibility in mental disease, 178
„ of the alcoholic, 179
Right-sidedness and left-sidedness, 858
Robertson, Dr. A., presentation to, 209

,, Dr. Ford, platinum method, 852
Bunge, E. C., border-line between sanity and insanity, 359

Sabraz&s, syringomyelia, 588

St. Pancras scandals, 819

Sarcoma of pia mater of brain and cord, 351

Savage, Dr. G. H., mental dissolution, 572

Schroder, sarcoma of pia mater of brain and cord, 861

Science, rdle of, in education of the people, 878

Sclerosis, multiple, diseases of optic nerve in, 579

Scottish district asylums, 190

Self-indicating locks, 209

Semelaigne, Dr. R., French retrospect, 174

Senile dementia and marriage, 671

Sensation et monvement, 586

Sewage disposal, 189

Sexual function and insanity and crime, 318, 815
Shennan, T. y Jores* formalin method of mounting, 352
Sibbald, Sir J., presentation to, 401
Siemerling, development of axial fibres of brain, 663
Sinkler, W., asthenic bulbar paralysis, 587
Skin diseases affecting insane, 60
Sleep, pathology of, 579
„ sleeplessness, and hypnotics, 698
Sleeplessness, 594
Sociology, 877, 598

Sougues and Castaigne, paralysis of serratus magnns, 374
Southey, Dr. R., obituary, 210
Speech and thought, 542
,, epileptic, 242

Spence, Dr. B., electric posh buttons in dormitories, 828
Spinal cord, diseases of, 545

Stanceleanu et Baup, mental confusion and infectious disease, 576
Starlinger, J., pathological anatomy of general paralysis, 590
Statistics of 6000 cases of insanity, 205
Stearns, H. P., heredity and insanity, 362
Strikes and insanity, 189

Strohmaver, W., causation of abortive epileptic attacks, 586
'Strfimpell's paralysis, 372

Digitized by VjOOQle

INDEX.

843-

Subcutaneous serous transfusion in acute psychoses, 376
Suicide and alcoholism, 260
„ in general paralysis, 571
Sulphonal poisoning, 376
Bupra-renal in the insane, lesions of, 375
Sutherland, G. A., Mongolian imbecility in infants, 369
Svenson, F., statistics of general paralysis, 569
Syllabus of practical work for training of attendants, 383
Syphilis and general paralysis, 208, 557
„ as cause of brain disorder, 553
„ in an infant resembling cretinism, 372

,, hereditary and pupillary anomalies in paralysed and idiot children, 421
„ prophylaxis, 598
Syphilitic insanity, 307
Syringomyelia, 588, 589
Systematic case taking, 255
Systematised insanity, 174

Therapeutics of insanity, 495

Thompson, Campbell H., locomotor ataxia treated by exercise, 377
„ „ structure of brain cells and degeneration, 562

,, Helen, functional cells in cerebral cortex, 565
„ R., hydrotherapy and balneotherapy, 596

Thyroidal fibrosis, 370

Tikanadse, psychical disorders in malaria, 577
Tongue, hemiatrophy of, 350
Toulouse, Dr., classification of mental diseases, 577
,, juvenile paralysis and epilepsy, 176
Treatment of insanity, 376, 593
„ „ the poor, 128

Tr6nel, amnesic aphasia, 371
Trfimner, Dr., pathology of delirium tremens, 874
Trophmddme chronique h6r6ditaire, 370
Truelle, M., general paralysis with hallucinations, 176
Tuberculin in phthisis, 13
Tuberculosis in asylums, 128
Tumour at base of brain, 689
Typhoid fever caused by celery, 616

Vallon and Wahl, methylene blue as an hypnotic, 376
Verger and Laubie, paraplegia, 587
Veroni, criminality in Rome, 600
Vice and insanity, 327

Vigouroux and Vignier, suppurative meningitis, 374
Villeneuse, offence against morals, 377
Villeneuve, morphinism associated with theft, 600
Vires, progress of neuropathology, 561
Viscera, disease of, and nervous system, 338

Wallace, J. R., hereditary syphilis in infant, 372

Walsem, van, the heavier brain, 347

Walton, G. L., and Cheney, tumour of pituitary body, 352

Water-softening process, 554

Waterston, D., craniometric observations, 560

Weir, private, case of, 819

Wiersma, hemiatrophy of tongue, 350

Will, free, 150, 533

Williams, E. C. t Striimpell’s paralysis, 372
Williamson, R. T., loss of knee-jerk in lesions of brain, 581
Wilson, J. C., astasia-abasia, 372

Youthful Offenders Bill. 819

Digitized by VjOOQle

*44

INDEX*

Pabt II.—ORIGINAL ARTICLES.

Surratt, Dr. J. O. W., on two eases of lepto-meningitis, 768

Beach, Dr. Fletcher, Presidential Address—the treatment of idiots, imbeciles,
feeble-minded, epileptic, and juvenile delinquents, 628
Beadles, Dr. C. F. t the insane Jew, 781

Blackwood, C. Mabel, Miss, cases of glioma of corpus callosum, 612
Blair, Dr. David, isolation and open-air treatment of phthisical insane, with notes
on seventy-four cases treated, 215
,, the influence of psychoses on nervous glycosurias, 749

Bolton, Dr. J. Shaw, demonstrations of preparations and lantern slides, from
pathological laboratory, 712

Bruce, Dr. Lewis, and Dr. H. de Main Alexander, observations on the various
physical changes occurring during the acute and subacute stages of melan¬
cholia, 725

'Campbell, Dr. Harry, the feelings, 219
Clark, Dr. A. Campbell, on epileptic speech, 242

Conford, Dr. G. J., on bodily disease as a cause and complication of insanity, 288
Cowen, Dr. T. P., emphysema of subcutaneous areolar tissue occurring in a case of
stuporous melancnolia, 517

'Crookshank, Dr. F. G., the physical signs of insanity, 48

Dawson, Dr. W. R., the best method of dealing with the pathological work of the
Irish asylums, 487

Easterbrook, Dr. C. C., an attack of epilepsy (status epilepticus) followed within
six weeks by an attack of chorea, occurring in a patient suffering from acute
puerperal insanity, 114

Edridge-Green, Dr. F. W., psychological perceptions, 766
Findlay, Dr. G., spurious pregnancy, 118

France, Dr. Eric, abstract of a paper on the necessity for isolating the phthisical
insane, 1

Griffin, Dr. E. W., cases of communicated insanity, 109

Hawkins, Rev. H., continuity of work under altered conditions, 469
Hitchcock, Dr. C. K., notes on 206 consecutive cases of acute mania treated without
sedatives, 80

Hotchkis Dr. R. D., a case of syphilitic insanity, 807

Hungerford, Dr. G., hysteria and its relation to insanity, 88

Hyslop, Dr. T. B„ on some of the rarer skin diseases affecting the insane, 60

Ireland, Dr. W. W., on the mental state of Auguste Comte, 80

Koenig, Dr. W. J., on pupillary anomalies in paralysed and non-paralysed idiot
children and their relation to hereditary syphilis, 427

Mandsley, Dr. H., the new psychology, 411

Mercier, Dr. C., concerning irresponsibility in criminals, 281

Newington, Dr. H. Hayes, plans of a new asylum for East Sussex, 678
Newth, Dr. A. H., systematic case-taking, 265

Orr, Dr. D., and Dr. T. P. Cowen, a contribution to the morbid anatomy and the
pathology of general paralysis of the insane, 638

Patterson, Dr. A. E., an analysis of one thousand admissions into the City of
London Asylum, 478

Digitized by

Google

INDEX.

845

Kenton, A. W. f Esq., comparative lunacy law, 42

Robertson, Dr. Ford, microscopical demonstration of the normal and pathological
histology of mesoglia cells, 724

Sainsbnry, Dr. H., the therapeutics of insanity, 496
Shoyer, Dr. A. F., an angeioma of Broca’s convolution, 775

Simpson, Dr. F. O., foreign bodies in both bronchi; broncho-pneumonia; death,
516

8 teen, Dr. R. H., the evolution of asylum architecture, and the principles which
ought to control modern construction, 87

Sullivan, Dr. W. C., the relation of alcoholism to suicide in England, with special
reference to recent statistics, 260
„ alcoholic homicide, 787

Turner, Dr. J., a theory concerning the physical conditions of the nervous system
which are necessary for the production of states of melancholia,
mania, etc., 605

„ pathological changes in the great nerve-cells of the insane with

special reference to " reaction at a distance,” 716

Walsh, Major J. H., major operations on the insane, notes of a case of cataract, 112
Watson, Dr. G. A., lantern demonstrations on changes in the cortical nerve-cells in
general paralysis, 714

White, Dr. E. W., epilepsy associated with insanity, 78
„ the remodelling of an old asylum, 467

Whiteway, A. R., Esq., the asylum at Pau, a self-supporting public asylum, 444
Wilcox, Dr. A. W., a case of remarkable chloral idiosyncrasy, 809

Past III.—REVIEWS.

Allbutt, T. Clifford, a system of medicine by many writers, 824
Ammion, Otto, the psychology of the cephalic index, 794
Asylum retrospects, 651

Bawden, Mr. H. Heath, a study of lapses, 796
Beevor, Dr. C. E., diseases of the nervous system, 344
Binet, Dr. A., Fannie psychologique, 166
Binso, C., del libero arbitrio, 588

Bourneville, Dr., recherches cliniquet et thlrapeutiques sur l'lpilepsie, l'hystlrie, et
l’idiotie, 158

Brissaad, Prof. E., lemons sur lea maladies nerveuses, 159
Carus, Dr. P., the soul of man, and Kant and Spencer, 798

Dr&hms, Auguste, the criminal, his personnel and environment: a scientific study,
800

Duigon, Dr. E. Le, contribution & l'ltude du prognostic de l’lpilepsie chez les
enfants, 167

Edinger, Prof. L., the anatomy of the central nervous system of man and of verte*
brates in general,

Elmira reformatory, the twenty-third year-book, 682

Flrl, Dr. Ch., the pathology of the emotions: physiological and clinical studies;
translated by R. Park, M.D., 841

,, sensation et mouvement: Itudes experimentales de psycho-mlca-

nique, 586

Franz, Dr. S. I., after-images, 884

Fraser, Dr. D., a sketch of the care and treatment of the insane in the parish of
Paisley, 561

Digitized by VjOOQle

846 INDEX.

Grasset, Dr, anatomie clinique des centres nerveux, 540

,, diagnostic des maladies de la moelle—sifcge de lesions, 545
Grotjahn, Dr. A., der alkoh'olismus nach Weaen, Wirkung und Verbreitung (alcohol
its nature, influence, and distribution), 548

Hamon, Dr. A., the universal illusion of free will and criminal responsibility, 150
Holden and Bosse, the development of colour perception and colour preference in
the child, 799

Ireland, Dr. W. W., the mental affections of children—idiocy, imbecility, aud
insanity, 550

Judicial statistics, England and Wales, 1897—1898, part i, criminal statistics, 155,

548

Kraepelin, Prof. E., psychology sche arbeiten, 835
Krafft-Ebing, Prof. R. von, m&Lecine legale des ali6o£s, 793

Lachr, Dr. H„ and Lewald, Dr. M., die heil und pflege-ausstatten fur psychisch-
kranke des deutschen sprachgebietes an 1 Jan., 1898, 552
Letchworth, Dr. W. P., the care and treatment of epileptics, 546

Manheimer, Dr. M., les troubles mentaux d’enfance, 342
Maurice de Fleury, Dr., introduction 4 la m£decine de l’esprit, 163
Mercier, Dr. C., the attendant's handbook, 552

Moele, Dr. C., die geistesstorungen im burgerlichen gesetzbuch und in der civil-
process-ordnung, 840

Moncalm, M., en l’origine de la pens£e et de la parole, 542

Morison, Dr. A., on the relation of the nervous system to disease and disorder in
the viscera, 838

Nisbet, J, F., The human machine, 168

Oppenheim,Prof.H.,Nervenleiden und Erziehung (neuropathy and education), 170

Paine, Mr. Wyatt, the law of inebriate reformatories and retreats, containing the
Inebriates Acts, 1879 to 1898, 791
Pearson, Prof. Karl, the grammar of science, 786
Perrier, Dr. C., les criminels, 537

Pontoppidan, Dr. K., klinische forelaesninger over nervesygdomme (clinical lectures
on nervous diseases), 171

Kaulin, Dr. J. M., Le rire et les exhilarants, 339

Benda, Antonio, l'ideazione geniale. Un esempio: Augusto Comte. Prefazione
di C. Lombroso (The ideation of genius. An example: Auguste Comte), 538
Renouvier et L. Pral, M., La nouvelle monadologie, 169
Reports of the Commissioners in Lunacy, England, 135
„ of the Inspectors of Lunatics, Ireland, 145
„ of the Commissioners in Lunacy for Scotland, 142

„ of the Chairman of Prisons upon the treatment of crime in the United
States, 151

Ribot, Dr. T., The evolution of general ideas, 169

Ripley, Dr. W. Z., The races of Europe: a sociological study, 331

Robertson, Dr. A., a short account of the origin and history of the Glasgow City
Parochial Asylum, with a note on the system of boarding out the insane, 562

Sergi, Prof. G., specie e varieta umane (human species and varieties), 328
SolUer, Dr. V., Genese et nature de Physt&ie, 161

„ P., Le problbme de la m^moire: essai de psychom£canique, 801

Digitized by tjOooLe

INDEX.

847

Thompson, Dr. C., diseases of the nervous system, 326

„ StClnir, the cerebro-spinal fluid: its spontaneous escape from the

nose, 343

Warner, Dr. F., the nervous system of the child, its growth and health in education,
641

Warren, Dr. H. C., the psychological index, 537
Wcstcott, Dr. W. W. t inebriety, its cause and cure, 653
Wilson, Dr. G. R., clinical studies in vice and insanity, 827
Woakcs, Dr. Ed., on deafness, giddiness, and noises in the head, 169

ILLUSTRATIONS.

Tables and charts elucidating paper by Dr. E. France, 3—11
Four photographs illustrating Dr. Hyslop’s paper, facing p. 62 and 68
Lithographed plans of asylum to illustrate Dr. Steen’s paper, 88
Woodcut „ „ „ „ 105

Photograph of Dr. Ludwig Meyer, facing p. 215
Lithogrnplied chart to illustrate Dr. Sullivan’s paper. 266

,, plans of asylu n to illust ate Dr. White's paper, 468

Photograph of brain to illustrate Miss Blackwood’s paper, 514
Six photogravures of brain and sections of, to face p. 774

Five photographs of brain sections to illustrate Drs. Orr and Cowen’s article, 708
„ „ „ Dr. Turner’s article, 722

Woodcut of urea scale, to illustrate Dr. Bruce and Alexander’s article, 726
„ showing culture, to illustrate Dr. Barratt’s paper, 771
Four photographs to illustrate Dr. Shoyer’s paper, 776

PRINTED BY ADLARD AND SON,

BARTHOLOMEW Cl.OSK, E.C., AND 20, HANOVER SQUARE, W.

Xlvi, 57

Digitized by fjOOQle

Digitized by

Digitized by '

Digitized by VjOOQle

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "The Journal Of Mental Science. 46.1900 Minnesota"

See other formats