Full text of "The Journal Of Mental Science. 49.1903 California"

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

v*\v

Digitized by v^.ooQLe

THE JOURNAL

MENTAL SCIENCE.

EDITORS i

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

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

ASSISTANT EDITORS:

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

VOL. XLIX.

LONDON:

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCIII.

Digitized by C.ooQLe

11 In adopting our title of the Journal of Mental Science , published by authority
of the Medico-Psychological Association , we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it haa
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 astfoncro«c&! science! bpt. it is the practical part of that science as it
is applicable to navigation which ne is compelled to study.”— Sir J. C. Bucknill,
MJ). t F.R.S.

Digitized by v^.ooQLe

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1902-3.

president.— JOSEPH WIGLESWORTH, M.D.

president ELECT.— ERNEST W. WHITE, M.B.
ex-president.— OSCAR T. WOODS, M.D.
treasurer.— H. HAYES NEWINGTON, F.R.C.P.Ed.

fHENRY RAYNER, M.D.
editors of journal. < A. R. URQUHART, M.D.

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

assistant editors. (JAMES CHAMBERS. M.D.
(Not Members of Council.) ?JOHN R. LORD, M.B.

(JAMES M. MOODY, M.R.C.S
\E. B. WHITCOMBK, M.R.C.S

divisional secretary for south-eastern division.— A. N. BOYCOTT, M.D.

divisional secretary for south-western division.— P. W. MACDONALD, M.D.

DIVISIONAL SECRETARY POR NORTHERN AND MIDLAND DIVISION.

C. K. HITCHCOCK, M.D.

DIVISIONAL SECRETARY FOR 8COTLAND. —LEWIS C. BRUCE, M.B.
DIVISIONAL SECRETARY FOR IRELAND.— W. R. DAWSON, M.D.

GENERAL SECRETARY. —ROBERT JONES, M.D., B.S., F.R.C.S.

secretary of xducational committee. —C. A. MERCIER, M.B. (appointed by
Educational Committee, but with seat on Council).

registrar.— ALFRED MILLER, M.B.

MEMBERS OF COUNCIL.

C. H. BOND, M.D. 1900.

J. G. HAYELOCK, M.D.

F. P. HEARDER, M.D.

H. GARDINER HILL,

M.R.C.S.

ALFRED MILLER, M.B.

L. A. WEATHERLY, M.D.

T. 8. ADAIR, M.B. 1901.

THEO. B. HYSLOP, M.D.

H. A. KIDD, M.R.C.S. „

R. L. RUTHERFORD, M.D. 1901.
J. BEVERIDGE SPENCE, M.D. „
A. R. TURNBULL, M.B.

R. C. STEWART, M.B. 1902.

F. W. MOTT, M.D.

A. D. O’C. FINEGAN, L.R.C.P.I. „

J. BRAINE-HARTNELL,

L R C.P.

MAURICE CRAIG, M.D.

DAVID YELLOWLEES, M.D. „

[The above form the Council.]

examiners.

JE. B. WHITCOMBE, M.R.C.S.
‘ITHEO. B. HYSLOP, M.D.

_ (LEWIS C. BRUCE, M.B.
“(JOHN CARSWELL, L.K.C.P.

IRELAND

CONOLLY NORMAN, F.R.C.P.I.
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.; J. CARLYLE JOHNSTONE, M.D.

PARLIAMENTARY COMMITTEE.

FLETCHER BEACH

{Secretary).

H. BENHAM.

G. F. BLANDFORD.

DAVID BOWER.

D. M.. CASSIDY.

T. 8. CLOU8TON.

A. D. 0*0. FINEGAN.

H. GARDINER HILL.

C. K. HITCHCOCK.

J. CARLYLE JOHNSTONE.
ROBERT JONES.

H. ROOKE LEY.

J. G. McDOWALL.

C. MERCIER

H. HAYES NEWINGTON

{Chairman).
CONOLLY NORMAN.

EVAN POWELL.

H. RAYNER.

G. H. 8AVAGE.

R. PERCY SMITH.

J. B. SPENCE.

A. H. STOCKER.

D. G. THOMPSON.

E. B. WHITCOMBE.

ERNEST W. WHITE.

J. WIGLE8WORTH.

OSCAR WOODS.

D. YELLOWLEES.

345771

Digitized by v^,ooQLe

EDUCATION Ala

T. S. CLOUSTON.

MAURICE CRAIG.

A. D. O’C. FINEGAN.

J. G. HAVELOCK.

T. B. HY8L0P.

J. CARLYLE JOHNSTONE. |

ROBERT JONES. !

W. 8. KAY.

P. W. MACDONALD.

S. R. MACPHAIL. |

T. W. McDOWALL. »

C. MERCIER (Secretary}.

W. F. MICKLE.

G. W. MOULD. j

H. HAYES NEWINGTON. ‘

CONOLLY NORMAN.

H. RAYNER.

COMMITTER

E. C. ROGERS.

J. RORIE.

G. H. SAVAGE.

T. CLAYE SHAW.

R. PERCY SMITH (Chairman).
J. B. SPENCE.

A. R. TURNBULL.

L. A. WEATHERLY.

E. B. WHITCOMBE.

ERNEST W. WHITE.

J. R. WHITWELL.

J. WIGLESWORTH.

J. KENNEDY WILL.

OSCAR T. WOODS.

D. YELLOWLEES, and
Th* PRESIDENT.

LIST OP CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. de Vitrl, Lancaster.

1843. Dr. Conolly, Han well.

1844. Dr. Tburnam, York Retreat.

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

1851. Dr. Conolly, Han well.

1852. Dr. Wintle, Warneford House.

LIST OP PRESIDENTS.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Digitized by t^oooLe

iii

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1896.

1881.

1900.

1881.

1876.

1902.

1887.

1902.

1872. r
1891.1

1879.

1865.

1892.

1895.

1872.

1868.1
1888. J

HONORARY MEMBERS.

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

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

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

Bresler, Johannes, M.D., Kraschnitz, Schlesien, Germany. ( Corr. Mem.,
1896.)

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

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

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

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

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

Courtenay, E. Maziere, A.B., M.B., C.M.T.C.D., M.D., Inspector of
Lunatics in Ireland, Lunacy Office, Dublin Castle. (Secretary for
Ireland, 1876-87.)

Echeverria, M. G., M.D.

Falret, Jules, M.D., 114, Rue de Boc, Paris.

Ferd, Dr. Charles, 37, Boulevard St. Michel, Paris.

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

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

Gairdner, Sir William T., K.C.B., M.D.Edin., F.R.S., formerly Professor
of Medicine in the University of Glasgow, Physician to H.M. the King
in Scotland, 32, George Square, Edinburgh. (Pbbbident, 1882.)

1898. Hine, George T., F.R.I.B.A., 35, Parliament Street, London, S.W.
1881. Hughes, C. H., M.D., St. Louis, Missouri, United States.

Digitized by v^.ooQLe

Honorary and Corresponding Members .

1866. Laehr, H., M.D., Schweizer Hof, bei Berlin, Editor of the Zeitschrift fur
Psychiatric.

1887. Lentz, Dr., Asile d’Al&nfo, Tournai, Belgique.

1898. MacDonald, A. E., M.D., Manhattan Asylum, New York, XJ.S.A.

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

1871.1 Manning, Frederick Norton, M.D.St. And., M.R.C.S. Eng., Inspector of
1884. J Asylums, 147, Macquarie Street North, Sydney, New South Wales.

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

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

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

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

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

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

1873. Pitman, Sir Henry A., M.D.Cantab., F.R.C.P.Lond., Registrar of the
Royal College of Physicians, Enfield, Middlesex.

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

Mem., 1890.)

1886. Roussel, M. Thfophile, M.D., S 6 nateur, Paris.

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

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

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

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

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

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

Villejuif, Seine, France.

CORRESPONDING MEMBERS.

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

1897. Buschan, Dr. G., Stettin, Germauy.

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

1902. Estense, Benedetto Giovanni Selvatico, M.D., 116, Piazza Porta Pia, Rome.
1880. Komfeld, Dr. Hermann, Gleiwitz, Silesia, Germany.

1889. Kowalowsky, Professor Paul, KharkofF, Russia.

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

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

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

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

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

1893. Semelaigne, Dr. Ren6, Secretaire des Seances de la Socidtd Medico-
Psychologique de Paris, 16, Avenue de Madrid, Neuilly, Seine, France.

Digitized by v^.ooQLe

MEMBERS OF THE ASSOCIATION.

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

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

1900. Abbott, Henry Kingswell, M.B., B.Ch., M.D.Dublin, D.P.H.Irel&nd.

Hants County Asylum, Farebam.

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

and Pathologist, Wadsley Asylum, near Sheffield.

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

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

Clapton, London.

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

1886. Agar, S. Hollingsworth, jun., B.A.Cautab., M.R.C.S., Glendossil, Henley*
in-Arden.

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

Asylum, Oxford.

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

Devon.

1899. Alexander, Hugh de Maine, M.D., The Hospital, Royal Asylum, Aberdeen.

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

Lunatic Asylum.

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

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

Officer, District Asylum, Armagh.

1901. Ambler, John Richardson, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, County Asylum, Chester.

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

1900. Anderson, John Charles, M.D.Durli., Darenth Asylum, Dartford, Kent.
1898.- Anderson, John Sewell, M.R.C.S., L.R.C.P., Assistant Medical Officer,

Hull City Asylum, Willerby, near Hull.

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

Cupar, Fife.

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

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

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

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

Asylum, South Africa.

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

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

1894. Baily, Percy J., M.B.Edin., Senior Assistant Medical Officer, London

County Asylum, Hanwell, W.

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

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

1876. Baker, Robert, M.D.Edin., Visiting Physician, The Retreat, York, 41,
The Mount, York. (President, 1.892.)

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

Square, Peckham, S.E.

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

Superintendent, Stretton House, Church Stretton, Salop.

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

Zealand.

Digitized by v^.ooQLe

vi Members of the Association.

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

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

1901. Baskin, J. Longlieed, L.U.C.P.&S.Edin., L.F.P.S.Glas., Assistant

Medical Officer, County Asylum, Exminster, Devon.

1902. Baugh, Leonard D. H.,M.H.,C.M., District Asylum, Larbert, Stirling,N.B.
1864. Bayley, J., M.R.C.S., Medical Superintendent, St. Andrew’s Hospital,

Northampton.

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

St. Andrew’s Hospital, Northampton.

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

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

1902. Beale-Browne, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., Berry-
wood, Northampton.

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

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

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

1899. Beresford, Edwyn H., M.R.C.S. & M.R.C.P.Lond., Tooting Bee Asylum,
Tooting, S.W.

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

Londonderry.

1894. Blachford, James Vincent, M.B., B.S.Durham, Assistant Medical Officer,
Bristol Asylum, Fishponds, near Bristol.

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

Asylum, near Sheffield.

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

1883. Blair, Robert, M.D., 30, Queen’s Square, Strathbango, Glasgow.

1901. Blake, Thomas Frederick Hillyer, L.R.C.P.&S.Edin., Wakefield Road,

Ackworth Moor Top, near Pontefract, Yorks.

1902. Blakiston, Frederick C., M.R.C.S., L.R.C.P., Claremont Rise, Seaford,

Sussex.

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

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

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

1888. Biaxland, Herbert, M.R.C.S., Medical Superintendent, Callan Park
Asylum, New South Wnles.

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

Road, Jersey.

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

Bridge, Essex.

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

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

1877. Bower, David, M.D.Aber., Springfield House, Bedford.

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

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

Borough Asylum, Ivybridge, Devon.

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

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

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

Digitized by v^.ooQLe

Members of the Association . vii

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

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

intendent, County and City Asylum, Powick, Worcester.

1893. Bramwell, John Milne, M.B., C.M.Edin., 15, Stratford Place, Oxford
Street, W.

1881. Brayn, R., L.R.C.P.Lond., Medical Superintendent, Broadmoor Asylum,
Crow th orne, Berks.

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

Westbrooke House Asylum, Alton, Hants.

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

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

• Brushfield, Thomas N., M.D.St. And., Budleigh Salterton, Devon.

1898. Bubb, William, M.R.C.S., L.R.C.P.Lond., Second Assistant Medical
Officer, Worcester County Asylum, Powick, near Worcester.

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

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

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

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

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

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

1894b Campbell, Alfred Walter, M.D.Edin., Pathologist, County Asylum,
Rainhill, near Prescot, Lancashire.

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

1897. Campbell, Robert Brown, M.B., C.M.Edin., Assistant Medical Officer,
Crichton Royal Institution, Dumfries, N.B.

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

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

1896. Cashman, James, M.B., B.Cb., B.A.O.Royal Univ. Irel., Assistant Medical

Officer, Cork District Asylum.

1902. Cassells, Alexander Henderson, M.B., Ch.B.Glasg., Senior Assistant
Medical Officer, District Asylum, Sunnyside, Montrose.

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

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

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

1878. Clapham, Wm. Crochley S., M.D., M.R.C.P., The Gables, Mayfield,

Sussex.

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

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

Digitized by v^.ooQLe

viii Members of the Association .

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

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

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

Street, W.

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

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

1902. Collie, Robert John, M.D., Assistant Medical Officer School Board for
London, for Mentally Deficient Children, 25, Porchester Terrace,
Hyde Park, W.

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

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

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

Rochester.

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

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

1902. Cooke, William Arthur, L.R.C.P.&S.I., Assistant Medical Officer, St*
Patrick’s Hospital, Dublin.

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

Lincoln.

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

Southgate, N.

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

Bishopston, Bristol.

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

County Asylum, Lancaster.

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

1884. Cox, L. F., M.R.C.S., Medical Superintendent, Connty Asylum, Denbigh.
1878. Craddock, F. H., B.A.Oxon., M.R.C.S.Eng., L.S.A., Medical Superin¬
tendent, County Asylum, Gloucester.

1892. Craddock, Samuel, M.R.C.S.Eng., Summerdale, Bath.

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

Medical Officer, Bethlem Royal Hospital, Southwark.

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

Officer, London County Asylum, Canehiil, Surrey.

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

Barnes, S.W.

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

Officer, Richmond District Asylum, Dublin.

1902. Curran, Michael, M.A., M.B., B.Ch., R.U.I., Assistant Medical Officer, St.

Patrick’s Hospital, Dublin.

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

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

1896. Davidson, Andrew, M.D., C.M.Aber., Straits Settlements.

1874. Davies, Francis P., M.D.Edin., M.R.C.S.Eng., Kent County Asylum,
Barmiug Heath, near Maidstone.

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

1894. Dawson, William R., M.I)., B.Ch.Dubl., F.R.C.P.I., Medical Superinten¬
dent, Farnham House Asylum, Finglas, Dublin.

Digitized by t^oooLe

Members of the Association .

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

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

Surrey.

1901. De Steiger, Ad&le, M.B.Lond., County Asylum, Brentwood, Essex.

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

Derbyshire.

1902. Dixon, Harry Livesay, M.A., M.B., B.C., D.P.H.Cantab., Senior Assistant

Medical Officer, County Asylum, Mickleover, Derby.

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

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

1S89. Donaldson, William Ireland, B.A., M.D., B.Ch.Univ. of Dubl., Medical
Superintendent, Horton Manor Asylum, Epsom, Surrey.

1892. Donelan, John O’Conor, L.R.C.P.I., L.R.C.S.I., M.P.C., First Assistant
Medical Officer, Portrane Asylum, Donabate, co. Dublin.

1899. Donelan, Thomas O’Conor, L.R.C.P. & L.R.C.S.Ireland, Menston Asylum,
near Leeds.

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

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

Goudhurst.

1897. Dove, Emily Louisa, M.B.Lond., Cowbitt Vicarage, nr. Spalding.

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

1902. Dudgeon, Herbert Wm„ M.D.Durh., M.R.C.S.Eng., L.R.C.P.Lond.,
Medical Officer to the Egyptian Asylum, Abassieh, Cairo, Egypt.
1899. Dudley, Francis, L.R.C.P.&S.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1899. Eades, Albert J., County Asylum, Winwick, Warrington, Lancs.

1874. Eager, Reginald, M.D.Lond., M.R.C.S.Eng., Northwoods, near Bristol.
1873. Eager, Wilson, L.R.C.P.Lond., M.R.C.S.Eng., Northwoods, Winter¬
bourne, Bristol.

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

1891. Earls, James Henry, M.D., M.Ch., &c., 71, Brighton Square, Dublin.
1895. Easterbrook, Charles C., M.A., M.D., M.R.C.P.Ed., Medical Superin¬
tendent, Ayr District Asylum, Glengail, Ayr, NIB.

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

1900. Edridge-Green, F. W., M.D., F.R.C.S., Hendon Grove, Hendon, N.W.
1902. Edwards, Charles, M.R.C.S., L.R.C.P., Assistant Medical Officer, City of

London Asylum, nr. Dartford, Kent.

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

intendent, Camberwell House, S.E.

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

Horton Manor Asylum, Epsom, Surrey.

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

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

1873. Elliot, G. Stanley, M.R.C.P.Edin., F.R.C.S.Ediu., 16, Killieser Avenue,

Streatham Hill, S.W.

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

Digitized by t^oooLe

x Members of the Association .

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

Singapore.

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

1901. Elswortb,T. G., M.B., C.M.Edin., Senior Assistant Medical Officer, County
and City Asylum, Hereford.

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

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

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

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

1891. Ewan, John Alfred, M.A., M.B., C.M.Edin., M.P.C., Greylees, Sleaford,

Lincolnshire.

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

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

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

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

Edin., Medical Superintendent, Bethel Hospital, Norwich.

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

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

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

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

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

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

1898. Finn, P. Taafte, L.R.C.P., L.R.C.S.Ed., Oakhill, nr. Bath.

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

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

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

District Asylum, Carlow.

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

Officer, District Asylum, Cork.

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

Asylum, Fishponds, Bristol.

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

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

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

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

mond Asylum, Donabate, Dublin.

1902. Forshaw, Wm. H.,M.R.C.S., L.R.C.P.Lond., 29, Tredegar Square, Bow, E.
1902. Forster, Hermann Julius, L.R.C.P. 1., L.S.A., Assistant Medical Officer,
East Sussex Asylum, Hayward's Heath.

Digitized by v^,ooQLe

Members of the Association. xi

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

1902. Forsyth, John Glen, M.B., C.M.Ed., c jo Dr. James Forsyth, Eyemouth,
Berwickshire.

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

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

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

1901. French, Louis Alexander, M.R.C.S., L.R.C.P., 104, Chnrch Road, Silver-

dale, Staffs.

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

Medical Officer, Darenth Asylum, Dartford, Keut.

1893. Garth, H. C., M.B., C.M.Edin., 4, Harrington Street, Calcutta, India.
1890. Gaudin, Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent,

The Grove, Jersey.

1885. Gayton, Francis C., M.D., Brookwood Asylum, Woking, Surrey.

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

County Asylum, Winterton, Ferryhill, Durham.

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

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

1899. Gil&llan, Samuel James, M.A., M.B.Edin., London County Asylnm, Cane-
hill, Purley, Surrey.

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

Liverpool.

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

1897. Gilmour, John Rutherford, M.B., C.M.Edin., West Riding Asylum,

Scalebor Park, Burley-in-Wharfedale, Yorks.

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

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

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

Assistant Physician, Royal Asylum, Gartnavel, Glasgow.

1899. Goldschmidt, Oscar Bernard, M.B., Ch.B.Vict., Durham House,

Withington, Manchester.

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

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

1899. Goodliffe, John Henry, Finbar House, 802, High Road, Lower Totten¬

ham, N.

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

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

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

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

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

Asylum, Antrim.

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

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

Digitized by v^.ooQLe

xii Members of the Association.

1890. Gramsbaw, Farbrace Sidney, M.D., L.R.C.P.I., L.R.C.S.Edin., L.M.,

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

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

1902. Green, Philip A. M., M.R.C.S., L.R.C.P., Assistant Medical Officer, Clay-
bnry Asylum, Woodford Bridge, Essex.

I 902. Greene, George Waters, B.A., M.B.Cantab., M.R.C.S., L.R.C.P., Assistant
Medical Officer, Claybury Asylum, Woodford Bridge, Essex.

1896. Greene, Thomas Adam, Assistant Medical Officer, District Asylum, Ennis,
Ireland.

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

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

1896. Griffiths, George Batho G., M.R.C.S., L.R.C.P.Lond., Assistant Surgeon,
H.M. Convict Prison, Parkhurst, Isle of Wight.

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

County Asylum, Chester.

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

Bootham, York.

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

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

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

House, Peckham.

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

Medical Officer, London County Asylum, Banstead, Surrey.

1896. Hanbury, William Reader, M.R.C.S., L.R.C.P., Senior Assistant Medical

Officer, West Ham Borough Asylum, Goodmayes, Ilford.

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

N.B.

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

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

Private Asylum, Tonbridge, Kent.

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

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

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

Superintendent, City Asylum, Hellesdon, Norwich.

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

Digbys, Exeter.

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

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

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

Royal Asylum.

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

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

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

Riding Asylum, Wakefield.

1886. Henley, E. W., L.R.C.P., County Asylum, Barnwood, Gloucester.

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

Denbigh, North Wales.

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

1877. Hewson, R. W., L.R.C.P.Edin., Medical Superintendent, Cotton Hill,
Stafford.

Digitized by t^oooLe

Members of the Association . xiii

1902. Higginson, John Wigmore, M.R.C.S., L.R.C.P., Resident Medical Officer,
Hayes Park Asylum, Hayes Park, Middlesex.

1882. Hill, Dr. H. Gardiner, Medical Superintendent, Middlesex County Asylum,
Tooting.

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

1902. Hingston, A. Alwyne, B.A.Cantab., M.B., C.M.Aherd., Assistant Medical
Officer, Cotford Asylum, Taunton.

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

1881. Hitchcock, Charles Knight, M.D., Booth am Asylum, York.

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

1896. Horton, James Henry, M.R.C.S.Eng., L.R.C.P.Lond., Lieut. I.M.S.,

c/o Messrs. W. Watson & Co., 7, Waterloo Place, S.W r .

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

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

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

1857. Humphry, J., M.R.C.S.Eng., Medical Superintendent, County Asylum,
Stone, near Aylesbury, Bucks.

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

Goodmaye8, Ilford, Essex.

1882. Hyslop, James, D.S.O., M.D., c/o Dr. Cullen Brown, Overton Park,

Alexandria, Dumbartonshire, N.B.

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

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

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

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

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

District Asylum, Melrose.

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

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

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

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

Officer, London County Asylum, Colney Hatch, N.

1898. Jones, W. Ernest, M.R.C.S.Eng., L.R.C.P.Lond., Brecon and Radnor

Asylum, Talgarth, R.S.O.

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

Redhill, Surrey.

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

Wadsley, near Sheffield.

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

1899. Keegan, Lawrence Edward, M.D., Medical Superintendent, Lunatic

Asylum, St. John’s, Newfoundland.

1902. Kelley-Patterson, Wm., M.D., M.Ch., R.U.I., Bally-Emond, Killowen,
Dublin.

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

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

District Asylum, Enniscorthy.

Digitized by t^oooLe

xiv Members of the Association .

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

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

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lanark
District Asylum, Hartwood, Shotts, N.B.

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

near Darlington.

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

1897. Kingdon, Wilfred Robert, M.B., B.S.Durh., 55, Haverstock Hill,

London, N.W.

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

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

Ireland.

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

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

Somerset.

1900. Lambert, Ernest Charles, M.R.C.S.Eng., L.R.C.P.Lond., Banstead
Asylum, Sutton, Surrey.

1902. Langdon-Down, Peroival L., M.B., B.C.Cant&b., Rudder Grange, Cedar
Road, Hampton Wick, Middlesex.

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

1902. Laval, Evariste, M.B., C.M.Ediu., Brislington House Asylum, near
Bristol.

1898. Lavers, Norman, M.R.C.S., Medical Superintendent, The Asylum,

Canterbury.

1899. Law, Charles D., L.R.C.P.&S.Edin., L.F.P.G.S., c/o District Asylum,

Inverness, N.B.

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

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

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

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

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

1894. Lentagne, John, B.A., F.R.C.S.I., Medical Visitor of Lunatics to the

Court of Chancery, 6, Upper Merrion Street, Dublin.

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

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

1863. Ley, H. Rooke, M.R.C.S.Eng., 2, Lowther Terrace, Lytham, Lancs.

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

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

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

1883. Lisle, S. Ernest de, L.R.C.P.I., Three Counties Asylum, Stotfold, Herts.

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

Digitized by ^.ooQle

Members of the Association . xv

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

1872. Lyle, Thomas, M.D.Glasg., 84, Jesmond Road, Newcastle-on-Tyne.

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

London,N.

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

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

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

1893. Macevoy, Henry John, M.D., B.Sc.Lond., M.P.C., 41, Buckley Road,
Brondesbury, London, N.W.

1895. Macfarlane, N**il M., M.D.Aber., Medical Superintendent, Government

Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.

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

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

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

• Mackintosh, Donald, M.D.Durh. and Glasg., L.F.P.S.Glasg., 10, Lancaster
Road, Bel size Park, N.W.

1873. Macleod, M. D., M.B., Medical Superintendent, East Riding Asylum,

Beverley, Yorks.

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

1899. MacLulich, Peers, M.B., B.C., B.A.Dubl., c/o Dr. Goodall, Joint Counties

Asylum, Carmarthen.

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

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

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

Street, Edinburgh.

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

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

1902. Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin., District Asylum,

Inverness, N.B.

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

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

Calabar, Southern Nigeria, W. C. Africa.

1896. Mallanab, S., M.B.Edin., Medical School, Hyderabad, Deccan, India.
1865. Manning, Harry, B.A.Lond., M.R.C.S., Laverstock House, Salisbury.

1900. Manning, Herbert C., M.R.C.S., L.R.C.P., Wye, Kent.

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

Asylum, Lenzie.

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

Asylum, Bridgend, Glamorgan.

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

Officer, District Asylum, Donegal.

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

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

Digitized by v^.ooQLe

xvi Members of the Association .

1902. McCarthy, Owen F., L.R.C.P.&S.I., District Lunatic Asylum, Cork,
Ireland.

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

1900. McConaghey, J. C., M.6., C.M.Edin., Parkside Asylum, Macclesfield,

Cheshire.

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

for Insane, Kew, Victoria.

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

Cambridge County Asylum, Fulboum, Cambs.

1876. McDowall, John Grei?, M.B.Edin., Medical Superintendent, West

Riding Asylum, Menston, near Leeds.

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

Northumberland County Asylum, Morpeth. (Pbesidbxt, 1897.)
1902. McGregor, John, M.B., Cb.B.Ediu., Assistant Medical Officer, County
Asylum, Fulboum, Cambridge.

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

1882. McNaughton, John, M.D., Medical Superintendent, Criminal Luuatic

Asylum, Perth.

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

Asylum, Morningside, Edinburgh.

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

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

County Asylum, Cheddleton, near Leek.

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

Westminster Hospital; Flower House, Cat ford, S.E.

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

Hull.

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

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

1893. Middlemass, James, M.D., F.R.C.P., C.M., B.Sc.Edin., Borough Asylum,
Ryhope, Sunderland.

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

1883. Miles, George E., M.R.C.P., &c.. Medical Superintendent, Hospital for

the Insane, Rydalmere, New South Wales.

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

Asylum, Warwick.

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

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

1885. Molony, John, F.R.C.P.I., St. Edmundsbury, Lucan, co. Dublin, v Ireland.

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

intendent, County Asylum, Cane Hill, Surrey.

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

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

Sanatorium, Virginia Water, Surrey.

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

intendent, County and City Asylum, Burghill, Hereford.

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

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

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

1862. Mould, George W., M.R.C.S.Eng., Medical Superintendent, Royal
Lunatic Hospital, Cheadle, Manchester. (President, 1880.)

Digitized by t^.ooQLe

Members of the Association .

xvi i

1807. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Royal Lunatic Hospital, Cheadle, Manchester.

1897. Mumby, Bonner Harris, M.D.Aber., D.P.H.Cantab., Medical Superin¬

tendent, Borough Asylum, Portsmouth.

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

1893. Murdoch, James William Aitken, M.B., C.M.Glasg., Medical Superin¬
tendent, Berks County Asylum, Wallingford.

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

Sutton, Surrey.

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

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

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

Oxford.

1876. Newington, Alexander, M.B.Camb., M.R.C.S.Eng., Woodlands, Tice-
hurst.

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

1893. Newington, John, M.B.Edin., Zoffany House, Bnshey Hall Road, Bnshey,
Herts.

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

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

1893. Nobbs, Athelstane, M.D., C.M.Edin., 339, Queen’s Road, Battersea Park,
S.W.

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

1892. Noott, Reginald Harry, M.B., C.M.Edin., Senior Assistant Medical

Officer, Broadmoor Criminal Lunatic Asylum, Crowthorne,
Wokingham.

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

Asylum, Dublin, Ireland. (Hon, Secretary for Ireland , 1887—1894.)
(PBBSIDBNT, 1895.) (Editor of Journal.)

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

ford. Ireland.

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

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

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

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

Ireland.

1886. O’Neil], E. D., L.R.C.P.I., Medical Superintendent, The Asylnm,

Limerick.

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

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

Lancs.

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

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

1899. Owen, Corbet W., M.B., C.M.Edin., Bryn Eira, Llanfair P.G., Anglesey.

1902. Parker, Charles Seymour, M.R.C.S.Eng., L.R.C.P.Lond., Assistant
Medical Officer, Darenth Asylum, Dartford, Kent.

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

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

Digitized by v^.ooQLe

xviii Members of the Association.

1898. Pasmore, Edwin Stephen, M.D.Lond., M.R.C.P.Lond., Croydon Asylum,

Warlingham, Surrey.

1901. Passmore, Wm. Edwi n, L.S.A Lend., 2, Sylvan Villas, Wocdford Green,
Essex.

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

Wormwood Scrubbs, London, W.

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

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

Officer, City of London Asylum, Dnrtford.

1899. Pearce, G. Heneage, M.R.C.S., Borough Asylum, Humberstone,Leicester.
1873. Pedler, George H., L.R.C.P.Lond., M.R.C.S.Eng., 6, Trevor Terrace,
Knightsbridge, S.W.

1899. Penfold, William James, M.B., C.M.Edin., Assistant Medical Officer,

City Asylum, Gosfortli, Newcastle-on-Tyne.

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

County Asylum, Prestwich, Manchester, Lancashire.

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

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

Eldon Square, Newcastle-on-Tyne.

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

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

Dudley, Stafford.

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

Asylum, Bexley, Kent.

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

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

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

Medical Superintendent, Middlesbrough Asylum, Cleveland, Yorks.
1901. Potts, George, L.R.C.P.&L.R.C.S.Kdin., Kent County Ophthalmic
Hospital, Maidstone.

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

Good Hope.

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

Lunatic Asylum, Nottingham.

1891. Price, Arthur, M.R.C.S., L.S.A., M.P.C., Merriebank, Moss Lane, Aintree,
Liverpool.

1876. Pringle, H. T., M.D.Glasg., Medical Superintendent, County Asylum,
Bridgend, Glamorgan.

1901. Pugh, Robert, M.D.Edin., Ch.B., Claybury Asylum, Woodford Bridge,

Essex.

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

tute, Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.D.Univ. Dubl., Third Assistant Medical Officer

and Pathologist, Richmond District Asylum, Dublin.

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

on-Tyne.

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

1893. Rawes, William, M.B.Durh., F.R.C.S.Eng., Medical Superintendent, St.

Luke’s Hospital, Old Street, London, E.C.

1870. Rayner, Henry, M.D. Aberd.,M.R.C.P.Edin., 16,Queen Anne Street, London,
W. (President, 1884.) ( Late General Secretary .) ( Editor of
Journal.)

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

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

Digitized by v^.ooQLe

XIX

Members of the Association.

1801. Renton, Robert, M.B., C.M.Edin., M.P.C., Courtburn, Coldingham,
Berwickshire.

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

Medical Superintendent, Central Criminal Asylum, 1)undrum,
Ireland.

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

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

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

Leicester.

1889. Richards, Joseph Peeke, M.R.C.S., L.S.A., 6, Freeland Road, Ealing, W.
1893. Rivers, William H. Rivers, M.D.Lond., St. John's College, Cambridge
University.

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

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

Asylum, Larbert, Stirling.

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

1900. Robinson, Harry A., M.B., Ch.B.Vict., Darenth Asylum, Dartford, Kent.

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

boura, Cambridge.

1859. Rogers, Thomas Lawes, M.D.St. And., M.R.C.P.Lond., M.R.C.S.Eng.,
Eastbank, Court Road, Eltham, Kent. (Pbbsidbnt, 1874.)

1895. Rolleston, Lancelot W., M.B., B.S.Durh., Senior Assistant Medical

Officer, Middlesex County Asylum, Tooting, S.W.

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

1879. Roots, William H., M.R.C.S., Canbury House, Kingston-on-Thames.
1899. Rorie, George Arthur, M.B., C.M., Senior Assistant Medical Officer,
Dorset County Asylum, Dorchester.

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

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

more, New South Wales.

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

1902. Round, John, L.R.C.P., L.R.C.S., L.F.P.S., 57, Ebrington Street,
Plymouth.

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

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

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

1877. Russell, A. P., M.B.Edin., The Lawn, Lincoln.

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

1896. Rutherford, James M., M.B., C.M.Edin., Assistant Physician, Royal

Edinburgh Asylum, Morningside.

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

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

1902. Sail, Ernest Frederick, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, West Sussex County Asylum, Chichester.

18Q4. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Borealton Park Licensed House, Baschurch, Salop.

Digitized by v^.ooQLe

Members of the Association .

• S&nkey, R. Heurtley H., M.R.C.S.Eng., Medical Superintendent, Oxford
County Asylum, Littlemore, Oxford.

1873. Savage, G. H., M.D.Lond., 3, Henrietta Street, Cavendish Square, W.
(Late Editor of Journal .) (Pbesidbnt, 1886.)

1899. Scott, Charles R., M.B., C.M.Edin., Bed well Place, Abingdon.

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

London, S.W.

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

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

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

Asbton-on-Ribble, Preston.

1889. Sells, Charles John, L.R.C.P., M.R.C.S., L.S.A., White Hall, Guildford.
1902. Serjeant, Robert, M.R.C.S., L.R.C.P., Camberwell House Asylum,
Peckham Road, S.E.

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

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

1891. Shaw, Harold B., B.A., M.B., B.B., D.P.H.Camb., Medical Superin¬
tendent, Isle of Wight County Asylum, Whitecroft, Newport, Isle
of Wight.

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

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

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

1900. Shera, J. E. P., L.R.C.P.I., Kent County Asylum, Ckartham, near Canter¬

bury.

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

Sussex.

1877. Shuttlcworth, G. E., M.D.Heidelb., M.R.C.S. and L.S.A.Eng., B.A.Lond.,
late Medical Superintendent, Royal Albert Asylum, Lancaster;
Ancaster House, Richmond Hill, Surrey.

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

Medical Officer, Loudon County Asylum, Cane bill, Purley, Surrey.

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

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

1895. Simpson, Francis Odell, M.R.C.S., L.R.C.P., Senior Assistant Medical
Officer, County Asylum, Rainhill, near Liverpool.

1838. Sinclair, Eric, M.D., Medical Superintendent, Gladesville Asylum, New
South Wales.

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

J898. Skeen, William St. John, M.B., C.M., County Asylum, Winterton, Ferry -
hill, Durham.

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

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

Brentwood.

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

Home Office, Whitehall, S.W.

1899. Smith, J. G., M.D., Herts County Asylum, Hill End, St. Albans, Herts.
1885. Smith, R. Percy, M.D., B.S., F.R.C.P., M.P.C., 36, Queen Anne Street,
Cavendish Square, W. ( General Secretary , 1896-7.)

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

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Lond., Medical Superin¬
tendent, Hospital for the Insane, Kcw, Melbourne, Victoria.

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

Digitized by v^,ooQLe

XXI

Member* of the Association.

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

1881. Snell, George, M.D.Aber., M.R.C.S.Eng., Vine Cottage, Norwood Green,
Southall, Middlesex.

1885. Soutar, James G., M.B., Barnwood House, Gloucester.

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

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

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

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

1891. Stansfield, T. E. K., M.B., C.M.Edin., The Heath Asylum Bexley, Kent.
1901, Starkey, William, M.B., B.Ch., B.A.O.Roy. Univ, Irel., Assistant Medical
Officer, Lancashire County Asylum, Prestwich, near Manchester.

1898. Steen, Robert H., M.D.Lond., West Sussex Asylnm, near Chichester.

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

Devon.

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

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

Bridgend, Glamorgan.

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

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

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

Middlesex.

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

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

1900. Stracey, Bernard, M.B., Ch.B.Edin., Sutton-Bonnington, Loughborough.

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

Willows, Lancashire.

1900. Stuart, Esther Molynenx, M.B., C.M.Edin., County Asylum, Morpeth,
Northumberland.

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

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

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

Asylum, Rosslynlee, N.B.

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

near Bromsgrove, Worcestershire.

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

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

chester.

1805. Sutherland, John Francis, M.D.Edin., Deputy Commissioner in Lunacy,
19, Mayfield Road, Edinburgh.

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

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

Asylum, Hellesdon, nr. Norwich.

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

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

Digitized by v^.ooQLe

xxii Members of the Association.

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

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

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

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

1888. Thomas, £. G., Haveringwell, Cater ham, Surrey.

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

Thorpe, Norfolk.

1902. Thomson, Eric M., M.A., M.B., Ch.B., James Murray's Royal Asylum,
Perth, N.B.

1902. Thomson, James, M.D., Gartloch Hospital for Mental Diseases, Gartcosh,
N.B.

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

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

Surrey.

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

Transvaal, South Africa.

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

Medical Superintendent, County Asylum, Lincoln.

1896. Townsend, Arthur A. i\, M.R.C.S.Eng., L.R.C.P.Lond., Assistant
Medical Officer, Hospital for Insane, Barn wood House, Gloucester.

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

Physician to the Leeds General Infirmary, 40, Park Square, Leeds.

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

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

Saughton Hall, Edinburgh.

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

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

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

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

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

County Asylum, Brentwood.

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

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

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

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

Asylum, near Sheffield.

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

1896. Walker, William F., L.R.C.S.&L.M.Edin., L.SJLLond., Plas-yn-Dinas,
Dinas Mawddwy, Merionethshire.

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

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

1900. Walters, John Basil, M.R.C.S.Eng., L.R.C.P.Lond., Kingsdown House,
Box, Wilts.

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

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

58, Parliament Street, Capo Town, South Africa.

1902. Watson, Frederick, M.B., C.M.Edin., Assistant Medical Officer, Ayr
District Asylum, Ayr, N.B.

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

Digitized by t^oooLe

Members of the Association . xxiii

1885 Watson, William Riddell, L.R.C.S. and L.R.C.P.Edin., Govan District
Asylum, Hawk head, Paisley.

1898. Watson, William R. K., M.A., M.B..C.M., 18, Montrell Road, StreAtham
Hill, London, S.W.

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

1902. Welch, Frederick Day, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Borghill Asylum, Hereford.

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

1872. Whitcombe, Edmund Banks, M.R.C.S., Medical Superintendent, Winson

Green Asylum, Birmingham. (Pbesidbnt, 1891.)

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond., Resident Physiciun

and Superintendent, City of London Asylum, nr. Dartford, Kent.
(Hon. Sec . South Eastern Division , 1897—1900.)

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

Suffolk County Asylum, Melton Woodbridge.

1883. Wigleswortb, J., M.D.Lond., Rain hill Asylum, Lancashire.

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

Officer, County Asylum, Hatton, Warwick.

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

Plymouth Borough Asylum, Blackadon, lvybridge. South Devou.

1887. Will, John Kennedy, M.B., C.M., M.P.C., Bethnal House, Cambridge
Road, N.E.

1902. Willis, Wm. Frederick, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, County Asylum, Exminster, Devon.

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

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

Lodge, Loanheak.

1900. Wilson, James Patterson, M.B., Ch.B.Glasg.

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

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

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

1875. Winslow, Henry Forbes, M.D.Lond., M.R.C.P.Lond., 14, York Place,
Portman Square, London.

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

Road, Portsmouth.

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

1869. Wood, T. Outterson, M.D., M.R.C.P.Lond., F.R.C.P., F.R.C.S.Edin.
40, Margaret Street, Cavendish Square, W.

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

1873. Woods, Oscar T., M.B., M.D.Dubl., L.R.C.S.I., Medical Superintendent,

District Asylum, Cork. (Hon. Secretary for Ireland , 1897.) (Pbb-
sidbnt, 1901.)

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

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

1898. Yeates, Thomas, M.B., C.M., Borough Asylum, Ryhope, Sunderland.

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

Digitized by v^.ooQLe

XXIV

Members of the Association.

Ordinary Members . 586

Honorary Members . 87

Corresponding Members . 12

Total . 635'

Members are particularly requested to send changes of address, S(c. % to Dr.

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

Digitized by v^.ooQLe

XXV

Lilt of those who have passed the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.C. (Med. Piych.

Certif.) to their names.

Adamson, Robert O.

Adkins, Percy, R.

£ Ainley, Fred Shaw.

Ainslie, William.

Alexander, Edward H.

Anderson, A. W.

^ Anderson, Bruce Arnold.
Anderson, John.

Andriezon, W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, H. T. S.

Ballantyne, Harold S.

Barbour, William.

Barker, Alfred James Glanville.
B&shford, Ernest Francis.

Begg, William.

Belben, F.

Bird, James Brown.

Blachford, J. Vincent.

Black, Robert S.

Black, Victor.

Blackwood, John.

Blandford, Henry E.

7 Bond, C. Hubert.

Bond, R. St. G. S.

Bowlan, Marcus M.

Boyd, James Paton.

Bnstowe, Hubert Carpenter.
Brodie, Robert C.

Brough, C.

Browne, Hy. E.

Bruce, John.

Bruce, Lewis C.

Brush, S. C.

Bulloch, William.

Calvert, William Dobree.
Cameron, James.

Campbell, Alex Keith.
Campbell, Alfred W.

Campbell, Peter.

Carmichael, W. J.

Carruthers, Samuel W.

Carter, Arthur W.

Chambers, James.

Chapman, H. C.

Christie, William.

Clarke, Robert H.

Clayton, Frank Herbert A.
Clinch, Thomas Aldous.

Coles, Richard A.

Collie, Frank Lang.

Collier, Joseph Henry.

Conolly, Richard M.

Conry, John.

Cook, William Stewart.

Cooper, Alfred J. S.

Cope, George Patrick.
Corner, Harry.

Cotton, William.

Couper, Sinclair.

Cowan, John J.

Cowie, C. G.

Cowie, George.

Cowper, John.

Cox, Walter H.

8 Craig, M.

Cram, John.

Crills, G. H.

Cross, Edward John.
Cruickshank, George.

Cullen, George M.
Cunningham, James F.
Dalgetty, Arthur B.
Davidson, Andrew.
Davidson, William.

6 Dawson, W. R.

De Silva, W. H.

Distin, Howard.

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

Downey, Augustine.
Drummond, Russell J.
Eames, Henry Martyn.
Earls, James H.

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

Edwards, Alex. H.

Elkins, Frank A.

Ellis, Clarence J.

English, Edgar.

Eustace, J. N.

Eustace, Henry Marcus.
Evans, P. C.

Ewnn, John A.

Ezard, Ed. W.

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

Ferguson, Robert.

Findlay, G. Landsborough.
Fitzgerald, Gerald.

Fleck, David.

Fox, F. G. T.

Fraser, Donald Allan.
Fraser, Thomas.

Frederick,* Herbert John.
Gaudin, Francis Neel.

Digitized by v^.ooQLe

XXVI

Gawn, Ernest K.

Gemm'ell, William.

Genney, Fred. S.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmonr, John R.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Werayss.

Grant, Lacklan.

Gray, Alex. C. E.

Griffiths, Edward H.

Hall, Harry Baker.

Halsted, H. C.

Haslam, W. A.

Haslett, William John Handheld.
Hassell, Gray.

Hector, Wiliiam.

Henderson, Jane B.

Henderson, P. J.

Hennan, George.

Hewat, Matthew L.

Hicks, John A., jun.

Hitching*, Robert.

Holmes, William.

Horton, James Henry.

Hotchkis, R. D.

Howden, Robert.

Hughes, Robert.

Hutchinson, P. J.

2 Hyslop, Thos. B.

Ingram, Peter R.

Jagannadhan, Annie W.
Johnston, John M.

Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Barty.

King, Frederick Truby.

Laing, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Bryden.

Deeper, Richard R.

Leslie, R. Murray.

Liveeay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Low, Alexander.

McAllum, Stewart.

Maedonald, David.

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

Macevoy, Henry John.

McGregor, George.

Maclnnes, Ian Lamont.
Mackenzie, Henry J.

Mackenzie, John Cumming.
Mackenzie, William H.
Mackenzie, William L.

Mackie, George.

McLean, H. J.

Macmillan, John.

5 Macnaughton, Geo. W. F.
Macneice, J. G.

Macpherson, John.

Macvean, Donald A.

Mallannah, Sreenagula.

Marr, Hamilton C.

Marsh, Ernest L.

Martin, A. A.

Martin, A. J.

Martin, Wm. Lewis.

Masson, James.

Meikle, T. Gordon.

Melville, Henry B.

Middlemans, James.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Monteith, James.

Moore, Edward Erskine.

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

Myers, J. W.

Nair, Charles R.

Nairn, Robert.

Neil, James.

Nixon, John Clarke.

Nolan, Michael James.

Norton, Everitt E.

Orr, David.

Orr, James.

Orr, J. Fraser.

Oswald, Landel R.

Paget, A. J. M.

Parker, William A.

Parry, Charles P.

Patterson, Arthur Edward.
Patton, Walter S.

Paul, William Moncrief.

Pearce, Walter.

Penfold, William James.

Philip, James Farquhar.

Philip, William Marshall.

Pieris, William C.

Pilkington, Frederick W.
Pitcairn, John James.

Porter, Charles.

Price, Arthur.

Pring, Horace Reginald.

Rainy, Harry, M.A.

Ralph, Richard M.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Renton, Robert.

Digitized by

Google

XXY11

Bice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.

Rivers, W. H. R.

3 Robertson, G. M.

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

Rose, Andrew.

Rowand, Andrew.

Rndall, James Ferdinand.

Rust, James.

Rnst, Montague.

Rutherford, J. M.

Sawyer, Jas. E. H.

Scott, George Brebner.

Scott, J. Walter.

Scott, William T.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Arnison.

Smith, Percy.

Smyth, William Johnson.
Snowball, Thomas.

Soutar, James G.

Sproat, J. H.

Stanley, John Douglas.

Staveley, William Henry Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

Stoddart, John.

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

Strong, D. R. T.

Stuart, William James.
Symes, G. D.

Thompson, George Matthew.
Thomson, Eric.

Thomson, George Felix.
Thorpe, Arnold E.

Trotter, Robert Samuel.
Turner, W. A.

Umney, W. F.

Walker, James.

Warde, Wilfred B.

Waters ton, Jane Elizabeth.
Watson, George A.

Welsh, Darid A.

West, J. T.

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

Williamson, A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, Dayid James.

Wright, Alexander, W. O.
Yeates, Thomas.

Yeoman, John B.

Young, D. P.

Younger, Henry J.

Zimmer, Carl Raymond.

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

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

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

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

5 To whom the Gaskell Prize (1895) was awarded.

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

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

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

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

Digitized by v^,ooQLe

Digitized by

THE

JOURNAL OF MENTAL SCIENCE

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

No. 204 [ToX”] JANUARY, 1903. Vol. XLIX.

Part I.—Original Articles.

Some Mew Features in the Intimate Structure of the
Human Cerebral Cortex. By John Turner, M.B.,
County Asylum, Brentwood, Essex.

The new features are—(1) a beaded network which
envelops the pyramidal cells of the cortex cerebri, and which
has not hitherto been observed in human brains, but only
around the nerve-cells of some of the lower animals (guinea-
pigs and rabbits) when subjected to the influence of methylene
blue injected into the tissues during life ; and (2) an inter¬
cellular plexus of extremely fine fibrils which has, I believe,
never before been actually demonstrated in any brains, human
or otherwise.

The method by which I am able to show these structures
was originally described in part xci, autumn, 1900, of Brain
(pp. 524—529). This was only a short preliminary notice,
and was followed by a fuller account in the summer number,
1901, of the same journal. But, previous to the appearance
of this paper, I gave a microscopical demonstration at a
meeting of the Neurological Society in May, 1901.

The method consists in staining pieces of cortex as they are

XLIX. 1

Digitized by v^.ooQLe

.2 STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

taken from the cadaver in a mixture of methylene blue (i per
cent.) and peroxide of hydrogen (i o per cent .)—four parts of
the former to one part of the latter. They are kept in this mix¬
ture from seven to ten days, and then fixed in io per cent.
of molybdate of ammonium, thoroughly washed, dehydrated,
soaked in xylol, embedded in paraffin, and cut.

In the second of the papers to Brain I laid great stress
upon the influence of light on the success of the stain, chiefly
because all, or nearly all, my successes occurred during the
summer-time. I now believe, however, that this idea is quite
erroneous, and that light has no influence at all on the reaction.
I have obtained a successful result in tissue kept in a dark
cupboard all the time it was in the staining fluid. The
successes were probably due to some slight decomposition
changes in the tissue, which would be facilitated by warm
weather.

It must not be supposed from this term that I use material
which presents any gross alteration of a decomposition nature,
or which can in any way be characterised as decayed. I am
referring to a supposititious delicate chemical change manifested
in some cases during the process of decomposition, which allows
the tissue to react in this characteristic way to the stain, and
which sometimes occurs shortly (7 hours) after death, and
perhaps sometimes (in septicaemic cases) even before death.
The delicacy of this change is shown by the fact that whilst
one part of a small piece of material will take on the stain
beautifully, contiguous parts often fail to react at all.

In the successful sections we meet with no obvious altera¬
tions in the contour of the nerve-cells, and in most cases the
fixation is so perfect that absolutely no trace of a pericellular
or perivascular space exists.

I have carried out a number of trials with tissues put into
the staining fluid at different intervals after death, and these,
although not decisive, on the whole bear out this contention ;
but not all material will give the reaction, however long after
death it is kept, before being put into the stain. Some of my
best results were obtained with the brains from cases of recent
and acute insanity, in which, in all probability, no demonstrable
structural alteration of the nervous matter had occurred.

I have made many trials with the brains of dogs, cats,
kittens, guinea-pigs, doves, etc., but have so far only succeeded

Digitized by v^.ooQLe

1903-]

BY JOHN TURNER, M.B.

in getting slight indications of the reaction in a cat’s brain, and
in a two-months-old pup, kept forty-six hours after death
before staining; in the latter the thorny processes of the Purkinje
cells showed faintly, but unmistakably.

The great delicacy of the reaction is indicated by the fact
already mentioned of the selection of the stain for individual
parts of the piece of tissue ; and further, while sometimes
one part of a cell stains faintly, the remainder colours quite
darkly. Apparently with certain chemical changes in the tissue
the pyramidal cells, which usually stain very lightly, tend to take
on a dark colour, and in these cases their dendrites can be
followed for considerable distances, and the picture has a
resemblance to a Golgi preparation. To some extent my
method is the complement to Golgi’s, for whereas this picks
out par excellence the pyramidal system of cells, mine, as a
rule, almost entirely neglects these, and especially selects other
cells, which I have termed “ dark cells,” on account of their
affinity for the stain.

In this paper I shall deal almost entirely with the cerebrum;
only a passing reference will be made to certain points in the
intimate structure of the cerebellum, where these serve to con¬
firm results obtained in the former.

The following are the points I shall treat of in the order
named :

1. The pericellular network.

2. The differentiation of cells into pale and dark varieties.

3. The origin of the network from dendrites of the dark cells.

4. The junction also of collaterals with the network.

5. The intercellular plexus.

The Pericellular Network .

This structure has been seen around the nerve-cells of some
of the lower animals by means of Ehrlich’s “ intra-vitam ”
method of staining, but I was the first to show it in the human
brain. Ehrlich’s method, however, does not bring out so much
detail as mine, and does not, I believe, reveal the network and
its appendages in their entirety, so that the accounts drawn
from tissues stained by the “ intra-vitam ” method are wanting,
in accuracy at least, when applied to the structure seen about
human nerve-cells.

Digitized by v^.ooQLe

STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

Drs. W. Aldren Turner and W. Hunter(i) give a careful
description of it, as observed about the cells of rabbits, guinea-
pigs, etc.

From their account, and the stress they lay on the fibril
passing to join the network, which they term the cellulipetal
fibre, it is evident that they look upon the network as a closed
sac drawn over the cell body, as it were, and resulting from the
ramification of a solitary nerve-fibril; but such a conception, at
least in the human brain, is very far from representing the
facts of the case.

The network in man consists of fine dark fibrils, on which,
at varying distances, are small dark beads, or sometimes rings,
which, as a rule, are the nodal points of the meshes. The
beads vary considerably in size, the average being about I /u.
The size of the mesh and the coarseness of its fibrils also
differ, so that, while sometimes one meets with a big-meshed
net, having consequently relatively few beads, and with very
delicate fibrils, at others the beads are larger, very closely
clustered together, or even partially coalescing, and the fibrils
much coarser.

It extends not only over the cell body, but over the apex
and dendrites, and in one case I have been able to trace it for
over two hundred micro-millimetres along the dendrite of a
Betz cell. It does not appear to invest the axon at all.

Now in contradistinction to the description of it drawn from
the lower animals, it is emphatically not a closed sac having
its origin from a single fibril. Multitudes of delicate branches,
like free tags, can be seen on all sides passing to the beads of
the network, not only over the cell body, but to that part of
the structure which envelops the apex and the dendrites.
These fine fibrils can often be traced back to thicker ones,
which in many cases must come from manifestly different
sources. This is an important fact, because it shows that the
network is in continuity with more than one cell of origin.

Another point to be noted is that practically the same net¬
work often extends over two adjacent cells.

This structure is obviously a pericellular one, and I do not
think it will be necessary to enter into a discussion as to its
possible neuroglial origin in face of the facts which I shall bring
forward, viz., that I can demonstrate its direct origin from the
dendrites of the dark cells, and there can be no question that

Digitized by v^.ooQLe

1903-]

BY JOHN TURNER, M.B.

these are nervous, as their axis-cylinders can be identified ; and
secondly, I can also demonstrate that collaterals blend with the
network.

It has been previously assumed that it is an offshoot from
axis-cylinders of the pyramidal cells ; that, in fact, it represents
the arborisation of a collateral from one pyramidal cell breaking
up around the body of another. This idea is not altogether
correct, for although collaterals do certainly make union with
the network, there is no evidence to show that they are directly
concerned in the formation of this structure ; while on the other
hand I can show, in several instances, its direct origin from the
ultimate splitting up of the dendrites from the dark cells.
Even before the actual demonstration was arrived at, the
remarkable similarity between the beaded fibrillae of the net¬
work and those obviously proceeding from the dark cells
rendered this assumption almost a certainty. Axis-cylinders
and collaterals, as I shall point out later on, in as far as they
are represented by my method, do not show beads or vari¬
cosities on them.

So far as I am able to determine at present this network is
only met with over cells of the pale variety, i. e . the pyramidal
cells. It can be seen over these in all the layers where they
are met with except the second layer, and probably the inner¬
most, or layer of spindle-cells, and I think that in all proba¬
bility it envelops these also, but unfortunately they lie in parts
which do not take on the reaction to the same extent as the
middle layers ; at the most one sees here and there a dark cell
picked out in the lower part of the second layer.

Taking for granted, then, that the network is a nerve
structure, its presence all along the dendrites is evidence that
these parts are concerned in the conduction of nervous impulses,
and are not merely, as Golgi and others think, roots having
only a nutritional value to the cell. On this point I think that
the demonstration of the dendritic origin of the network will be
sufficient of itself to dispose of this idea.

Thoms .—Before leaving these pale network-enveloped
pyramidal cells I wish to make a few observations on the
occurrence of the so-called “ thorns ” or “ gemmules ” with
which their apex and dendrites are studded when prepared by
Golgi’s method.

Dr. Alexander Hill (2) believes that these structures are

Digitized by v^.ooQLe

STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

formed by the overflowing from the cell-plasm of a softer
staining substance along the course of fibrils which the method
of Golgi does not reveal. And as his remarks on the appear¬
ances sometimes shown by the thorns are highly suggestive, from
my point of view, of the part which the beaded network plays
in their production, I shall quote them :—“ Sometimes the
thorns appear as rods with knobs at their ends (gemmules).
Sometimes one dot or several dots are seen unconnected with
the dendrite, but so placed as to indicate that they have been
led into position by an invisible fibril. Occasionally the thorn
is replaced by a filament of considerable length.”

There has always been a strong feeling with some that these
little bodies were artificial, and probably produced by deposits
of silver along the protoplasmic processes. When, however,
Ramon y Cajal (3) announced in 1896 that he had been able
to demonstrate them by methylene blue on cerebral cells, the
view of their natural origin was strongly reinforced, and they
received notice in the text-books.

With all due deference to the opinion of such a distinguished
observer, I suspect, in view of the facts which my method shows,
that these thorns are, strictly speaking, of artificial production
in the case of the pyramidal cells of the cerebrum. I am
inclined to believe that they are not intrinsic parts of the cell
at all, but belong to the network, and represent deposits of
silver about the beads and numerous fibrils, which, as I have
stated, pass off from all parts of the network in great numbers.

It may be considered that this is a somewhat presumptuous
statement to make, as I have already said that my method
practically neglects the staining of the pyramidal cells. This
is so as a rule, but with some conditions, the nature of which
we do not understand, and which are accompanied by altera¬
tions in their chemical structure, these pyramidal cells here
and there stain deeply, and so also do the antler cells of the
cerebellum. And when this state of affairs is present the latter
show most beautifully numbers of little lateral projections along
their dendrites, whereas the pyramidal cells never do ; their
dendrites certainly do on these occasions show an irregular and
somewhat shaggy aspect, but I think that this appearance can
be much more satisfactorily explained as due to the beads and
fibrils surrounding the dendrites than as representing an integral
portion of the dendrite itself, and they unquestionably show no

Digitized by ^.ooQle

BY JOHN TURNER, M.B.

1903 ]

resemblance to the crowds of little projections seen regularly
arranged alongside the branches of the antler cells.

I am well aware of the risks one runs in arguing from
negative appearances, as it were, in cerebral microscopical
anatomy, but I think that when a method under certain con¬
ditions shows structures plainly in one part of the nervous
system, one is at least justified in being sceptical about the
existence of these structures in other parts when they do not
appear.

Ramon y Cajal does not appear to have demonstrated thorns
on the Purkinje cell branches with methylene blue—at least
I can find no reference to such an observation,—and they are
not alluded to in the last edition of Quain’s Anatomy as
occurring here, just in the place where, as I can show, they
almost unquestionably exist as intrinsic parts of the cell
structure.

The Dark Cells .

The second feature to be noticed is the differentiation by
this method of the cortical cells into two classes, viz ., those
which stain of a very pale blue colour, often almost colourless,
and those which stain very deeply, nearly black.

The pyramidal cells and the giant cells of Betz belong to
the first class or pale variety, and the other consists of cells
scattered irregularly throughout the cortex. It is quite
remarkable the sharp distinction which the same staining fluid
draws between these two classes of cells. This marking off of
the cells is maintained in the molecular layer of the cerebellum ;
in that organ the antler cells are the pale ones, whilst the
basket and small cortical cells are the dark.

In both cerebral and cerebellar cortex, however, occasionally
the pale variety tends in places to stain deeply, but it is seldom
that they approach the dark colour of the other variety.
Sometimes this alteration affects only a part of the cell, so that,
whilst the apex and dendrites may be dark, the body may be
pale, or sometimes one portion of the body will be dark and
the remainder light. This alteration, as already mentioned,
seems to depend on some delicate chemical change, often, but
not of necessity, accompanying pathological conditions.

Besides the difference in staining affinity, there are other
points of distinction between the two kinds of cells.

Digitized by ^.ooQle

8 STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

a . The pale or pyramidal cells are definitely orientated.
The dark are not; they lie in any direction, and sometimes, as
will be referred to later on, their axis cylinder arises from the
surface aspect and sometimes from the lower border. This
lack of orientation is particularly well shown among the dark
cells of the cerebellum.

b. Size and shape .—Generally speaking, they are smaller
than the pale, and many of them are quite minute and easily
overlooked under low powers (quarter inch). Some, however,
reach a relatively large size, almost as big as a medium-sized
pyramidal cell. They are of diverse shapes—round, oval,
polygonal, and triangular—and in the frontal cortex I have
met with a number which are very long and slender, spindle
shape.

c. Position .—They occur with certainty from the lower part
of the second layer inclusive down to the commencement of
the innermost layer of the cortex. I am not able to speak of
the other layers, as the reaction does not take place in these.

d. The largest number of them are seen, roughly speaking,
at the junction of the outer and middle third of the cortex.
In a comparison between frontal, ascending frontal, and
occipital cortex, which are the three regions I have chiefly
examined, they seem to be least numerous in ascending frontal.
Both frontal and occipital contain many more, but I am not
certain in which of these two they are most numerous.

In the frontal besides the spindle variety we meet with
large numbers of small, often angular, cells, and in the occipital
chiefly with small rounded or pentagonal ones, and here they
seem to be most thickly clustered about the layer of small
granule cells, either just above it, within it, or just below it.

e. Nucleus .—This stains even darker than the cytoplasm,
and appears as a homogeneous body, and not granular like the
nucleus of the pale variety.

f. Axis cylinder .—This is easily recognised, and the descrip¬
tion given of it applies also to the axis cylinder of the pale
cells. It has a perfectly smooth contour, and is generally at
its origin disposed in somewhat sharp twists reminding one of
a corkscrew. At its commencement it stains deeply, but at a
little distance from the cell it gradually loses its colour and
appears as a very pale blue or grey fibril. When it can be
followed for any distance it shows here and there dark areas

Digitized by CjOOQle

1903]

BY JOHN TURNER, M.B.

of several ft in length. At these sites it is sometimes slightly
swollen, at others shrunken; very often from these parts
branches are given off—generally, but not always, at right
angles to the parent stem. In some preparations these axis
cylinders and collaterals can be seen in large numbers and
traced for very long distances ( e.g, 600 /1), but they never, so
far as I have observed, show any beads along their course.

I take it that the pale fibre is myelinated, and that the dark
areas referred to represent the sites of nodes of Ranvier.
Although the above description applies to myelinated fibres,
yet a study of the axis cylinders of the basket cells of the
cerebellum, which are not myelinated, and which stain deeply
throughout their course, confirms the observation that axis
cylinders and collaterals by my method do not show beads or
varicosities.

g. Dendrites .—The main protoplasmic branches have gene¬
rally a shaggy aspect, and are usually given off from the body
of the cell abruptly, not passing off, as it were, by insensible
degrees like the apical process of a pyramidal cell. They
divide at somewhat infrequent intervals, and the branches can
often be followed a very long distance without any sensible
diminution in calibre, which is a point in marked contrast to
the axis cylinder, which very rapidly dwindles to a small fibril.
The finer (ultimate) branches of the dendrites are always
beaded. Although I have just stated that the branches divide
at infrequent intervals, yet apparently, all along their course,
quite fine threads pass off nearly at right angles from the
bigger branches along which they are closely set ; these,
together with the terminal fine-beaded fibrils just alluded to,
form a dense inter-cellular plexus which pervades the entire
matrix of the grey matter wherever the staining is successful.

The Origin of the Network from Dendrites of the Dark Cells .

I have been able in several instances to trace the actual
passage of one of the finer branches of a protoplasmic process
of a dark cell into a network, of which it evidently forms an
integral part.

In one case a stout dendrite, proceeding from a dark cell,
terminated in a triangular-shaped mass, from the base of which
two delicate branches proceeded ; one of these again widened

Digitized by v^.ooQLe

IO STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

out into a triangular shape, and gave off from its base two
more threads which terminated in beads, the whole structure
manifestly forming part of a network over a pale cell. This is
Very clearly shown in the figure, page 13. The dark cell, from
which the dendrite passing to the network proceeds, is not in the
picture. From the base of its terminal triangular mass two
delicate fibres proceed. One is out of the plane of the photo¬
graph ; the other is shown, passing down to end in another
triangle, from which two fibres ending in beads pass off. The
body of the pale cell is scarcely shown, but its dark prominent
nucleus and the beaded fibrils around indicate its position.

Sometimes a comparatively stout dendrite blends directly
with a network ; sometimes a stout fibre courses up alongside a
pyramidal cell, and gives off at intervals extremely fine fibrils
to supply the network.

The Junction of Collaterals with the Network .

This is another feature which can be clearly shown. The
appearances by which myelinated axis cylinders can be
recognised have been previously mentioned, and in some
sections very large numbers of extremely fine axis cylinders
and collaterals can be seen, but they require very careful
looking for, as they are by no means conspicuous objects,
owing both to their small size and to the fact that except at
the nodes they stain very faintly.

Fig. 2 shows a collateral blending with a network. The
axis cylinder passes across the upper part of the picture, and
at the dark nodal area near its centre gives off a short collateral,
which fuses on to the darkly-stained network around a pyra¬
midal cell, whose outline is roughly indicated by beaded fibrils.

As this collateral remains pale till its junction with the dark
fibril, it probably retains its myelin sheath up to this point.
In another case the axis cylinder or collateral could be followed
for some considerable distance before its junction with the net¬
work ; its origin was not in the field of section, and there were
no beads on it. From what cells do these axis cylinders
come? It seems most probable from the pyramidal, because,
as already shown, it is from the dendrites of the dark cells
that the network arises, and union of their axons also with this
structure would result in short circuiting.

Digitized by v^.ooQLe

1903 .]

BY JOHN TURNER, M.B.

I I

If, then, they come from the pyramidal cells, and the
unions are not exceptional cases, the unavoidable implication is
that these cells also, by a round-about route, are in organic
continuity with each other.

Inter-cellular Plexus .

I shall now proceed to give a somewhat fuller account of the
inter-cellular plexus, which has already been briefly referred to.
It seems probable that Golgi’s method does not show it at all;
at any rate, if it does it gives no means of discriminating it from
the mass of other details shown.

Again, as the method in question fails to show the network,
and as the inter-cellular plexus is essentially a part of this
structure, this seems another reason why it should not be
revealed by this process.

Golgi’s cells of Type 2 have particularly shaggy dendrites.
It is from these cells, among others, that the plexus arises, and
I imagine that it is at these shaggy points that the chief
number of the fine fibrils forming the plexus are given off, and
just here, apparently, the silver stain fails, for it shows no
further indication of a fibre.

Long ago Gerlach (4) postulated the existence of a diffuse
net or felt-work in the grey matter which resulted from the
ultimate dendritic branchings of the nerve-cells, and from which
originated nerve fibres, which became meduilated and (speaking
of the spinal cord) formed the dorsal nerve roots. Gerlach’s
view, therefore, quoting Barker (5), was that “ the axis
cylinders of motor nerves represent nervous processes coming
off directly from nerve cells, while the sensory fibres of the
dorsal roots are to be looked upon as nerve fibres arising from
nerve cells only indirectly, through the intervention of a diffuse
network made up of their protoplasmic processes.”

More recently Golgi (6) has supposed the existence of a
delicate and intricate inter-cellular network, differing, however,
widely from Gerlach’s conception. This observer denies to the
cell body any participation in the passage of nerve currents ; he
believes that the functions of the nerve-cells and their dendrites
are purely nutritive. The nerve currents, according to him,
pass solely along axis cylinders and their collaterals. He
describes two types of nerve-cells, of which Type 1 is motor
and Type 2 sensory in function. Now, the axis cylinders of

Digitized by v^.ooQLe

12 STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

Type 2 divide and branch in the most profuse manner, and he
believes that a dense network results in the grey matter from these
diffuse branchings and from the collaterals of cells of Type i.

Nissl (7) has, within the last few years, also brought for¬
ward, on purely circumstantial evidence, the view that there is
a dense extra-cellular fibrillary structure, which indeed consti¬
tutes, in his opinion, the essential difference between grey and
white matter. His view, based largely upon the work of
Apdthy and Bethe, is that this felt-work comes directly from
the nerve-cells.

Apparently, so far as I can gather, the fibrils of this extra¬
cellular plexus are assumed to be continuous with the fibrillar,
of which some observers consider the axis cylinder to be
formed, and these fibrillae, running uninterruptedly through
the nerve-cell in the unstainable substance, leave it by way of
the protoplasmic branches to form the extra-cellular plexus.
Nissl admits that at present this supposed structure is quite
undemonstrable.

The idea, therefore, of a plexus of nerve fibrils pervading
the grey matter has been very generally in the minds of
neurologists for many years past, but they have hitherto not
been able satisfactorily to demonstrate it.

Now, my method very clearly reveals an extremely dense
plexus of delicate, beaded nerve fibrils ; indeed, so dense is it,
and so fine the individual fibrils, that in successful preparations
it gives to the grey matter, when viewed with a low power, an
indistinct or slightly blurred appearance.

The fibrils of which it is composed are so extremely delicate
that they are barely visible with a magnification of 800
diameters, and although they intersect each other in all direc¬
tions there are certain appearances which indicate that they do
not form a network but only a felt-work, by which I mean that
although the fibrils overlap each other they are not joined
together at the overlapping points. It is possible, as a rule,
when two fibrils intersect, to bring one quite clearly into focus,
and thereby fling the other out. Again, it is not at all an
uncommon thing to be able to follow an individual fibril for a
very long distance—several hundred /u—and these throughout
their course give no indication of being connected with any others.

Although this plexus is so exceedingly fine, it is capable of
being fairly satisfactorily photographed, but of course such a

Digitized by ^.ooQle

JOURNAL OF MENTAL SCIENCE, JANUARY, 1903.

Fig. 1. -Shows a dendrite dividing terminally to form part of network
over a pale cell, (x 1,360.)

Fio. 2.--Shows collateral making union with network over a pale cell.

(x 1,380.)

To illustrate Dr. John Turner’s paper.

Hole and Daniehson, Ltd.

Digitized by

Google

Digitized by

BY JOHN TURNER, M.B.

I903-]

procedure will give us but a poor idea of the wealth of fibrils
concerned, as it necessarily includes those only in one plane.

The fibrils can frequently be traced directly into the network
over the pale cells, and where they join there is a bead or
thickening, so that there can be no doubt that the inter-cellular
plexus and the network form parts of one continuous structure.
But the fibrils of the plexus can also, without doubt, be traced
to the dark cells, of which they form the ultimate extensions of
their dendrites.

No doubt among the myriads of fibrils met with are also
many fine collaterals, which one may have a difficulty in dis¬
tinguishing from the others, especially if not myelinated ; but
I think that unquestionably the great bulk of the plexus is
formed in the manner above described.

Thus it is apparent that the inter-cellular plexus I can
demonstrate differs essentially from either that conceived by
Gerlach, Golgi, or Nissl, inasmuch as it is not a derivative of the

pyramidal cells at all, but results from the dendritic branchings
of an entirely distinct system, vis ., the dark-cell system.

The accompanying diagram shows clearly the points that

Digitized by v^.ooQLe

14 STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

can be demonstrated by my method and which are directly
opposed to the current idea of the relationship which the
nerve-cells are supposed to bear to one another. The pyra¬
midal cell (a) (representing my pale-cell system) is invested
by a beaded network which extends over its processes as well.
The network is practically an extension of the dendrites of the
dark cells (b b). One of these latter cells is shown with an
axon passing upwards, the other with an axon passing down¬
wards, and both give off collaterals. It will be observed that
the dark cells are organically united to each other by means of
the network.

Many other fibrils are represented springing from the net¬
work, and these, of course, represent the termination of dendrites
from other dark cells not shown in the diagram.

A short collateral (d) passing off from the axis cylinder (c)
also makes union with the network. The cell to which (c) be¬
longs is not shown in the figure, because I have not yet
succeeded in tracing one of the collaterals or axis cylinders
which join the network to their cell of origin, but in all proba¬
bility they are given off by pyramidal cells.

Conclusions.

Showing some of the bearings of these observations on the current
ideas of nerve structure.

The bare facts which I can demonstrate must, whatever
interpretation we may put upon them, lead to considerable
modification in our views of the structure of the brain cortex.
For, in the first place, they show that there is a distinct
system of cortical cells which, by means of the ultimate branch¬
ings of their dendrites, are in organic continuity with each
other through the medium of a peri-cellular network enveloping
the pyramidal cells.

And secondly, they show that collaterals also blend with the
network, so that if these collaterals arise from the axis cylinders
of pyramidal cells, which in all probability they do, and this
union is not an exceptional occurrence, this implies that in a
round-about fashion the whole pyramidal system of cells is also
joined together, and that therefore practically all the cortical
cells are in continuity with one another.

Digitized by v^.ooQLe

1903.]

BY JOHN TURNER, M.B.

Time will not permit of more than a passing reference to
the views of other investigators which tend to a similar con¬
clusion, but I shall mention Dr. Alex. Hill’s (8) observations
on the fusion of the axis cylinders of the granule cell of the
cerebellum with one another, and also Held’s (9) observations
on the blending of axis cylinders with the bodies of other cells,
which he has described as occurring in the nucleus of the
trapezoid body—a fusion which he terms “a zone of con¬
crescence.”

Such observations all tend to show that the rigid concep¬
tion of each nerve-cell and its processes as a separate entity
having no direct connection with other cells (the neuron
theory) must be abandoned or greatly modified. I am speak¬
ing now of the doctrine of the neuron as formulated by
Waldeyer, and which insists on an anatomical independence of
cell units. I see that Dr. Mott, in a paper recently read
to the Medico-Psychological Association (“ Importance of
Stimulus in Repair and Decay of the Nervous System,” Journal
of Mental Science , October, 1902), does not now insist on an
anatomical independence, but on a trophic or nutritional, and
yet, curiously enough, in another part of the same paper he
quotes with approval the experiments of Dr. Warrington,
which, if confirmed, show that cells have no such trophic inde¬
pendence. For Warrington shows that if you cut off one
system of cells which is in physiological and functional con¬
nection with another, the latter is affected and its cells die.

With regard to the interpretation to be placed upon such of
my observations as admit of discussion, I would suggest
that the difference in staining properties, shape, etc., points to
a difference in function, and as we have very good grounds for
associating motor functions with the pale or pyramidal system,
that the probabilities are that the dark cells are concerned with
sensory functions; in other words, that they are the bearers of
afferent stimuli.

If this be allowed, then it follows that we can by this
method very distinctly show the ultimate termini of the
afferent stimuli—the site where ingoing currents end and
where outgoing currents are initiated—and this, of course, will
be at the network and its contained cell.

In my second paper to Brain I pointed out that whilst
in the cerebral cortex the pale cells far exceed in number the

Digitized by

Google

16 STRUCTURE OF THE HUMAN CEREBRAL CORTEX, [Jan.,

dark, in the cerebellar cortex an opposite condition exists, and
I mentioned how well this fact harmonised with Herbert
Spencer’s conception of the cerebrum as the great organ for
the co-ordination of movements in sequence, and of the cere¬
bellum as the organ for the co-ordination of movements in
simultaneity. But if we may assume that the dark cells are
conductors of afferent stimuli, it follows also that nerve currents
do not invariably flow in one direction, viz., from the dendrites
towards the cell body and thence outward by its axis cylinder,
a view which is very generally held. The current must flow
to the dark cells by way of their axis cylinders, and from
thence to the network by way of the dendrites, whilst in the
pyramidal system, of course, it will pass % in a reverse direction.
But inasmuch as it can be shown without doubt that certain
of the dark cells of the cerebellar cortex envelope the bodies
of the antler cells with a basket arrangement formed by the
splitting up of their axis cylinders or collaterals, then, if these
cells also form part of the afferent system, in them the current
flows in a reverse direction to what it does in the rest of
the cells of this system.

Such conclusions may not seem satisfactory, but we must
remember that the upholders of the one-way doctrine have
equally awkward facts to face, viz., in the case of the cells of
the posterior spinal ganglia. These, as is well known, are uni¬
polar cells, and the single process divides by a T-shaped
junction not far from the cell. Now this process has all the
characters of an axis cylinder ; above all, it is myelinated.
And yet, to meet the requirements of the advocates of this
theory, we are asked to believe that one half of the T-shaped
process is not an axis cylinder at all, but a dendrite, which, in
this solitary instance, has taken on all the anatomical pecu¬
liarities of ah axis cylinder.

These suggestions are, however, only tentatively offered, for
inasmuch as my method fails to display any of the complicated
structures which we have good reasons for supposing are con¬
cerned in the formation of the pyramidal cells, and in the face
of the important results obtained by Apdthy (io) and others in
leeches, which show a most complicated system of fibrils per¬
vading the whole nervous system and apparently passing un¬
interruptedly through the nerve-cells, it will be well for the
present to keep an open mind on many points concerning the

Digitized by v^.ooQLe

1903]

BY JOHN TURNER, M.B.

intimate relationship of the cells to one another. But, however
much we may feel induced to apply conclusions drawn from
such lowly organisms to those so much higher in the scale, we
must, of course, give the chief place in our consideration to
observations actually made on human brains, and however per¬
plexing and difficult it may at present appear, yet these con¬
clusions from invertebrates must be made to harmonise with
details of structure demonstrable in man before they can be
accepted as applying to human cerebral anatomy.

In the discussion which followed the demonstration of my
specimens at the British Association meeting, Professor Schafer
said he was satisfied as to the general accuracy of my facts, but
dissented from some of the interpretations put upon them, e.g .,
in reference to conduction both ways along cell processes, he
did not agree that there was sufficient justification for looking
on the dark cells of the cerebrum and the cerebellum as similar
in function. He referred to the fibres coming from the
thalamus, which Golgi’s method shows with free endings in the
cortex in proximity to the processes of the pyramidal cells, and
suggested that stimuli from these fibrils might excite not only
the pyramidal cell, but at the same time the dark cells by
means of the network ; and he suggested that the dark cells
represented a system conveying stimuli in the same direction
as the pyramidal system, vis., from the dendrites to the axons,
and about the functions of which we knew nothing whatever.

Many objections can be urged against this view. Apart
from the inadvisability of introducing a system of cells into our
conception of the structure of the cortex, about the functions of
which we are ignorant, it is difficult to conceive of the efficacy
of a stimulation so vague and dispersed as would result from the
excitation of this system in the manner which Professor Schafer
suggests. Admitting, as he does, that the dark cells are joined
together through the medium of the network, an excitation
applied to this structure in the above manner would only result
in a diffuse stimulation extending in all directions along the
fibres of the inter-cellular plexus, over an area proportional to
the strength of the stimulus, and could not affect any one
particular cell or group of cells.

The very accurate adjustment of the network to the pyra¬
midal cell and its dendrites points strongly, I consider, to this
structure being concerned in the excitation of its enclosed cell.

XLIX. 2

Digitized by v^.ooQLe

18 STRUCTURE OF THE HUMAN CEREBRAL CORTEX. [Jan.,

The meaning of such a disposition of the network is, according
to Professor Schafer’s view, difficult to perceive.

Although in its scope my method at present falls far short
of the Golgi method, yet in the particular regions where it
succeeds it reveals far greater detail and delicacy of structure.

I believe that wherever Golgi’s method shows us collaterals
or axons ending in proximity to dendrites of pyramidal cells,
we must go a step further and presuppose the existence of an
actual junction with a network, neither the connecting fibril nor
the network being shown by Golgi’s method.

The assumption that stimuli pass only in one direction along
cells and their branches, rests, so far as I know, on purely
anatomical considerations. Such physiological evidence as we
have, although perhaps not conclusive, appears to show that
stimuli pass both ways. Thus long ago Kiihne’s experiment
with the gracilis of the frog demonstrated the passing of stimuli
both ways, and more recently Budgett and Green (American
Journal of Physiology , 1899, iii, p. 115) have succeeded, after
section of the left vagus above its ganglion, in joining it to the
peripheral cut end of the hypoglossal. When such a prepara¬
tion, two or three months after the operation, is excised,
together with the tongue, excitation of the peripheral end of
the vagus causes the tongue muscles to contract, showing that
stimuli can pass up the vagus to take effect on the tongue
muscles.

References.

1. W. Aldren Turner and W. Hunter, ‘A Form of Nerve Termina¬
tion,’ Brain } Spring No., 1899.

2. Alex. Hill, 1 Anatomy of Central Nervous Organs,’ 2nd Edit., p. 155.

3. Ramon y Cajal, 4 Las Espinas Colaterales de las celulas del
Cerebro Tenidas por el Azul de Metileno,’ Revista Trimestral Micro -
gr&fienj Madrid, vol. i, fasc 2 y 3 ; Agosto, 1896, pp. 123—136.

4. J. Gerlach, ‘ Human and Comparative Histology,* Strieker N. S. S.
translation, 1872.

5. Barker, L. F., ‘ The Nervous System,’ 1900, p. 7.

6. Barker, L. F., Ibid, pp. 14 and 15.

7. Nissl, F., 4 Nerven zellen und graue Substanz, Munch, med. Wchn.-
schr., Bd. xlv, s. 988, 1023, 1060. (My account is taken from Barker,
4 The Nervous System,’ pages 96 to 99.)

8. Alex. Hill, 4 Considerations opposed to the 44 Neuron Theory,” ’
Brain , xxiii, 1900, pp. 657—688.

9. Held, H., from Barker, • The Nervous System,’ pp. 48—50.

10. S. Apdthy, Ibid, pp. 52—65.

Digitized by v^.ooQLe

1903-]

INSANITY IN IMBECILES.

Insanity in Imbeciles. By A. F. Tredgold, L.R.C.P.Lond.,
M.R.C.S.Eng., formerly London County Council Research
Scholar in Insanity.

INSANITY is rarely met with in the more pronounced grades
of amentia. In the milder degrees of imbecility, however, such
a complication is far from being infrequent, and out of over
200 imbeciles whom I examined in the asylums of the London
County Council considerably more than half had at one time
or another been insane. Of course it is impossible from these^
figures to deduce the actual proportion of all imbeciles liable
to be so affected, but they sufficiently attest the frequency, and
therefore the importance, of this condition. The exceedingly
scant attention which the subject has received in this country
is a further excuse for the following remarks.

The general characteristics of these higher-grade imbeciles
are too familiar to necessitate any description here, but it may
be remarked that an excellent indication as to the existence of
a mild degree of amentia is furnished by the history of the
progress, or, rather, want of progress, during school life. It is
one of the commonest things to hear the mothers state that
“ he could never learn at school,” and it is the rule to find that
these children have not passed beyond the third, second, or
even the first standard, arithmetic in particular being a great
stumbling-block. In addition, they may have been late in
learning to walk and talk, and dentition and development
generally have been delayed ; also in a considerable number
of them well-marked stigmata of degeneracy are present.

But although all the cases of insanity in imbeciles that I
have hitherto seen have been in those of high or medium
grade, it by no means follows that all high-grade imbeciles
are liable to be so affected. In them, as in individuals of
normal development, a special predisposition appears to be
necessary, the presence of which is, as a rule, easily recog¬
nisable.

It will nearly always be found that those imbeciles who
subsequently become insane have for some years before the
actual outbreak been prone to sudden fits of irritability, “ bad
temper,” moroseness or sulkiness, often accompanied by acts of
violence ; or that they have been in the habit of wandering

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

away from home, in many instances being brought back by
the police ; or they have evinced a restless disposition, making
it impossible for them to settle down to any kind of employ¬
ment. Indeed, from a very early age these patients have been
a source of endless worry and anxiety to their friends and
relations, or, should they have been in an institution, to the
attendants and other inmates. Such characteristics are by no
means typical of all higher-grade imbeciles, many of whom are
placid, harmless, and industrious to the end of their days, and
although their mental deficiency renders it impossible for them
to make any headway, they are, nevertheless, capable of
useful employment, and in many cases of earning their own
living. Neither can such conditions be well described as
insanity, though they are, I believe, the shadow of the coming
event, being evidence of that special predisposition which will
sooner or later terminate in insanity. Perhaps the best term for
it would be mental instability, and the higher-grade imbeciles
may therefore be divided into the two groups of mentally
stable and mentally unstable .

This instability appears to me to be by far the most im¬
portant factor in the causation of insanity in these patients,
and exciting causes seem to play but a minor part. It is true
that in some cases the latter may act as contributory factors,
[e. £*., alcohol, religious or other forms of excitement, or a severe
fright causing great emotional disturbance], and help to hurry
on the attack which was only threatening ; but at the most
they only bring matters to a crisis somewhat earlier, and in
many cases are entirely absent. I would say that, given a
high-grade imbecile whose mental condition is unstable, the
chances of his passing through the third decade without
becoming insane are very small indeed. Could the education
of such an individual be more carefully supervised and better
adapted to his capabilities from a very early age, and could
his youth and adolescence be passed in an orderly and
systematic manner, devoid of the bustle incident to the daily
life of most of the poorer classes, it is possible that the attack
might be deferred, or even entirely prevented. As things are,
however, the first attack of insanity usually appears between
the ages of puberty and adolescence. Institution life of the
right kind, if begun sufficiently early, would probably do much
for these patients, and I have frequently found that even

Digitized by v^.ooQLe

1903.]

BY A. F. TREDGOLD, L.R.C.P.LOND.

where the surroundings are adverse the instability may be to
a certain extent controlled by a free use of the bromides.

As to the probable nature and cause of this instability, we
may obtain some light by referring for a moment to what is
known of the etiology and pathology of amentia. It is now
well known that amentia is the final manifestation of what may
be termed the neuropathic diathesis, and in an inquiry into its
etiology which I made two years ago ( l ) I was enabled to show
that in 90 per cent, of cases morbid hereditary influences were
present, and that these, in all probability, act by interfering
with the normal growth of the germinal plasm. If the
morbidity is very pronounced its effect upon the growing
embryo is extensive, upon the nervous system causing gross
amentia, upon the body generally causing the stigmata with
which we are all familiar. With a less pronounced morbid
influence, the normal development is less interfered with, and
the more specialised parts of the growing embryo, i.e. the
higher portions of the nervous system, are chiefly affected,
giving rise to a mild degree of imbecility.

The result of recent pathological research shows that the
degree of mental deficiency present during life is directly pro¬
portionate to the amount of change discoverable in the brain
under the microscope, and that, speaking generally, whilst the
brain of the idiot is characterised by a paucity of imperfectly
developed and irregularly arranged nerve cells and processes, in
that of the imbecile the cells much more nearly approach the
normal in both their number and degree of development, the
principal change being an irregularity of arrangement. Further,
in the milder degrees of imbecility the changes appear to be
almost entirely confined to the second and third cortical layers
(small and medium-sized pyramids), and to the frontal and
parietal regions of the brain ; in gross idiots imperfectly
developed cells are more noticeable in the same cell layers and
regions, but are also to be found throughout the entire brain ;
indeed, in some of these cases I have seen the cells of the
spinal cord affected.

There can be no doubt that the different degrees of patho¬
logical change which occur in these cases are the cause of the
great variations of mental capacity which exist in the various
types and degrees of amentia, and that, whilst the idiots
scarcely develop beyond mere automata, capable of little

Digitized by

Google

2 2 INSANITY IN IMBECILES, [Jan.,

beyond reflex action, the higher-grade imbeciles are possessed
of good perception, of memory, of emotion, and of ideation.
They are, however, deficient in the power of concentration, of
continued application, and of comparison, their appreciation of
their surroundings being therefore inaccurate, and their higher
faculties of deliberation, judgment, and control remaining un¬
developed.

We may therefore conclude from our clinical knowledge of
these cases, from histological examination, and from etiological
considerations, that in the higher-grade imbeciles the arrest of
development has involved more particularly or exclusively
what are called the " higher ” portions of the brain, and that
the lower faculties have attained a fairly normal development.
These lower faculties, however, require for their useful and
proper action to be constantly controlled and corrected by
those of a higher order, and when these latter are deficient the
equilibrium of the brain is unstable, and the various manifesta¬
tions of mental instability which have been described are very
liable to occur.

The faculties of ideation and emotion, which are usually well
developed in high-grade imbeciles, are especially in need of
this higher inhibitory action, since there can be no doubt that
the uncontrolled and uncorrected action of either of them may
seriously endanger the individual's sanity. It is therefore not
difficult to see how this condition of mental instability may
readily develop into a state of true insanity, the nature of
which will depend largely on whether the disturbance is of an
ideational or emotional type.

In one class of these imbeciles uncontrolled ideation can be
readily demonstrated. The original idea may be of the most
simple description, and the result of an impression received by
one of the ordinary sensory channels, or in some cases it may
be caused by an hallucination of sense (auditory or visual); but
since the patient is incapable, by reason of his mental
deficiency, of correcting or controlling the primary idea, it
rapidly assumes such dimensions as to entirely alter his mental
attitude towards his surroundings. Hence delusions result,
which may be of various kinds, as of identity, of persecution,
etc.; these may remain fixed or be subject to rapid change,
but their persistence soon brings about a condition of mania or
melancholia in most instances.

Digitized by v^.ooQLe

I903-]

BY A. F. TREDGOLD, L.R.C.P.LOND.

Thus in some of these cases of mild imbecility I believe that
the patients themselves are, to a certain extent, conscious
of their infirmity, and do not fail to notice that they are
somewhat neglected, put on one side, and “ of no use.” As a
result of this they acquire a habit of brooding over their fancied
wrongs, pronounced delusions of persecution soon follow, which
rapidly pass into a state of acute melancholia, in which they
may attempt suicide. It is very common to find this type of
patient complain that he has “ not had fair play.”

Delusions and hallucinations, therefore, figure largely in the
ideational type of insanity, and as a rule their presence is
easily recognised.

Uncontrolled emotional action is characteristic of another class
of imbeciles. I have already stated that emotional storms of a
transient nature are very common in many of these patients
for perhaps years before the actual outbreak of insanity, and it
is probable that such are very closely allied to true insanity ;
their short duration, however, renders it practically impossible
to certify these patients as lunatics at this stage. But in
course of time the outbreaks become more severe and pro¬
longed, until finally they may last for several weeks and present
every feature of acute mania or melancholia.

All the cases of insanity in imbeciles which I have seen
conform at first to one or other of these types, and they
therefore appear to be the direct consequence of the imperfect
development of the higher mental faculties, with its associated
instability. As already stated, however, many imbeciles are
of perfectly stable equilibrium, and in such I believe the
ideational and emotional faculties to be also imperfectly de¬
veloped, so that overaction in either of these directions does
not take place. It is certainly a fact that the unstable ones
are the brighter and more vivacious of the two.

In this connection it is interesting to consider for a moment
the insanity which is frequently present in association with
primary dementia. The physical basis underlying this con¬
dition has been demonstrated to be a degeneration of, inter
alia , the cells of the cerebral cortex, and although the process
varies greatly in rapidity it appears to be essentially the
same whether the disease is an acute degeneration, like
general paralysis, or a more chronic change, like senile
dementia ; in fact, many cases occur which are intermediate

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

between these two extremes, and which cause considerable
doubt to the pathologist and the clinician as to the class in
which they should be placed. For our present purpose it is
an unimportant matter whether this form of degeneration be
considered as primarily neuronic or primarily vascular, the
essential point being that it is a pathological change which
affects the cortical layers in varying degrees, and, as a rule,
those of a higher order, and whose action is chiefly inhibitory,
first and most. Consequently in many of these cases a dis¬
turbance of the equilibrium is brought about analogous to that
occurring in mild amentia, with the result that there is a great
liability to ideational and emotional disturbances, readily passing
into insanity. Since, however, the degeneration is a progressive
one, a stage is at length reached at which all mental processes
are annihilated (complete dementia), the individual being re¬
duced to the vegetative condition of the gross ament. The
insanity in these cases, therefore, is but temporary, being
symptomatic and an incidental phase of the underlying
degeneration.

I have said that insanity “ frequently ” occurs in these cases
because, as in high-grade imbeciles, it is not universal, and
numerous cases of both general paralysis and senile dementia
run their course without its appearance.

It has been stated that in these imbeciles the first attack of
insanity usually appears between the ages of puberty and
adolescence, and it will be remembered that this is the age at
which the ideational and emotional faculties are conspicuously
active in the healthy individual. Here, however, the higher
processes of deliberation and judgment, by their controlling
influence, prevent a disturbance of the mental equilibrium
sufficient to produce insanity, although they do not always
prevent the youth from making a fool of himself; and with
further experience the imaginations, day dreams, and castles in
the air ripen into originality of thought and breadth of intellect,
whilst the fulminating emotion of youth becomes the righteous
indignation of mature age.

I am inclined to think that the age at which the insanity
appears not infrequently leads to these cases being diagnosed
as adolescent insanity, and several undoubted imbeciles I have
met with in asylums have been so classed. The question is
important from the prognostic point of view, and although a

Digitized by v^.ooQLe

I 9°3*]

BY A. F. TREDGOLD, L.R.C.P.LOND.

correct diagnosis is not always easily arrived at during the
actual attack of insanity, a careful examination of the patient
as this abates, with a history of his previous condition from the
parents, usually suffices to make it perfectly clear whether he
is really imbecile or not.

Let us now turn to the clinical features of the insanity from
which these patients suffer. On the whole they closely
resemble those occurring in ordinary patients, so that it is
unnecessary to enter into any very detailed description.
There are, however, a few points which must be noticed.

The insanity is chiefly mania or melancholia ; mania is the
most common form, occurring in about 55 per cent, of all
cases, melancholia in about 40 to 45 per cent. Monomania
and pure delusional insanity must be very rare if they occur
at all, for I have not seen one case. General paralysis occurs
probably to the extent of 2 to 3 per cent. Delusions can be
ascertained in about two thirds of the cases ; hallucinations
are also very common. I have excluded all those cases of
insanity in which epilepsy was also present, thinking it better
to deal with epilepsy in imbeciles separately on a future occasion.

These figures will give some idea of the prevalence of the
different clinical types as ordinarily described, but since all these
cases may be referred to a disturbance of either the ideational
or emotional faculties, they may more advantageously be con¬
sidered from this aspect.

In the ideational variety of insanity , to which the greater
number (about 80 to 85 per cent .) of the cases belong,
delusions are a prominent feature, although they are not
always to be readily elicited ; in a quarter of these cases
hallucinations also exist, usually of an auditory, somewhat
less often of a visual nature. These delusions, as already
mentioned, are generally simple, such as those of persecution
or identity; I have never met, amongst these imbeciles, such
elaborate delusions as are common amongst ordinary lunatics,
the most complicated being that of a youth who was under the
impression that he “ had fallen to pieces and lost some of his
parts,” and a girl who thought that “ people drew her brain and
used her thoughts up ” ; in these cases the delusions only lasted
for a few weeks, and it is rarely that they persist unchanged as
long as this.

In some of the cases the existence of delusions can be

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

ascertained for days, and occasionally for some weeks, before
any more acute mental disturbance ; but sooner or later acute
mania or melancholia supervenes. Delusions of a persecutory
nature are usually accompanied by melancholia, those of
identity by mania ; but this is by no means invariable, and on
the whole the nature of the acute insanity seems to be chiefly
dependent upon the temperament of the patient, mania pre¬
dominating more in males and melancholia in females.

Acute mania occurs in rather more than half these idea¬
tional cases, the patient being in a state of ceaseless activity
day and night. He is constantly talking, shouting, or singing,
his language being often of the most vile description ; he tears
up his bedding and clothing, smashes windows and breaks
furniture, his destructiveness being often so great that confine¬
ment in the padded room is necessary ; personal attacks upon
the attendants and other patients are by no means uncommon,
and in some cases I have seen, the imbecile has attacked his
relatives with a knife and other weapons ; one youth of 13,
in addition to assaulting a girl with a knife, made a determined
attempt to set fire to the house.

One of these patients, who was recovering from such an
outburst, accounted for his actions by saying that he “got
some thought on his mind which he tried to get off* and
couldn't; this caused the blood to rush to his head and sent
it rushing down his arms and legs;" not a bad explanation
for an imbecile!

Melancholia is the form assumed by the insanity in nearly
half the cases. This is a much greater proportion than in the
non-imbecile class of lunatics, the probable explanation being
that the temperament of these patients is more apt to be
gloomy, owing to their general health being poor. Both
active and passive varieties of melancholia occur, the first
being somewhat more common. In the active form the
condition appears almost invariably to be associated with
terrifying delusions. Thus, one young girl was frightened by
seeing a fight in the street, she became timid and anxious, and
in a few days developed pronounced delusions to the effect
that people were trying to kill and bum her; she heard voices
threatening her, thought her food was poisoned and refused to
eat it, and was apprehensive of danger from every imaginable
quarter. She was constantly in tears, wringing her hands, and

Digitized by v^.ooQLe

1903.] BY A. F. TREDGOLD, L.R.C.P.LOND. 27

muttering, “ What are they going to do to me ? ” Case
No. 3, in the Abstract of Cases, is a similar example.

In the passive form of melancholia the patients are silent
and depressed ; if they can be got to converse at all their
remarks will generally be to the effect that they are “ tired of
life and want to die,” and, indeed, attempts at suicide are by
no means uncommon. More often they are utterly apathetic,
refusing to wash, dress, or take food, entirely careless of
personal cleanliness, and resisting any attempt to attend to
these matters for them. At times actual stupor may be
present, occasionally so intense as almost to amount to
catalepsy, and the state of these patients so closely resembles
dementia in many ways that recovery or remission is often
the only distinguishing sign.

Suicidal attempts occur in two-thirds of these melancholic
patients, and they are real and definite efforts to put an end
to existence, unlike the somewhat feeble impulses which are
common in the insanity of an emotional type, to be presently
referred to. The feeling of misery and depression may be
responsible at times, but in many instances it is the result of
delusions of persecution, the patients feeling that everyone is
so much against them that suicide offers the only way out of
their difficulties ; or in other cases they hear voices telling
them to make away with themselves. Death by drowning
would appear to be the most attractive method. In the same
way the refusal of food occurring in half the cases may be
either the result of delusions that the food is poisoned, or part
of the general condition of utter indifference to surroundings.

Whether the mental disturbance be mania or melancholia,
it usually subsides within a comparatively short time; im¬
provement may be noticed at the end of a week, or the acute
condition may persist for a month or more, but in 60 to 70 per
cent . of cases it has entirely disappeared in two or three months.
The mental deficiency, which had been to some extent masked
by the insanity, is then perfectly obvious. Seeing the patients
again quiet and tractable the parents not infrequently desire,
and obtain, their discharge, but any hopes they may have of
permanent recovery are nearly always doomed to disappoint¬
ment, for, as far as my experience goes, there is scarcely any
class of patient in whom recurrence of the insanity is so likely
to take place. It is true that occasionally nothing further is

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

seen of one of these imbeciles after his discharge from the
asylum, but of the greater number it can safely be said that
within a few months, or at most a year, they will be back
again. There is also no doubt that recurrences are more
favoured by a life at home than by the routine of an institu¬
tion, and if these patients cannot be kept in a general asylum,
it would be better to transfer them to a special establishment
than to set them at liberty.

As a rule the second and subsequent attacks are of the
same clinical type as the first, and they continue to occur at
periods varying from three to twelve months for many years.
In the intervals the patient is fairly quiet and may do a certain
amount of work in the wards and out of doors, although his
mental deficiency and instability usually prevent any regular
and systematic employment. With the lapse of time the
insane attacks tend to occur more frequently, and the patient
eventually passes into a state of chronic insanity which is only
terminated by the onset of dementia.

In a small proportion (probably about 15 per cent.) the sub¬
sequent attacks are different to the primary one, and the
patient who was at first maniacal becomes melancholic, or
vice versd y this condition of depression, alternating with
exaltation, continuing for years. In the end, however, the
patient tends to become more and more apathetic until
dementia is established.

In about a third of the cases there is no recovery from the
first attack ; the mania or melancholia, although becoming
lessened in their intensity, still persist. The patient remains
for some years in a state of chronic insanity, which almost
invariably terminates in dementia.

The emotional variety of insanity differs from the ideational
in several important features. The attacks are violent storms,
entirely independent of hallucinations or delusions, or, as far as
can be ascertained, of any ideational process. They resemble
the fits of “ temper ” and hysterical outbursts already alluded
to, probably also the transient outbreaks of rage and passion
frequently seen in gross idiots ; but they differ from these in
their intensity, and in being of longer duration. Occasionally
it seems as if they might be the result of some trivial alterca¬
tion, and it is nearly always said of these patients that they
cannot bear to be “ crossed ” ; more often, however, the attacks

Digitized by ^.ooQle

1903 -]

BY A. F. TREDGOLD, L.R.C.P.LOND.

appear to be entirely spontaneous. Notwithstanding their
resemblance to the milder forms of emotional disturbance, their
duration and the intense mental agitation make it impossible
to look upon them as other than true insanity.

The condition is not nearly so common as the ideational
form of insanity, and probably only occurs to the extent of
1 o to 15 per cent . of all the cases ; further, it is almost entirely
confined to the female sex. The patients are, as a rule, very
plausible, and in between the attacks of a gentle and pleasant
disposition. The degree of mental deficiency is usually slight,
though definite.

The mental disturbance may be exaltation or depression,
mania, however, being the more frequent, and one never sees in
these cases the state of profound melancholia that is elsewhere
met with. The mania may give place for a period to sullen
obstinacy or listless apathy, with perhaps refusal of food and
threats or even attempts at suicide, or the patient may become
tearful and obviously miserable ; but I have never seen the
intense apprehension of approaching harm, or the state of
abject terror which mark the ideational melancholiacs ; also in
these cases threats of suicide are more common than attempts,
and where the latter occur they are of a feeble and half¬
hearted description, or are obviously the sudden yielding to a
childish impulse.

The mania is often extremely violent, and the patient will
rush about for days gesticulating, singing, shouting, using
abominable language, and smashing everything within reach ;
the attacks, however, are of shorter duration, and do not so
readily tend to pass into a chronic stereotyped condition as in
the patient suffering from delusions. On the other hand,
recurrences are more frequent, it being unusual for more than
two or three months to intervene between the attacks, and as a
rule the periods of quiescence are much less than this.

Many of these patients certainly seem to improve somewhat
under firm and judicious treatment, and the diminished severity
and frequency of the outbursts would appear to indicate that their
power of control is, in some degree, capable of development,
probably never to a sufficient extent to enable them to be freed
from supervision, but enough to fit them for a certain amount
of useful work. The future of these patients depends largely
upon the patience and intelligence of the charge attendants.

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

In many ways these emotional attacks bear a close resem¬
blance to the sudden seizures of the epileptic, and they are also
probably analogous to the various forms of impulsive and moral
insanity, and to the cases of extreme cruelty which are
occasionally recorded of lunatics; indeed, some of these
imbeciles are subject to uncontrollable impulses in definite
directions, in addition to the maniacal outbursts. Thus one girl
was a most inveterate liar, and another was quite unable to
resist pilfering small articles from the other patients or from
the work-basket as soon as the nurse’s back was turned.

I believe that most cases of insanity in imbeciles may be
readily referred to one or other of the above-mentioned groups.
Insanity with delusions, however, does not exclude the possi¬
bility of emotional storms, and patients suffering from insanity
of emotional type may occasionally have delusions. Cases Nos.
7 and 8 in the appended abstract are good examples of this.

DEMENTIA. —Primary dementia in imbeciles is of such
rare occurrence that if the signs of dementia make their appear¬
ance without antecedent insanity or epilepsy the case will in
all probability turn out to be one of general paralysis.
Secondary dementia , however, is the natural termination of
most of these cases of insanity ; its advent depends chiefly
upon the type and the frequency with which recurrences occur.
In the emotional form it is decidedly rare, and I have known
such patients show no sign of dementia after the lapse of
fifteen years. In the ideational form, on the other hand, it is
common, and the shorter the intervals between the attacks the
earlier does the dementia appear. In some cases it is well
marked within two or three years ; some may possibly continue
for from twelve to fifteen years without any sign occurring, but
on the average symptoms are observable within about eight
years.

General Paralysis. —My figures are not sufficiently
numerous to enable me to state definitely to what extent
this occurs, but amongst rather more than 200 imbeciles
I met with six instances (three males and three females).
The disease may be of the adolescent or of the ordinary
variety, but although a few cases of the latter have been
recorded I have not myself seen an example of it in an
imbecile. Accepting the view that syphilis is the most com¬
mon cause, one would suppose that the state of the nervous

Digitized by v^.ooQLe

1903 .]

BY A. F. TREDGOLD, L.R.C.P.LOND.

system of the imbecile would render him particularly liable to
its action should he become infected ; possibly, however, the
explanation of the comparative infrequency of the ordinary
variety of general paralysis in imbeciles may be that they are
not so much exposed to the chances of syphilitic infection.

In my cases the symptoms first made their appearance
between the ages of fourteen and nineteen years, all the patients
being well-marked imbeciles. In three of them delusions of
persecution were present, accompanied at one time by attacks
of mania, at another by profound depression with attempts at
suicide. In the other three cases the mental disturbance con¬
sisted of emotional storms like those already described. These
conditions persisted with occasional exacerbations and remis¬
sions for from one to two years, when signs of dementia
appeared. Up to the time of writing four of the patients have
died with the unmistakable physical signs, the diagnosis being
confirmed by microscopical examination ; and the remaining
two are in the last stage of the disease.

The adolescent form of general paralysis has been so fully
discussed by many writers that any further description is here
unnecessary, since the clinical features in imbeciles do not
materially differ from those in ordinary patients. It is possible
that in the early stages of the disease the imbecile might
be thought to be suffering from ordinary insanity, delusions of
grandeur being rare, and there being nothing peculiar to the
mental change. But if the history shows that the patient has
not previously given indications of mental instability, and if,
further, there should be marks or a history of syphilis, the case
in all probability will be one of general paralysis. The super¬
vention of dementia within one or two years (earlier than in
the ordinary insanity of imbeciles) makes the diagnosis prac¬
tically certain, although even at this stage there may be none
of the ordinary physical signs of dementia paralytica. It is
perhaps more common for an error of diagnosis to be made in
the opposite direction, and for a normally developed patient
suffering from adolescent general paralysis to be regarded as
an imbecile, the early dementia being mistaken for amentia.

It may be added that in these four imbeciles which I have
had the opportunity of examining post mortem , the naked-eye
appearances of the brain were precisely similar to those
occurring in ordinary cases. Microscopically the changes are

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

also much the same, with the exception that in the imbeciles
there appears to be rather less acute cellular disintegration and
less marked structural vascular change.

The appended abstracts of a few cases illustrate some of the
points mentioned in this paper.

Case i . High-grade imbecile ; attack of acute mania with
delusions lasting six weeks ; recovery ; discharge .—C. H. C—,
No. in series 180. A high-grade imbecile with several well-
marked stigmata of degeneracy, said to have always been very
excitable, no regular employment. Admitted to asylum aet. 16
with acute mania of three weeks* duration. He had suddenly
become noisy and sleepless, throwing himself into strange
attitudes, utterly irrational in his conversation, shouting out
“ God save the Queen,** and asking to be allowed to fight the
Boers ; alternating with this he was tearful and anxious, with
delusions of being constantly followed by policemen, and by
boys who called “thief** after him. He was in a state of
restless agitation, begging for the door to be kept locked. For
a week after admission to the asylum he remained in this
excited condition day and night, and it was quite impossible to
control him. He was terrified of the other patients, thinking
they were all trying to strangle him. After a week he
gradually became quieter, and at the end of two months had
become so quiet and well behaved that he was able to be dis¬
charged. Up to the present (one month after discharge) I
have heard nothing further of this boy, but it is highly probable
that he will be again admitted before very long.

Case 2 . Medium-grade imbecile; attack of acute mania
with delusions and hallucinations , subsiding in two months;
subsequent recurrences for two years; signs of dementia .—
A. C—, male, No. in series 2. Has always been backward, and
never learnt to read or write. After leaving school earned a
few shillings weekly by doing odd jobs, but had no regular
employment. Apt to behave queerly at times from early boy¬
hood, and on several occasions disappeared from home for two*
or three days. At the age of twenty-four began to attend
music-halls frequently, and shortly afterwards became exceed¬
ingly strange in his manner; he refused to do any work, and
spent most of his time standing at the open window talking to*

Digitized by v^.ooQLe

1903]

BY A. F. TREDGOLD, L.R.C.P.LOND.

people he imagined he saw. Much of his conversation was
about one Flo Arnold, whom he wished to marry, and for
which purpose he said he had taken £2 out of the bank. He
gradually became quarrelsome, and finally violent and acutely
maniacal, and had to be sent to the asylum. This condition
of mania, with delusions and aural hallucinations, lasted for
two months, after which he became quieter. He has now been
in the asylum for nearly two years. He is subject from time
to time to sudden outbursts of maniacal excitement lasting
from a few hours to several days; these are probably due to
delusions, although none can be ascertained. He shows indica¬
tions of the onset of dementia.

CASE 3 . High-grade imbecile; attack of melancholia with
hallucinations and delusions , passing into a condition of recurrent
insanity ; signs of dementia in six years .—C. D—, male, No.
in series 3. He could never learn arithmetic at school, as
the master said his brain was too weak. Used to behave very
oddly at times. After leaving school was employed in a boot-
shop. At the age of sixteen he was frightened by a large
black dog, and shortly afterwards became much depressed,
gradually passing into a condition of melancholia. On admis¬
sion to asylum he was found to have aural and visual hallucina¬
tions with delusions. He thought he was surrounded and
threatened by black men ; he said that he was afraid he was
going to be killed in the China war, and that God told him to
kill himself. For several days he was restless and anxious,
afterwards becoming dull, listless, lethargic, and a confirmed
masturbator ; he would occasionally waken out of this
stuporose condition to become aggressive and violent. Four
years after admission he had so much improved that he was
discharged to his friends, only to be readmitted six weeks
later, as they found it impossible to manage him. He is now
twenty-two years of age and is still in the asylum, being idle,
and as a rule dull and depressed and constantly muttering to
himself; occasionally destructive and aggressive; signs of
dementia are apparent.

Case 4 . Medium-grade imbecile ; attack of melancholia with
attempted suicide ; recovery in four months ; relapse eight months
afterwards ; now again recovering .—T. K—, male, No. in
series 53. Mental deficiency noticed from early childhood ;
xlix. 3

Digitized by v^.ooQLe

INSANITY IN IMBECILES,

[Jan.,

incapable of learning at school ; no work subsequently ; never
earned any money. Gave much trouble to his parents, being
“very bad-tempered,” and frequently wandering away from
home. At sixteen years of age became much depressed, and
attempted suicide by taking carbolic acid. On admission into
asylum was wretched and tearful, saying that he wanted to die,
and there was no reason why he should live. He gradually
became brighter and even cheerful, and a month after admis¬
sion was able to work out of doors; the improvement con¬
tinued, and he was discharged in four months. Eight months
later he was readmitted, having been found by a policeman
battering his head against some iron railings. On the way to
the station he said that he would kill either himself or his
father, the latter stating that he had been violent and had
attempted to cut his (the father’s) throat. He was profoundly
depressed, thought he heard voices, and that people had con¬
spired to kill him. At the present time he has been in the
asylum four months. He is still depressed and solitary, but
on the whole decidedly brighter, doing a little work, and
appears to have lost his delusions.

CASE S. High-grade imbecile; acute mania of e 7 notionat
type> cet. 16, passing into a condition of recurrent insanity ; no
dementia after three years .—A. F—, female, number in series
66. “ Always simple from quite a child.” Left school aet. 12,

being only in third standard ; afterwards in a training home ;
very bad-tempered and addicted to smashing windows ; sent
home after three years, as they found they could do nothing
with her. At the age of 16 she became so violent that she
had to be removed to the asylum, having previously hurled a
cooper’s hammer at a man and thrown a heavy padlock at a
woman. She remained in a condition of maniacal excitement
for three months, with an occasional short interval of com¬
parative calm. During one of these I asked her why she
behaved so violently ; she said something came over her and
she felt she “ must do it.” In three months she had become
much quieter, and for the following five months she remained
silent and gloomy, refusing to have anything to do with the
other patients; then she relapsed into a state of restless
excitement lasting for a month, followed by another period of
depression. She is now 19 years of age, having been in the

Digitized by v^.ooQLe

BY A. F. TREDGOLD, L.R.C.P.LOND.

* 903 -]

asylum three years. She is at times fairly quiet and does a
little ward work, but is very untrustworthy, and liable to
sudden outbursts of maniacal excitement with destructiveness ;
she is highly emotional and unstable, bursting into a fit of tears
or laughter without any apparent cause. There are no indica¬
tions of dementia.

Case 6 . Medium-grade imbecile; attack of acute mania of
emotional type, cet. 14/ condition practically unchanged at the
end of six months .—C. R—, female, number in series 63.
Never passed first standard at school; subsequently kept at
home; could never be depended upon; and from 9 years of age
has been at times very violent and addicted to using disgusting
language. She had to be sent to the asylum at the age of 14,
and on admission was in a state of mania, chattering to herself
and singing or shouting the whole day; at times destructive
and aggressive ; very restless at night. She has now been in
the asylum for six months, and on the whole there is very
little improvement. She is occasionally fairly quiet and
rational, but as a rule she is raging up and down the wards
singing, shouting, and swearing at the other patients. The
charge-nurse says she is her most troublesome patient. She
will probably remain in this state until the advent of dementia.

Case 7. High-grade imbecile; attack of acute mania of
emotional type , cet. 16 ; constant recurrences , at times accompanied
by delusions ; under observation four years , no improvement .—
R. D—, female, No. in series 82. Very backward at school;
left act. 1 3 and went to service, but was so liable to what her
mother calls “ fits of temper ” that she could not keep any
situation more than a few months ; altogether she had fourteen
situations in less than three years. At the age of 16 she
became so violent that she was sent to the asylum. On admis¬
sion she was in a state of acute mania, screaming, shouting,
singing, and resisting all attempts to keep her in bed ; she
also threatened to cut her throat. This condition lasted for a
few days after admission ; she then became quieter, and by
the end of a fortnight was doing some work in the wards.
Within a month she had a relapse exactly similar to the first
attack. She is now 20 years of age, and has been in the
asylum four years. At times she is quiet, well-behaved, and
answers questions readily and pleasantly ; it is, however, quite

Digitized by ^.ooQle

INSANITY IN IMBECILES.

[Jan.,

impossible to depend upon her, and she is subject from time
to time to sudden outbreaks of excitement, in which she
becomes most abusive, uses the foulest language, and violently
attacks anyone who may be in her way. These attacks last
for three or four days and nights ; as a rule, they seem to be
purely emotional storms, but in some of them delusions are
present, generally to the effect that the medical officers and
the nurses are trying to cut off her head or to torture her in
various ways. I see no prospect of any recovery in this case.

Case 8. High-grade imbecile; attack of acute mania sub¬
siding in three months, followed by frequent recurrences ; under
observation for seven years without any improvement .—E. S—,
female, No. in series ioi. Noticed to be simple-minded from
birth ; did not get on at school; subsequently kept at home to
help mother, “ as she did not seem to have enough sense to go
out to work ; ” was at times very troublesome, and caused
much annoyance by suddenly rushing into the neighbours*
houses. At the age of 16 became so restless and excitable
that they could do nothing with her, and sent her to the
asylum. The medical certificate states “she exhibits undue
mental excitement, talks, sings, shouts, and laughs im¬
moderately, and behaves in an insane manner ; very restless,
imagines the attendants to be her former school teachers, and
seems altogether too excited to control herself and talk
sensibly” This acute condition gradually abated, and by the
end of three months she had become quiet and able to do
work ; two months later she relapsed, again becoming excited,
noisy, and destructive day and night, in which state she
remained for three weeks, then becoming quiet and industrious
again. She has now been in the asylum seven years, has
ceased to do any work, and is subject to frequent acute out¬
breaks, becoming noisy, destructive, and aggressive. In some
of these attacks delusions are present; thus a short time ago
she stated that she had given birth to a child, which had been
stolen from her in the night. She is very impulsive, and on
one occasion, seeing a pail of water standing in the ward, she
suddenly plunged her head into it. She is becoming untidy in
her dress and personal appearance, though there are as yet no
other indications of dementia.

(') " Amentia—its Etiology, Classification, and Pathology,” Archives of Neuro¬
logy, vol. ii.

Digitized by v^.ooQLe

1903-]

TRAINING OF NURSES.

On the Training of Nurses in Institutions for the Insane.
Abstract of a paper by Bedford Pierce, M.D., M.R.C.P.,
Medical Superintendent of the Retreat, York.

All will agree in the wish to secure the services of intelli¬
gent high-principled women upon the nursing staff of our in¬
stitutions for the insane. I myself, and no doubt many will
agree with me, believe that we are more likely to obtain this
kind of woman from amongst the middle class than from the
artisan or domestic servant class ; and I am prepared to go
further, and say that the well-educated portion of the former
(the upper middle class) is most likely to supply the best type
of woman for our purpose. It is generally admitted that this
is so as regards our general hospitals, and, in my opinion, the
same considerations apply to our hospitals and asylums for the
insane.

The present position of affairs is peculiar—the sick poor are
nursed by educated women, often of gentle birth, whilst insane
gentlewomen are frequently nursed by those not far removed
in culture from their maid-servants. Our efforts in the
Retreat have been directed to remove this paradox. In the
nursing world to take up asylum work is generally looked
upon as taking a step downhill professionally, a prejudice not
without some justification in the past. In the future, in my
opinion, the nursing of the insane will become a branch of the
profession in no way behind other branches. It will become a
vocation for cultured women, wherein they will find ample
scope for the exercise of their powers.

Such women will not merely become more competent and
the better able to render intelligent obedience than often
obtains at present, but the wants of our patients will be more
readily anticipated, and their mental outlook and peculiar
difficulties will be better understood.

In these remarks I do not for one moment wish to suggest
that women who have had few educational advantages may
not make good nurses, or that amongst the less educated
classes we do not find as much kindness of heart as exists
higher in the social scale. We all know that virtue is not
confined to one class. But I venture to think that, if the

Digitized by v^.ooQLe

TRAINING OF NURSES,

[Jan.,

nursing in asylums is left as it has been, we practically exclude
the class of women most likely to help us in our work.

It is found wise in general hospitals not to be too strict in
insisting that gentlewomen only need apply, and I believe, that
in the best of them, women of very different social position
are working side by side. This should be the case in our in¬
stitutions for the insane. We should provide an opening for
any conscientious woman with refined instincts and the
necessary qualities of intelligence, tact, and patience.

In order to obtain the services of the women I have in view,
it is, in the first place, necessary to provide the nurses with
greater privacy and comfort when free from duty than
generally obtains at present. To this end the Committee of
the Retreat built, in 1898, a nurses* home, the first, I believe,
in any institution for private patients in Great Britain. At
the same time the hours on duty at the Retreat have been re¬
duced, the holidays lengthened, and it has been found wise to
give each nurse on every full working day an hour free from
duty in addition to meal-times. The salaries of the senior
nurses have been raised, but the probationers receive rather less
than formerly. No doubt in course of time, when the value
of a sound training is better recognised than at present, the
junior nurses will be glad to come at a much reduced salary.
But at the same time the more responsible posts must be
much better paid than is now usual.

With regard to the organisation of the staff, I find myself
at variance with Dr. Robertson, who, in his excellent paper in
the April number of the Journal of Mental Science on
“ Hospital Ideals in the Care of the Insane,” advocates the
introduction of a number of assistant matrons, each of whom
superintends the work of a ward or group of wards. These
are in his scheme hospital nurses, often without any asylum
experience, and are additional members of the staff. Dr.
Robertson claims that they do not interfere with position and
promotion of the other nurses, though they are superior officers
and receive a higher salary. The wiser course appears to me
to follow the organisation of a general hospital. The head of
the nursing staff is the matron, who, in a large institution, will
doubtless require one or possibly more assistants, to whom she
will assign certain duties, such as oversight of linen, clothing,
and the service of meals. The assistant matron, however, does

Digitized by v^.ooQLe

1903]

BY BEDFORD PIERCE, M.D.

not form an intermediate officer between the nurses and the
matron, and has no special territorial sway, but rather con¬
stitutes an extension of the matron’s faculties where one
person cannot possibly undertake all the duties of the
position.

Each ward is under the charge of a thoroughly qualified
nurse, who, at the Retreat, following the practice of general
hospitals,, is called the Ward Sister. She receives the instruc¬
tions of the medical officers as to the treatment of her patients,
and generally is mistress of the ward. She should be well
educated, and experienced in both hospital and mental work.
The sisters at the Retreat form a class by themselves, they have
meals together, and possess several privileges that the nurses
do not enjoy.

The nurses are divided into staff nurses, who hold the
Association certificate, and probationers. The sisters, staff
nurses, and probationers wear distinctive uniforms.

There is in this organisation little difference from that
usual in most institutions for the insane, the chief distinction
being that the ward sister under this arrangement becomes a
more important officer than the charge-nurse was apt to be,
there is more decentralisation of authority, and she bears a title
which emphasises the fact that she holds a distinct and im¬
portant place upon a hospital staff.

In many institutions where private patients are received
ladies’ companions are employed to assist in the occupations
of the patients. Though for special reasons we have two
companions still in the Retreat, I consider it a necessary
corollary to the introduction of well-educated women as
nurses and probationers, that no untrained officer be placed
over them in any capacity, to do the more agreeable part of
the duties and escape the more unpleasant.

It is also essential that a thoroughly good training be given
the staff. I look upon the engagement of a probationer in the
light of a contract with two sides to it; she undertakes to give
her best services and to take every pains to learn how to
become an efficient nurse, and the Committee of the institution
undertakes to give her every reasonable opportunity of doing
so. But the usual terms on which nurses are engaged are
much the same as those for domestic servants, and no under¬
taking is given to provide any training whatever. If a person

Digitized by

Google

TRAINING OF NURSES.

[Jan.,

is engaged by the month, the engagement gives no suggestion
of a long course of instruction and training for the acquisition
of a profession. It, moreover, has the hurtful effect of the nurse
feeling free to leave directly she thinks she knows her work, a
result that has too frequently followed success in obtaining the
Association certificate.

I therefore strongly recommend the adoption of the hospital
system of receiving probationers for a definite term of years. At
the Retreat, after a period of trial for two months, the nurses
enter for a four years’ engagement. The agreement that the
nurses sign after the time of trial has elapsed may not be very
binding in the legal sense, and it is not intended to compel a
nurse to stay who does not want to, for such an one would be
of little use; but it constitutes a clear understanding quite
sufficient for honourable persons. The Committee reserve the
right to terminate the engagement at any time, and if a nurse
wishes to be relieved before the end of the period agreed upon
she must apply to the Committee, who will, no doubt, liberate
her if sufficient reason be assigned.

On entering, the nurse is provided with a statement setting
forth the conditions of service, the character of the training,
and is informed that she is expected to enter for the Associa¬
tion examination at the end of her second year, and at the end
of the third year for the examination for the Special Certificate
of Training at the Retreat.

In deciding to engage nurses for such a long period as four
years, twice as long as is thought necessary to qualify for the
certificate of proficiency given by this Association, I was
influenced by the following considerations :

1. I satisfied myself that two years was too short a time to
turn an untrained woman into a qualified nurse, and that in
reality four years’ experience of mental diseases was necessary.

2. A four years’ engagement would tend to secure the
services of a greater number of experienced nurses in the
institution, by preventing the resignation of those who had
obtained the Association certificate.

3. I considered it probable that a four years’ engagement,
as is commonly the case in good general hospitals, would in
reality be more attractive than a shorter period to the kind of
woman whose services I wanted to secure.

It should, however, be explained that it is understood that

Digitized by v^.ooQLe

I903-]

BY BEDFORD PIERCE, M.D.

the training, so far as lectures and classes and examinations
are concerned, is complete in three years, and that during the
fourth year the nurse either takes up a position of greater
responsibility in the wards or enters the private nursing depart¬
ment, where she will gain self-reliance and additional ex¬
perience. In the latter case she receives a commission upon
her earnings in addition to her salary.

The teaching that the nurse receives at the Retreat during
the first two years corresponds to that laid down in the Hand -
book . If an average woman is to understand what is there set
forth she will require to work hard through two winter sessions.
In the course of the forty lectures and demonstrations given by
the medical officers of the Retreat in these two years every
effort is made to avoid theoretical subjects, and to deal with
practical matters. The matron and ward sisters also give the
nurses instruction in the wards.

In considering this one cannot but realise that the real
training the nurse receives depends upon the discipline in the
wards, the cultivation of orderly habits, of obedience, and the
development of powers of self-control and patience; and the
question naturally arises in respect to the dogmatic teaching
upon the outlines of anatomy and physiology, cut bono ?
The answer appears to me to be precisely the same as that
we give the medical student, who asks what is the good of
learning the anatomy of the amphioxus or the development
of the chick.

It is evident that much that we have learnt as students, and
much we teach the nurses, is purely educational, and has often
no direct utility. It affords part of the equipment which
enables us to perform our work intelligently. A knowledge of
the composition of the atmosphere may not be needful to
enable a nurse to ventilate a room properly, yet acquaintance
with this makes the simple duty more interesting, and may
add to her influence over a patient who objects, as she is no
longer ignorantly carrying out an instruction.

One difference between the nursing of the sick and the
nursing of the insane is that, in the latter case, many more
faculties are called into play. Thus social gifts and accom¬
plishments, as they are called, fill an important place in asylum
life, and they should be assiduously cultivated. Moreover the
medical treatment covers a wider field, and there are a number

Digitized by v^.ooQLe

42 TRAINING OF NURSES, [Jan.,

of special methods of treatment of value in certain cases that
rarely are used in general hospitals. These two facts seem to
me to make it clear that we should train our own nurses, and
not look to general hospitals for assistance. So far we have
been compelled to do this, as there were so few well-trained
and well-educated women, with asylum experience, available
for responsible posts, but I trust this will not long be the case.

Among the special methods of treatment I may mention
open-air treatment as for phthisis, massage and various forms
of medical gymnastics, the use of special dietaries, Turkish and
electric baths; and in all these we require the assistance of in¬
telligent nurses.

Whilst one can hardly expect any nurse to be familiar with
all these, and the many other “ cures ” that may be thought
specific in mental cases, it has been decided at the Retreat to
give systematic instruction in medical gymnastics and massage
to the nurses in their third year after they have obtained the
Association certificate.

In America this is a recognised method of treatment, and
considered of great therapeutic value. So far as I have tried
it, I can confirm this. In America and on the Continent
many asylums have well-equipped gymnasia which, I fear, are
not found at present in England. I further think it would be
a wise departure to require all the junior attendants and nurses
to take a regular course of Swedish drill. Its value does not
depend upon the muscle it may develop, or on the hygienic
results as regards health, so much as upon the training of the
attention. It is an essential part of the Swedish system that
prompt obedience to commands be given, which cultivates an
alertness of mind of much educational value. Arrangements
have already been made to hold classes of this kind at the
Retreat, under the care of qualified instructors, for men and
women respectively, in addition to the classes in medical gym¬
nastics and massage which the senior nurses attend.

A class in invalid cooking has also been held for the
instruction of the senior nurses, and the medical officers have
given them an additional short course of lectures on the nurs¬
ing of mental and nervous diseases.

Dr. Robertson, in the paper I have already mentioned,
suggested that nurses upon the insane should first train in
general hospitals, and afterwards take up their special branch

Digitized by v^.ooQLe

1903-]

BY BEDFORD PIERCE, M.D.

of work. Life is too short for this. A course of training in
one of the larger hospitals occupies four years, and includes
much surgical work not necessary in an asylum. We can
hardly expect all our nurses to devote six years to their train¬
ing. It seems to me much wiser for the probationer to
commence amongst the insane, and find out early whether she
possesses the needful qualities. It must be remembered that
the duties in a general hospital are entirely unlike those in an
asylum ; the discipline is quite different, and by no means
necessarily assists the nurse in learning how to manage properly
the insane. On the contrary, on undertaking mental work the
hospital nurse has to unlearn not a little. It is evident, how¬
ever, that the training undergone in hospital, on the whole, is
helpful, and should materially shorten the time necessary to
obtain proficiency in mental nursing.

In order to cope with the bodily disorders that so frequently
accompany mental disease, it is certainly desirable that nurses
upon the insane should have some hospital experience, but it
is not easy to secure this without incurring considerable
expense. I hope, however, that some co-operation between the
hospitals for the sick and for the insane will be possible before
long, so that nurses intending to undertake mental work may
obtain on easy terms a year's experience in a large hospital or
infirmary.

But it must, in the first place, be thoroughly understood that
a nurse trained as I have suggested is not qualified to under¬
take the nursing of bodily illness unless she has taken a full
course of hospital training ; nor, on the other hand, must the fully
trained hospital nurse be considered qualified for mental work
unless she has undergone an adequate course of training in a
well-equipped asylum.

If there is to be co-operation between the two branches of
the nursing profession, neither branch must assume proficiency
without proper justification.

I make no claim for originality as regards the proposals in
this paper; many of them have been practised in America,
and many are but an adaptation of hospital methods to asylum
life. I can only say that the scheme sketched out has, up to the
present, been attended with success. It has largely attained
the end I had in view, viz ., the introduction of a greater number
of well-educated women upon the nursing staff of the Retreat,

Digitized by v^.ooQLe

TRAINING OF NURSES.

[Jan.

and this has, in my opinion, proved to be an unmixed benefit to
the patients under my care.

Discussion

At the Meeting of the Northern and Midland Division, October 8th, 1902.

The Chairman (Dr. Pope) expressed his admiration of the work which Dr.
Bedford Pierce had accomplished in securing the services of educated women and
in training them as mental nurses. He fully recognised the value of such a pro¬
cedure, but feared that at present it would not be practicable to carry it out to any
extent in county and borough asylums.

Dr. McDowall said it was a mistake to make people believe that the women
who would take charge of them were gentlewomen when they were not. In a very
well known private asylum it was found that women of distinguished birth and
education stood the restraints necessary in mental treatment more readily from
persons who were socially very much their inferiors than from women approaching
their own position in life; and he knew this, that in a public asylum where it was
a boast that the staff consisted of gentlewomen they were not gentlewomen at all—
they were of the poorer professional and commercial class.

Dr. Hitchcock said he should be very glad indeed to try some of the pro¬
posals mentioned by Dr. Pierce, but he did not see where the money was to come
from.

Dr. Miller said there was a question in connection with the training of
nurses which it would be interesting to the branch to know, and that was the
number of asylum attendants who held the qualifications of the Association.
He had received a letter from a Continental physician asking for some information.
He found there were some 2200 trained attendants and nurses in the rate-supported
institutions in this country. He was now sending out circulars inquiring as to
the numbers in licensed houses acknowledged as training institutions. There were
also a great many who, having received the training necessary to qualify them,
gave up asylum work and joined some nursing institution. He did not wish
to throw any cold water on Dr. Pierce’s enterprise in this matter, but were
he in Dr. Pierce’s shoes he should dread the completion of the term of four
years, when these people could leave and join some more lucrative institution. Of
course we have to face the monetary question in rate-paying asylums. We could
never hope to pay the salary which Dr. Pierce now pays his people. It would
be outside the capability of a rate-supported institution.

Dr. Pierce explained that only the ward sisters received ^30 to £40. The
salaries of the nurses were £16 for the first year, £ 18 for the second, £22 for the
third, and £2$ for the fourth. The salaries must be higher than now usually obtains,
if we are to secure the right type of women on the nursing staff.

Dr. Hedley said, on behalf of Dr. Walker, Dr. Townsend, and himself, that they
had been very much gratified by the invitation they received to meet a branch of
the profession which he, at any rate, had not had the advantage hitherto of having
much communion with. He had been very much interested in the discussion on
the paper, and he could quite see what energy and enterprise and enthusiasm there
was among that branch of the profession, whose task he was sure was exceedingly
difficult and, if he might add, very unpleasant to perform. He hoped they would
accept their very best thanks for their very kind reception.

Dr. Middlemass said the class they drew from in the county and borough
asylums was not the class he should like to see. He agreed with Dr. Pierce that
there was room for very considerable improvement. He wished they could bring
the arrangements in asylums into harmony with those in hospitals. He did not
think it mattered whether they called the women gentlewomen or anything else.
What they wanted was women with a certain mind and intelligence, and, above all,
a sense of duty.

Dr. Bedford Pierce, replying on the discussion, said Dr. Miller had asked about
the women going away to private nursing institutions. Of course a certain number did
go away. There were, however, two good reasons why a nurse would prefer to be asso¬
ciated with a recognised institution rather than with a private association which

Digitized by v^.ooQLe

1903 .] CASE-TAKING IN LARGE ASYLUMS. 45

might be devoid of any soul, and whose only object was to make money. One reason
was that the nurses knew they had the support of the institution behind them. When¬
ever they were placed in any unfortunate position, or their work was unduly hard or
more severe than was reasonable, they knew that the authorities of the institution
would support them—would withdraw them, or see that things were put right. An
institution could make better conditions of service with employers than an associa¬
tion. Another thing, which applied to men, and which was the real reason why
men stayed with them for so many years, was that the trustworthy attendant could
marry and have a home of his own; and to such, private nursing and constant
travelling about were naturally distasteful. He thanked the members for the kind
way in which they had listened to and criticised the paper. As to whether the
nurses would undertake to stay in a county asylum for three or four years, he thought
it very likely that if Dr. Middlemass were to try the experiment he would have little
difficulty in carrying it through satisfactorily.

Case-taking in Large Asylums . By Daniel F.
Rambaut, M.D.

In the very large asylums, where the insane are counted by
thousands, there will always be a difficulty in keeping an
accurate record of the mental and physical condition of the
patients, and the changes which occur from week to week in
these conditions. Unless some method is adopted in case¬
taking many records will be omitted and many interesting
and important changes will be overlooked.

The assistant medical officer, who proceeds through the
wards of an asylum with his note-book in his hand, will doubt¬
less obtain much information of value, but those suffering
from acute forms of insanity—the demonstrative, the impor¬
tunate—will force themselves upon him, to the exclusion of
the retiring, the tranquil, and the hard-working. Without
some system in note-taking patients will be passed over—will,
in fact, be never seen, except by the wide-angled, vague,
routine official gaze.

Without a system by which each patient’s state is thoroughly
investigated at regular stated intervals, and by which notes are
made immediately after each examination of a patient, our
case-books are bound to become a mass of useless writing, from
which no scientific fact can be obtained, which would give no
data for a diagnosis or a prognosis, and are wholly valueless to
the medical statistician.

I have seen case-books in which cases were written up by
fifty at a sitting. Who is there who has not seen such notes

Digitized by v^.ooQLe

CASE-TAKING IN LARGE ASYLUMS,

[Jan.,

as, “No change,” “ He continues in the same mental and
physical condition,” “ His condition remains unaltered ” ? I
have even seen a case-book which contained a three-monthly
record of a patient's mental and physical state for a period of
one year after his death !

I shall try to explain in as few words as possible the
method of case-taking employed in the Richmond Asylum,
Dublin—a method which has worked with excellent results
during the last five years.

In the first place, it is necessary to keep a small register of
patients, which I call the “ Register of First Year.” In this
book is entered merely the name and general asylum register
number of each patient on the day of his admission. One
page of this book contains the names of all the patients
admitted during one month.

The following represents the month of May, 1902 :

May , 1902.

1. John Noon, 20,290.

2. Ttnini!tiY^ , oote 7 ,, 5 n^^T^ 1

3 .

4 -

5 .

6 .

7 -

8 .

9 -

10. Wtttfanr Smith, |

11. TtiunicB"lC5tty7^n7?ijTJ^

12.

13. Thomas Toole, 20,299.

14. William Cdlldll, 2U,JU1. William Hay, 20,302.

15. Patrick Murphy, 20,303.

16.

17. Edward Barry, 20,305. J usupli Tiuy, JU,jU4. 1

18. Michael Hayden, 20,308. William Bl UWII, ZU,jU/.

IP-

20.

21 .

* Those names through which a line is drawn are discharged or dead,
f The Register numbers are not consecutive, because the list only includes males.

Digitized by v^.ooQLe

1903 -]

BY DANIEL F. RAMBAUT, M.D.

22 .

23. John Byrne, 20,312.

24.

25.

26.

27.

28.

29. Thomas Cook, 20,318. Peter Mullen, 20,319.

30. Ed w jid Diul, 20,32a

31. Henry Morris, 20,323. Michael Doyle, 20,324. Edward

Jo nes, 2 0 ,30 8 1

From this register one can rapidly find, on any given day,
the names of those patients who were admitted on the day
before the given day, on the same day of the week seven days
before, fourteen days before, a month before, two months before,
and three, four, six, nine, and twelve months before.

If one makes a list of the names so found, and makes a
similar list on each succeeding day, one can be certain that
each patient who has been admitted during the past year is on
the list for examination and note-taking on the day after his
admission, one week after admission, two weeks after admis¬
sion, one month after admission, two, three, four, six, nine, and
twelve months after admission.

In the second place, it is necessary to keep a second small
book, which I call the “ Chronic Register.” In this book one
page is allotted to each day of the year of all previous years,
and on each day of the year are entered all the cases which
were admitted to the asylum on that day of any previous year.

The following represents the entries for one day of the year
of any previous year :

May 23 rd.

James Smith (15,555). 1891.

T l ro i rayJu T fia 1 (rgfl 5 7). f 8 9l *

Joseph Shane (16,966). 1894.

Dumud Rubiiuoi T ■ > 6 9 4. '

Patrick J. Stowe (17,889). 1896.

Adam Bede (18,240). 1897.

Sherlock Holmes (19,370). 1889.

• The name through which a line is drawn is that of a patient discharged or dead.

Digitized by v^.ooQLe

CASE-TAKING IN LARGE ASYLUMS,

[Jan.,

For instance, under the date May 23rd you will have the
names of all the patients at present resident in the asylum who
were admitted on May 23rd of any previous year. In making
the list for examination for any given day, besides adding the
names of any patients admitted on that day twelve months
ago, it is necessary to transfer these names from the “ Register
of First Year” to the “Chronic Register.”

To complete the list for examination for any day, say May
23rd, 1902, one takes from the “ Chronic Register” the names
found on the page allotted to May 23rd for all years, and on
the pages allotted to February 23rd, November 23rd, and
August 23rd of all previous years. In this way all chronic
patients will appear on the list for examination every three
months.

On the 30th April, June, September, and November the list
for examination will always be a little larger, because the 30th
and 31st of other months must on such days be taken as one
day. And for a similar reason an enlargement of list must
occur on the last day of February; but this increased list
occurs on only five days in the year, and it is compensated for
by decreased lists on the last day of the remaining seven
months, which contain thirty-one days.

As the result, then, of making notes on the patients who
are on the list for each day, obtained as I have described
above, one knows that each patient has had a note made of
him—

I day after admission,

1 week „

2 weeks „ „

1 month „ „

2 months „ „

9
12

and every three months as long as he remains in the asylum.

Each asylum can easily vary the intervals between each
note, and thus increase or decrease the number of reports on
each patient. The number of names on the list will depend
on the number of the patients and the length of the intervals.

Digitized by v^.ooQLe

I903-]

BY DANIEL F. RAMBAUT, M.D.

In an asylum with 1000 patients the number on the list
will vary between ten and twenty.

Any clerk, head attendant, or intelligent hall-porter can
easily keep these two small registers, entering each day the
names of the patients admitted, crossing out each day the
names of those discharged or dead, and transferring each day
names from the “ First Year Register ” to the “ Chronic
Register.” The correction of the two registers and the making
of the list for note-taking involve only a few minutes’ work
each day.

The list obtained, as I have attempted to describe above,
is made out for, say, May 23 rd, on the afternoon of May
22nd, and is placed in the attendants’ dining hall, so that
each charge attendant can carefully investigate the history of
any of his patients, who may be on the list, during the period
which has elapsed since his patients were last entered on the
list.

Each charge attendant then writes a report on any patient
in his ward who may be on the list, and in this report he
enters the dates of each transfer of a patient from ward to
ward, and the reason of the transfer, and he states any special
events which may have occurred, such as accidents, attempts to
escape, refusals of food, seizure^ and their number by night
and by day.

He also gives a short description of the patient’s conduct in
the ward, of any peculiar habits, and mentions any prominent
delusion or hallucination.

He also mentions whether the patient is 'receiving medicine
or extra diet, and adds a note about appetite and sleep.

He reports in what manner the patient is employed during
the day, and having weighed the patient he enters the weight
in the report on patient.

The charge attendant enters his report on a printed form,
and returns it to the office before eight o’clock in the morning.

In making his report on the patient it is necessary for the
charge attendant to review each case in turn, and much
valuable information is often obtained by the charge attendant
which might otherwise have been lost.

Digitized by v^.ooQLe

CASE-TAKING IN LARGE ASYLUMS,

[Jan.,

Report on patient for period since last examination.

Name,

1. Divisions in which the patient

has been ....
Date and cause of transference

2. State any special events :—

Accident, escape, refusal of
food, seizures, etc.

Conduct in ward .

Peculiar habits

Prominent delusions or halluci¬
nations ....

3. Medicine
5. Appetite
7. Weight

Reg. No. Ward.

4. Sleep
6. Extra diet
8. Occupation

Charge attendant ,

Date>

In each ward any patient who may be on the day’s list is
brought before the medical officer when making the morning
round, and they are afterwards brought to the office, where the
case-books are kept, for further examination, both mental and
physical.

A copy of the list for the day is made in a book for the
convenience of the medical officers, and when the medical
officer has entered the record of his examination in the case¬
book he places his initials opposite to the patient’s name.

By this periodical examination disease in its incipient stage
is often discovered, and patients are afforded an opportunity of
having their complaints investigated and their wants attended
to, and it in no way interferes with, or takes the place of, the
frequent recording of sudden changes and other interesting
phenomena observed in the acuter forms of insanity.

The details of such a scheme are necessarily obscure when
described in writing, but when put into practice no difficulty
presents itself.

Discussion

At the Meeting of the Irish Division, May, 1902.

The Chairman (Dr. Oscar Woods), in inviting discussion on Dr. Rambaut’s
paper, said that one knows how easy it is to forget the details of cases, and how

Digitized by v^.ooQLe

•9°3]

BY DANIEL F. RAMBAUT, M.D.

desirable it is to have accurate notes made at definite times. He considered that
if Dr. Rambaut’s system proved to be easily worked, it would be a very great
assistance.

Dr. Nolan said that he had adopted this system, and that he found it easily
worked and exceedingly useful. He regarded the training that it involved for the
attendants as a most desirable feature.

Dr. Conolly Norman said that the form described by Dr. Rambaut had been
devised by that gentleman, and had been in use in the Richmond Asylum since 1898.
The speaker had formerly experienced the usual difficulties in having case-books
kept systematically. In his asylum, as elsewhere, it not seldom used to occur that
a chronic patient was lost sight of by the officer whose duty it was to make the
notes. The speaker did not allow of notes made post mortem from memory or
fancy and antedated, neither did he allow the note so dear to the official mind—
“ No change in this patient.” So the case-books now and again presented a bald
and barren appearance, and what was no doubt less serious from an official point
of view, though in itself of some moment, took place—namely, certain patients
were neglected. After much consultation and deliberation on the part of the medical
staff, his assistant, Dr. Rambaut, hit upon the plan which was placed before them
that day, which the speaker had immediately adopted. Since then no case is to
be found in the asylum which has not been noted at the stated periods. Two
things are required. The first is a statement of the patient’s physical condition.
This has frequently led to the detection of chronic diseases which under a less
careful system might have escaped detection for long periods. As an example, a
case may be mentioned of a tranquil dement who, after some sixteen years’ residence
in the asylum, was found on one of the periodic examinations to be suffering from
early progressive muscular atrophy. Precisely when the disease began it was, of
course, impossible to say, but it must have been between the dates of the ultimate
and the penultimate examinations. The second matter insisted upon, even in the
most “chronic ” find “ uninteresting ” cases, is a definite statement of the mental
symptoms found at the period of examination, and at the head of each page is a
printed instruction that the note is not to consist of a diagnosis or an opinion, but
of facts. Dr. Norman said : I wish to dwell for a moment upon this, because some
years ago, when it was enacted in England that every patient should be re-certified
every year, it was looked upon by a number of our colleagues as being an insulting
and also a superfluous provision, and it was said that insane patients in an asylum
no longer required to be certified. It has been found, I believe, to work very use¬
fully, and it has insured that at least once a year in English asylums every patient
shall be examined with the view of ascertaining whether he is insane or not, and
that his mental symptoms shall be described in some detail. We have arrived at
a similar result working from a different point of view, and I think it is a result
that is very desirable. Another feature in our system is the note required to be
made by the charge attendant of the ward where the patient lives. This note, on a
printed form devised for the purpose, must be handed to the medical officer on the
day when the patient’s case is to be noted. Besides helping to ensure that nothing
is forgotten, this procedure is useful by teaching the attendants what they as well as
ourselves need to learn, via., that the “ chronic ” and “ uninteresting ” patients must
be observed and noted ; it keeps alive their interest in their cases; and,finally, from
these attendants’ notes very valuable information is often obtained.

Dr. Mills said that the system was a most admirable one, and that the only
barrier to its universal adoption would be the difficulty of securing the services of a
clerk or hall porter who would be capable of keeping the registers.

Dr. Drapes said that the system was excellent, and would tend to ensure the
detection of the onset of an insidious disease. He, however, feared that in those
districts where the people are comparatively illiterate it would be difficult to find
attendants of sufficient education to make proper records.

The Chairman said that he would like to ask Dr. Rambaut how much time an
assistant medical officer would take in writing up the notes on 400 cases; also
whether there was any classification of the cases at the Richmond Asylum, e. g .
into acute and chronic, so that one medical officer was responsible for the acute,
and another for the chronic cases.

Dr. Rambaut, in replying, said: With regard to the first question as to the
work of the hall porter or of the clerk, that only takes about three minutes

Digitized by v^ooole

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

in the day; in the Richmond Asylum it is done by an intelligent hall porter,
but if there was not an intelligent hall porter it could be done by the medical
officer. I could make out the list for you now for any given day from these
books in about three minutes. As regards keeping registers, it only means striking
off those who die, and entering the admissions. I think chronic cases quite
as important as the more acute forms of insanity. They may not need note¬
taking so often, but when notes are made they should be done with much care, and
1 think in that way locomotor ataxy, phthisis, and other diseases will be discovered
very early, and also that cases of recovery will not be overlooked. Dr. Woods
has asked how long would it take one medical officer in an asylum with 400 patients
to write up the notes. It would take from two to two and a half hours. We have
no very definite system of classification in the Richmond Asylum. Some of the
wards belong to one medical officer and some to another, and hence each officer
has a variety of cases. I thank you very much for the kind way in which you have
received my paper.

The Chairman. —We are all very much indebted to Dr. Rambaut for the trouble
that he has taken in bringing this matter forward, as it is very interesting and
important.

The Treatment of Phthisis in Asylums by Urea and its
Salts. By J. Lougheed Baskin, L.R.C.P., L.R.C.S.Edin.,
Assistant Medical Officer, Devon County Asylum.

There has been a considerable amount of attention called to
the subject of phthisis in asylums lately, and since the publica¬
tion of the report of the Tuberculosis Committee the subject
has appeared in a broader light. Although much is being and
has been done for the prevention of phthisis by means of the
Sanatorium movement, and the varieties of the technique of
hygiene which are included in that treatment, yet there are still
many aspects of the disease (both in the sane and insane)
which require precise investigation, such as the variations in
the composition of the secretions and excretions when the body is
in the state of phthisical toxaemia ; the relationship of the tuber¬
culous toxaemia to other toxaemias, such as the influenzal (27),
gouty, etc. ; the accumulation of toxins, and its relations to
recurrent forms of disease. The number of deaths from
tubercle here during the past year we find to be ten ; in
1900 it was nine, and 1899 it was fifteen, so that from a
percentage of 1*3 in 1899 it has dropped to 0*85 in 1901.
On examining the position of this asylum in the tables drawn
up by the Tuberculosis Committee (1) we find it tenth in the
asylums in England and Wales which are classified under
Division 1, which asylums have a tubercular death-rate of from

Digitized by v^.ooQLe

1903]

BY J. LOUGHEED BASKIN, L.R.C.P.

0 # 5 to 2*2, the county asylum at Exminster having a per¬
centage of 1*3. This compares favourably with other asylums,
some in the Division 2 having a tubercular death-rate of 5*1
and 8 per cent . respectively.

On analysing the notes on the patients which suffered from
phthisis in 1901 and in 1902 up to October 20th, we find
that out of seven patients to whom I have administered the urea
treatment, one died, two recovered, not only physically but
mentally, and of those at present under treatment four show
distinct signs of getting better, if we may include one case
which is that of a former asylum attendant, whose condition,
looked on as hopeless a year ago, has since shown im¬
provement.

The patient J. C— made the most successful recovery con¬
sidering the severity of his illness of any of those treated with
urea. He had been in bed for ten weeks suffering from advanced
tuberculous disease in each lung, when a large abscess formed
in the left interscapular region. His temperature ranged from
ioi° F. to 103° F. His sputum was crowded with the bacilli
of tubercle, and he was reduced to 85 lbs. in weight. In July,
1901, this abscess was opened, drained, and he was put on
the urea treatment, 20 grains thrice daily to begin with. From
85 lbs. in weight in July he rose to 90 lbs. in August, and in
September he was 102 lbs. in weight, not only recovered in his
bodily condition but in his mental, and he was discharged
from the asylum in October. Mentally this patient showed
obstinacy, accompanied with delusions of being poisoned from
time to time throughout his illness (28, 30).

The patient G. A—, one who recovered physically and
mentally and was discharged, showed signs of tubercular
disease of the left apex in January, 1901, when he weighed
150 lbs., his temperature being 100*2° F, in the evenings.
He was ordered urea in 20-grain doses, and in February his
weight rose to 155 lbs. On March 17th he was taking 180
grains of urea daily, and in April he was practically cured, and
on May 6th was discharged recovered mentally. This patient
showed the spes phthisica continually throughout his illness, and
the mental variability of the insanity of phthisis (28). His urine
contained urea varying from 4 to 5 grains per ounce ; this
deficiency lasted for three months.

The patient E. T—, admitted with pulmonary emphysema,

XLIX. 4

Digitized by v^.ooQLe

54 TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

developed phthisis; the right apex gave evidence of disease.
She was, on September 12th, 1902, in bed, her temperature
being ioo° F., and was ordered urea in 20-grain doses thrice
daily. On September 16th she asked for more food, her
constant refusal of which, and suspicions of poison (28), being
the chief mental symptoms up to this time. On September
29th she had gained 12 lbs. in weight. On October 7th her
weight had still improved, the physical signs of disease
in the lungs were much altered for the better, and she was
allowed up on October 14th. She now goes daily to sit in a
sunny spot on the veranda of the ward away from the other
patients. During the last week she has been taking uric
acid, in which time her weight has not increased, nor was any
change seen in the percentage of urea in the urine, which
has remained at from two to three grains in the ounce for weeks.
She now constantly inquires for food, looks brighter, and states
she is much better.

The patient M. S— on September 17th, 1902, weighed
77 lbs. ; her lungs gave evidence of advanced tubercular
disease; her temperature in the evening reached 99 0 F.
Urea was administered in doses of 20 grains thrice daily ; she
had increased 1 lb. in weight on September 23 rd, and on
October 14th she maintained her increase and general physical
improvement Mentally she showed signs of increased activity
(29) by chattering louder and more incoherently than formerly.
The percentage of urea in this case did not rise above three
grains to the ounce at any time it was examined, and on
October 6th it fell to two grains in the ounce.

Another patient, L—, when first taken in hand had been
reduced from 113 lbs., his normal weight, to 102 lbs.; both
lungs were diseased, and a cavity was diagnosed at the left
apex ; his temperature ranged from ioi° F. in morning to
102 0 F. in evening, and his sputum contained numerous bacilli
of tubercle grouped in pairs. He was put on the urea treat¬
ment in the middle of October, 1901, when his weight was
only 102 lbs. The following dates give his increase in weight :

November

1901,

102

lbs.

12,

105

18,

107

27 ,

108

December

4 .

I IO

Digitized by v^.ooQLe

1903-]

BY J. LOUGHEED BASKIN, L.R.C.P.

December n, 1901, 108 lbs.

„ 16, ,, 108 ,,

» 23, „ 113 „

»> 1 1 3 »

On December 5 th an abscess which had formed in the left
groin was opened, and over half an ounce of pus removed.

In January, 1902, he contracted influenza and lost ground,
sinking to 11 oJ lbs. in weight; since then his weight has
fluctuated, but in July it went up to 113 lbs., and his lungs,
which had been extensively diseased in November, were so
much improved that he was able to go on a visit to his friends
and undertake a railway journey. The percentage of urea in
this patient’s urine was at times as low as three grains in the
ounce. The percentage of phosphoric acid in his urine on
analysis showed an increase from the normal 16 per cent . to
18 per cent . (40), probably due to his treatment with the phos¬
phate of urea.

J. A—, admitted as a patient in 1893, when his-lungs were
unhealthy and he suffered from asthma. In September, 1902,
he developed phthisis, and had to give up his work as shoe¬
maker, at which he had always toiled unsparingly. His
sputum contained numerous bacilli of tuberculosis, and his
urine showed a low percentage of urea, on one occasion being
as low in quantity as three grains in the ounce. The phosphoric
acid in his urine showed on analysis a reduction to 1 o per cent.
(26, 40). For the latter reason the phosphate of urea was
administered, 30 grains thrice daily to begin with. He has
put on 6 lbs. in weight during the last three weeks. His
cough is less hacking, and he now seldom expectorates. He
sits in the open air for many hours each day, and his tempe¬
rature last time it was taken in the evening was 98*8° F.
His appetite has much improved, and though mentally he re¬
mains much deluded, he has become very cheerful and optimistic.

Whilst the tissues are being built up by well-prepared and
suitable articles of diet, and the blood enriched by medicinal
aids, such as urea, it is important not to neglect some other
points of treatment, which may be looked upon also as more
or less prophylactic.

1. The patient must have pure air. This is arranged for by
due regard to overcrowding and ventilation ; the more recent
patients here have been isolated as far as possible ; one lives

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

practically the whole of the day in the open air, and two
others spend many hours each day on a balcony where they
are surrounded by fresh air apart from the other patients.

2. A bracing atmosphere is a great desideratum in the
treatment of phthisis. The cold sponging carried out here in
the mornings on patients acts as a tonic, and partially makes
up for any relaxing effects of the atmosphere. Dr. Arthur
Latham, in his address to the Hunterian Society on August
16th (37), refers to the beneficial influence of cold, and quotes
an essay of George Bodington, who wrote, “ Cold is never too
intense for a consumptive patient. ,,

3. It is very difficult to get insane patients suffering from
phthisis to take exercise; this is one of their characteristics
referred to by Clouston in his work on Mental Diseases (25).

The patient in the incipient stage should have gentle
exercise such as walking, and, if possible, “ dumb-bell exercise,”
as suggested by Dr. Harper, but. he must avoid anything like
excess, and, as advised by Niemeyer (2) in his Practice oj
Medicine , vol. i, “he must avoid great efforts in running
and dancing.” This suggestion is particularly applicable in
the treatment of maniacal and excitable patients suffering
from phthisis.

4. With regard to the dryness of the air : nothing can
be done to alter the condition of air moisture out of doors,
but when mist or dampness prevails, or rain is falling, the
patients should remain indoors. This point is one of the
strong factors in the climatic treatment of phthisis. The
relation of the wet winds to the elevation of the phthisical
death-rate in our own county is well shown by Dr. Gordon
in the Lancet of June 15th, 1901, in which he refers to the
low death-rate in the parishes of Gidleigh, Chagford, and
Drewsteignton, where the “ collective mortality from phthisis
during the last ten years has been 0*7 per thousand per
annum.” These parishes are sheltered by the heights of
Dartmoor from the prevalent wet winds ; “ the west wind and
south-west wind have practically no access to them.”

The most sheltered rural district in Devon as regards west
and south-west winds is the Axminster district, and it has the
lowest death-rate from phthisis. In the rural districts of
Barnstaple, of Newton Abbot, and St. Thomas we find the
same relationship between the wet winds and phthisis.

Digitized by v^.ooQLe

1903-3

BY J. LOUGHEED BASKIN, L.R.C.P.

5. The floors especially require attention, as it is here by
spitting, and the action of gravity on small particles of matter,
dibris accumulates. It is not enough merely to wash the floor
or to polish it. By the first you only reduce the numbers of
bacilli on the floor, and by the second you rub what are left
more intimately into the interstices and crevices of the wood.
In the dormitories on the male side in this institution floors are
first scrubbed with an antiseptic soap and water, then a solution
of carbolic acid is applied, of the strength mentioned in Muir
and Ritchie’s Bacteriology calculated to kill the Bacillus
tuberculosis in less than sixty seconds (22) ; the quantity used
is one gallon to the ten square feet. The floor is then
polished with Ronuk, a preparation of wax of a healthy
terebinthine odour.

Dr. Byrom Bramwell, in his late articles in the Lancet
dealing with “ Prevention of Phthisis,” states, “ The rooms in
which phthisical patients live should be kept scrupulously
clean. No dust should be allowed to accumulate in them ; the
floors, walls, etc., should, from time to time, be rubbed over
with a damp cloth. We have seen that the inhalation of dust
tends to produce in the respiratory tract catarrhal and other
conditions which form a suitable nidus for the development of
the tubercle bacillus, and that the inhalation of dust which
contains living tubercle bacilli or their spores is the chief
means by which the tubercle bacillus is conveyed from one
human being to another.” This is another of his precautionary
measures : “ If a phthisical patient should cough into the face
of a healthy person, his nurse, or medical attendant, the
healthy person should immediately blow his nose so far as to
clear out his nostrils, and rinse out the mouth and throat with
some disinfecting solution ” (38). All discharges from tuber¬
culous cases (discharges from diseased bones, joints, glands, etc.)
should be treated in the same way as the sputum, t\e.
immediately disinfected or destroyed.

In order to understand the rationale of the “Urea Treat¬
ment,” it is necessary to briefly consider some facts relating to
urea.

Urea is the diamid of C 0 2 , and is an isomer of ammonium
cyanate. It was first prepared synthetically in 1828 by
Wohler, and was the first organic substance prepared syn¬
thetically by chemists (16). It can be made in a variety of

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

ways, as described in works on organic chemistry (31, 32, 33).
It can be easily prepared from human urine, and the dog's
urine is specially suited for this purpose, on account of the
large urea excretion which occurs in this flesh-eating mammal.
For the purpose of administration to man, it is prepared syn¬
thetically from pure materials, and not derived from any excre¬
tory source (4).

If we study the comparative physiology of urea , we find that
it is generally regarded as the chief end product of proteid
metabolism in mammals, and that further down the animal
scale it finds its homologue in uric acid.

This acid is excreted in such small quantities from the
human being that one authority stated that it may be regarded
as a “vestigial phenomenon connoting the evolution of the
mammal from an ancestor which eliminated its nitrogen as uric
acid" (15), and that the “residuum of uric acid in mammalian
urine may be something in the nature of a vestigial feature,
something analogous to the vermiform appendix or the ductus
arteriosus ” (15). “ The graminivorous birds excrete uric acid

and no urea ; on the other hand, the Carnivora—lions, tigers,
etc.—a quantity of urea, but very little uric acid" (Luff, 5).
Sir William Roberts, comparing the functions of the kidneys of
birds and serpents with those of mammals, considers that an
immense functional evolution has taken place in the mammalian
kidney, and that the evolution of mammalian urine has probably
turned mainly on the point that the mammalian plan required
that the excretion should be voided, not in the solid or semi¬
solid form, but as a watery solution. This modification would
require the discarding of the sparingly soluble uric acid as a
medium for the elimination of nitrogen, and the substitution of
a nitrogenous substance readily soluble in water, such as urea.
He considers it possible that the reason why this substitution
has not been completely effected is that, in that particular, the
mammalian type has not yet reached its ideal perfection, and
that the residuum of uric acid in mammalian urine may be
something in the nature of a vestigial feature.

Let us briefly consider the rble of urea in the body . The
ingestion of proteids, whether as meat, eggs, or cheese, etc., is
always followed in health by an increase of urea in the urinary
excretion in such a manner that the urea is increased, after a
proteid meal, for five or six hours, until it reaches a maximum

Digitized by v^.ooQLe

1903]

BY J. LOUGHEED BASKIN, L.R.C.P.

Meantime it is maintained in the blood at a fairly uniform
standard, I in 3000, and in chyle 2 in 1000 (Laridois and
Stirling). In the renal vein it is half as much as in the renal
artery (Picard), according to Sir Alfred Garrod one third (14).
It is also found in liver, lymph-glands, spleen, lungs, brain, eye,
bile, saliva, and amniotic fluid. Moreover “ it is always present
in the blood of the mammalia, including man” (5).

It is found in the urine in the average proportion of
30 grammes, or from 460 to 500 grains, or a little over an
ounce, in the twenty-four hours ; that is about 2 per cent .

The following facts throw light on its origin from products
of proteid digestion.

When fully decomposed, proteids yield, as their final
products, ammonia and amido acids. Cheese, when it decom¬
poses, breaks up into albuminate of sodium, leucin, and tyrosin ;
in fact, the latter word is derived from the Greek turds , mean¬
ing cheese.

The peptone resulting from digested albumin is further
decomposed in the tryptic digestion into leucin and tyrosin.
Gelatin, which is an albuminoid, and easily obtained from
connective tissue by boiling water, when treated with sulphuric
acid yields ammonia, leucin, and glycocine.

Lysatinine, a product of tryptic digestion of proteids, when
examined is found to consist of the two hexone bases lysine
and arginine; and urea can easily be obtained from the silver
salt of arginine by boiling it with barium carbonate (16).

When leucin or glycocine is introduced into the bowel, urea
is increased in the urine ; moreover in acute yellow atrophy of
the liver the urea is much diminished, and its place is taken by
leucin, tyrosin (8), and ammonia (2 3).

In the Goulstonian Lectures, 1897, we read: “Glycocine
is probably one of the antecedents of urea, for in man glyco-
cholic acid, a compound of glycocine and cholic acid, passes in
the bile into the intestine, and having served its purpose, and
its constituents having been set free, the glycocine, together
with the other amido bodies, passes in the portal blood to the
liver, and probably in the hepatic cells is converted into
urea.”

Ammonia, when administered to man, is excreted as urea (34,
35); and Schroder’s experiments demonstrate that carbonate of
ammonium is an immediate precursor of urea, and Nencki

Digitized by

Google

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

obtained similar results with ammonium carbamate, which is the
carbonate of ammonium minus one molecule of water (16) :

Ammonia

carbonate

■ O + C

< O.NH 4 . Ammonia
O.NH 4 . carbamate

•O + C

/NHj.

\O.NH 4

Urea- 0 + C

NH-.

nh;.

There is no doubt that a certain amount of nitrogen must
come from muscular metabolism, for we know that on the day
following great muscular exertion there is an increase of urea in
the renal excretion ; in muscle, creatine is found in fairly large
quantities, and creatine splits into urea and sarcosin on treat¬
ment with baryta water. Moreover sarcosin + cyanamide =
creatine, and cyanamide + water = urea (i 6). It is also known
that sarcolactic acid is the result of muscular metabolism, and is
found in the blood in small quantities. Some hold the view
that lactate of ammonia is the form in which part of the
muscular metabolic products reach the liver, where it is further
broken up into urea. In birds, when the liver is excluded
from the |drculation, ammonia and lactic acid are found in the
excreta replacing the normal uric acid (17).

From these facts we see that ammonia, leucin, or glycocine
is always amongst the ultimate products of proteid digestion,
and as ingestion of proteid increases the urea excreted, it is
evident that among these is its immediate precursor.

That it is a body of great importance in the human economy
is clear from its universal distribution in the tissues, and its
intimate chemical relationship to them and their metabolic
products, its presence in the blood of man and mammals, its
formation from proteid products of digestion as far back in the
scale of glands as the liver, and its normal percentage in the
urine of the body; and that its beneficial action has been
marked where administered in phthisis is shown in the cases
previously mentioned.

The great deficiency of urea in phthisical urine, especially
when the disease has made progress and the patient is rapidly
wasting away, is so marked that the idea of administering urea
immediately suggests itself. Now, in what conditions do we
find the urea diminished in the urinary excretion ?

1. Where there is diminution in the ingestion of proteid
and every degree of the same leading up to starvation.

2. In toxaemias, such as phthisis, acute yellow atrophy of
the liver, phosphorous poisoning, etc.

Digitized by

Google

1903.] by J. LOUGHEED BASKIN, L.R.C.P. 61

3. In disease of the renal excreting organ, such as chronic
interstitial nephritis.

We are not likely to meet cases of starvation in practice,
and in the recorded case of the fasting man Cetti, whose ten-
day fast has been studied (8) by careful observers, we learn
that the urea excreted fell in quantity from 29 to 20 grms.

We are, however, likely to meet with patients whose intake
of nitrogenous food is very small, and the baneful effects of
such a diet are shown in the high percentage of deaths from
phthisis in races who are small meat eaters, such as the negro.
“ The best specimens of scrofulous glands are to be found in
the open glens and seaside villages around the coast of Ireland
and in the poor parts of Scotland, where the people live on a
diet deficient in nitrogen ” (6)—potatoes, porridge, milk, with
an occasional meal of fish or fat bacon. “ The cow is an in¬
teresting animal from this point of view, as it is the animal
more often attacked with tuberculosis than any other.
Here we have a large amount of energy expended in procuring
a sufficiency of nitrogen from herbs, and a large daily loss in
proportion, in the casein of milk. This process of extraction
of nitrogen goes on far beyond the ordinary period of lactation”
(19). And the most frequent cases of tuberculosis amongst
the animals confined in the Zoological Gardens occur in those
whose diet consists of farinaceous material or vegetables. This
fact is proved by the post-mortem examinations held there (18).
The importance of a highly nitrogenous diet is being more
recognised every day, and the method termed zomotherapy,
of giving raw meat and meat plasma in phthisical cases, as
adopted by MM. Richet and J. Hericourt, has given the most
satisfactory results (9). It may be urged that in the proteid
food administered there should be enough urea to bring about
a cure ; if normally assimilated and the products of digestion
normally dealt with in the proteolytic function of the liver,
probably so ; but in the toxaemia of phthisis, the appetite,
digestive and glandular activities are impaired, usually to such
an extent that the mere giving of proteid food is unavailing.
In such cases the administration of urea—the ultimate repre¬
sentative of those varied proteid substances taken as food, a
ready-made preparation of known strength and character—
removes a burden of work from the failing organs.

In gout and diabetes mellitus, urea is excreted in larger

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

quantities than in health. In the latter disease, in addition to
glycosuria, there is a great drain of nitrogenous matter from
the system in the form of urea and ammonia; phosphoric acid
is also increased in the urine. This abnormal loss leaves the
system depleted of its physiological resistive power; hence the
frequency of phthisis as a complication in the diabetic.

If we consider in reference to this the fact that the white
mouse, which is immune to tubercle, can be made to entirely lose
its immunity by hypodermically injecting dextrose (6), we see
an analogous condition, viz ., the large amount of saccharine
matter in the blood and the susceptibility to phthisis. In
gout, on the other hand, though there is an increase of urea
and urates in the urine, it occurs because there is an excess of
these matters in the system, which, instead of being depleted
of nitrogen, is over-nitrogenised. This leads us to inquire as
to the immunity of the gouty to phthisis, and on this point
there is a great unanimity of opinion.

Gout and tuberculosis are very rarely associated together.
Sir Dyce Duckworth, in his book on gout, states, “I think it
may be fairly affirmed that gout and active tubercular disease
are not often associated. I recognise an antagonistic influence
of the gouty upon the tubercular habit, and agree with those
who find tubercular processes checked often for long periods
and rendered obsolete in virtue of gouty predisposition ” (io).

Sir Hermann Weber states that “ gout is a most favourable
complication of tuberculosis ; out of twenty-five cured pa¬
tients within his knowledge eighteen had developed distinct
gout in some form ” (19).

In Fagge’s Practice of Medicine (11) we find the remark,
“It would be interesting to know how often deposits of urate
of sodium in the great toe-joint are found in bodies which also
show evidence of obsolete or recent disease of the apices of
the lungs. Antagonism between phthisis and gout has also
been generally accepted, and probably not without reason. The
period betweeen 25 and 40 in men is very liable to both
diseases. Yet cases of their concurrence in the same patient is
rare.” How is gout so antagonistic to phthisis? Probably
through the amount of urea in the blood, and its intimate
relationship to *uric acid.

When the metabolism of glycocine (a precursor of urea) is
interrupted in the liver, there is an abnormal formation of uric

Digitized by ^.ooQle

I 9°3-]

BY J. LOUGHEED BASKIN, L.R.C.P.

acid (as shown by Dr. Latham [12] in his Croonian Lectures);
this accumulates, and eventually becomes deposited in the
tissues in combination with sodium, giving rise to some of the
symptoms of gout. Glycocine is capable of combination with
urea to form uric acid, as Horbaczewski has demonstrated ; and,
according to Dr. A. P. Luff, “uric acid is probably formed
from urea and glycocine in health ” (5).

Dr. Latham’s (12) explanation of the formation of uric acid
in the animal economy is that the amido bodies—glycocine,
leucine, etc.—are normally converted in the liver into urea ; but
if from any cause the metabolism of glycocine be interrupted,
there would then be present in the liver glycocine and urea,
which would produce hydantoic acid and then hydantoin, and
the latter, which is freely soluble, would then pass on in the
circulation to unite in the kidneys with urea or with biuret to
form an ammonium salt of uric acid. Moreover, Magnier de
la Source has effected by hydration a conversion of uric acid
into urea, as shown in this equation :

C5H4N 4 0 3 +4 H 2 0 =2 C H 4 N a O + C s H 4 0 5
Uric acid. Urea. Tartronic acid.

And Gerard (13), by the agency of micro-organisms derived
from the air, has also effected a similar result—converting
uric acid into urea.

Bearing these facts in mind, we conclude that if we
administer urea we take one of the steps in the production of
gout We do not wish to produce gout or to push the
administration to the length of causing pain in the joints of
the toe or in the lumbar region ; our aim is to make the blood
so charged with urea as to enable it to effectually overcome
the inroads of the Bacillus tuberculosis .

It may be suggested, Why not administer uric acid ? Our
reasons for not doing so are as follows :

1. Because uric acid and its salts are the direct cause of the
worst physical features of gout, their deposition in the joint
cartilages producing the excruciating agony associated with
the gouty paroxysm.

2. Because irregular gout often shows itself by functional
disorders in many organs of the body, in which cases there is
not that excess of uric acid salts necessary to lead to the
deposition of tophi or production of “ gouty toe” (39).

Digitized by

Google

6 4

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

3. Because in health there is merely a trace of uric acid in
the blood, according to some physiologists, and Sir Alfred
Garrod and Dr. Luff state that there is none in the mammalian
blood, or in the blood of birds, whose nitrogen is eliminated
as uric acid (5, 14).

4. Because it is insoluble in ordinary media, and trouble¬
some to administer internally on that account.

5. When taken internally it is partly excreted as urea
(Landois).

6. That in diseases where its presence is highly marked in
the blood, as in leucocythaemia and severe anaemia, diarrhoea
is a common symptom (21).

7. Its taste is disagreeable, and no improvement followed
its administration to patients here, or the administration of
urate of sodium.

Urea, on the contrary, does not cause the pain referred to
above ; it is also present in irregular gout in the blood, and
highly in the urine of the same. It is found in the blood of
mammals and birds in health, and it is soluble in the ordinary
media employed in pharmacy. It has a not unpleasantly
bitter taste, acts as a sialogogue, and improves the appetite.
Patients have increased in weight during its administration, and
in one case particularly, where there was no addition whatever
to the proteid allowance he was on at the time of the onset of
his illness, there was a steady improvement in nutrition.

Pure urea is the best form to administer, on account of its
more pleasing taste and rapid solubility in ordinary media,
water, etc., at ordinary temperatures. Care must be taken not
to heat the solvent employed to a high temperature, as the
urea is then decomposed into ammonium carbonate ; nitrous
add also breaks it up into free nitrogen, carbonic acid, and water.

The phosphate of urea is very soluble in water, and has
been administered in phthisis, where there is a marked dimi¬
nution of phosphoric acid and urea.

The nitrate of urea is soluble in water, but not so freely
when any nitric acid is present. It has a very acrid taste ; it
forms beautiful crystals of the rhombic system when carefully
prepared.

Now with regard to the dosage of urea; we find urea
present in the urine of the tuberculous in varying proportions,
but nevertheless there is a constant deficiency; we use this

Digitized by ^.ooQle

BY J. LOUGHEED BASKIN, L.R.C.P.

I 9 O 3 ]

deficiency as the basis on which to calculate the dose. If we
take urine with only two grains of urea in each ounce, it is
clear that seven grains are wanting in each ounce to bring the
urine up to its normal 2 per cent . strength of urea. In the
excretion of forty ounces of such urine in the twenty-four
hours 280 grains are necessary to bring the complement of
urea up to its normal in the time ; in fifty ounces of excretion
350 grains are necessary. But as the activity of the patient
is much reduced during his sleeping hours, and as during this
time he usually takes neither food nor drink, we can eliminate
them from the calculation, and this leaves us, say, twelve hours
to consider, the urine of which time will require 140 grains to
bring it to its normal. This is the point on which the dosage
principally hangs, so that 140 grains per diem can be adminis¬
tered in suitable doses three times, with intervals of four
hours between each dose. If the patient is particularly weak
and advanced in disease the full 46*6 grains may be given
thrice daily; if he is less seriously ill a smaller dose will suffice.
If the urine contains, say, four grains per ounce of urea, then
the deficit in the twenty-four hours in fifty ounces of urine
would be 250 grains : 9 grains — 4 grains = 5 grains x 50
= 250 grains, i.e. 125 grains in the twelve hours of day,
12 5“ 4 “3 == 4 1# 6 grains at each dose, and as children excrete
more urea relatively to their body weight than adults (21), no
difference should be made in the principle of dosage.

This quantity of urea should be given in cases where there
is ample intake of nitrogenous food and no improvement in
the urine; where the patient has not been having sufficient
proteid diet, it is wise to increase the amount of proteids
(meat, etc.) concurrently with a smaller dose of urea. Harper
usually begins with 15 grains or 20 grains thrice daily, and
increases it by increments of 10 grains until the patient is
consuming 60 grains thrice daily.

That the urea treatment may give rise to uraemia is im¬
probable. There have been no symptoms of uraemia in any of
the patients taking the urea. On no occasion has there been
the delirium, coma, or convulsions pointing to the nervous
type of uraemia, nor has there been any nausea, vomiting, or
diarrhoea pointing to the gaLStro-intestinal type, and these
u latter symptoms are remarkably constant ” (Dr. Rose
Bradford) (21).

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

The view that urea is the direct cause of uraemia is not held
now. Many patients dying of uraemia excrete I o to
12 grammes of urea in the last twenty-four hours.

The blood normally contains *015 percent, of urea. Now,
in renal disease without uraemia this may increase to *15 per
cent., and this when the patient is at the time excreting
quantities of urea within the limits of health.

No one has been able to produce all the symptoms of
uraemia by injection of urea, but the blood, in ordinary cases
of uraemia, contains a large excess of nitrogenous extractives.

Peris and Schottin suggested that abnormal metabolism
might produce toxic substances in the blood, giving rise to
uraemia, the percentage of extractives found in the blood and
muscles in uraemia being far greater than that found in com¬
plete calculous anuria (21). Moreover, the phenomena are not
those of simple suppression.

Dr. Rose Bradford shows that when available kidney substance
is reduced by experiment, there is a considerable increase of
nitrogenous extractives found in the tissues, due to their
abnormal metabolism, for the urea and the urinary water
excreted are both increased (21).

That urea decomposes into ammonia carbonate in the blood
(24), and that its toxic effects show themselves in uraemia, was
the view held by some, and we know that a direct application
of ammonia carbonate to the cerebrum causes some of the
symptoms of uraemia. Again, creatin, or creatinin urates, or
acid potassic phosphate, when so applied, cause all the symptoms
of uraemia ; not so urea (Landois).

Bouchard holds that urea is not the toxic body, but that the
toxic or poisonous matters are the pigmentary bodies and salts.
He found, by comparing the amount of the urine injected with
the weight of the animal, that he could get an equivalent, which
he termed uro-toxic equivalent, and that in rabbits 25 to 7 5 c.c.
of urine per kilogramme of the body weight was fatal (21).

Dogs have died in convulsions after the subcutaneous injec¬
tion of urea equal to 1 per cent, of their body weight; that this
is an enormous quantity will be seen from the data, that a dog
weighing 2 5 lbs. would have a £ lb. of urea injected into his
system ; but these convulsions are different to the intermittent
convulsions of uraemia. Dr. Harper has administered 120 grains
in one dose (7), without any of the symptoms of uraemia, to

Digitized by v^.ooQLe

1903]

BY J. LOUGHEED BASKIN, L.R.C.P.

6 7

phthisical patients, and without any increase in the urine of
urea; and I have administered 180 grains of urea to two
patients, and 190 grains to another, in the course of twelve
hours, without any ill effect. Moreover, the urine did not show
any increase in the amount of urea excreted.

Bernard, Traube, Feltz, and Ritter, all ascribe the symptoms
of uraemia to an accumulation of the neutral potassium salts in
the blood (Landois), and we know that the acid potassic phos¬
phate, when applied to the brain, produces symptoms of
uraemia. These facts show that urea can be administered with¬
out any fear on the part of the practitioner that he may
produce uraemia.

Action of Urea in Tuberculosis; ways in which it may Act.

1. It may enable white blood-corpuscles to do more work,
*. e. increase phagocytosis.

2. As a solvent for the bacilli of tuberculosis it may have a
local action.

3. As a general alterative.

4. As a specific anti-toxin to the toxin of the tubercle germ.

1. That uric acid may in the body be formed into urea

under certain conditions is well known. Horbaczewski pro¬
duced uric acid by the interaction of urea and glycocine. This
fact has been confirmed by Dr. Latham ; and that uric acid is
formed from the leucocytes is held by some on the grounds
that in leucocythaemia where uric acid is present in the blood,
it is formed from the nuclein of the leucocytes. Again, a
relationship is found between the number of leucocytes in the
blood and the excretion of uric acid, and is observable in
human beings during fasting and after taking food.

During fasting the number of leucocytes falls, and the
amount of uric acid excreted falls. After taking food the
number of leucocytes increases, and the uric acid excreted
rises. Horbaczewski concluded from experiments that uric
acid is formed in health by the disintegration of nuclein, and
that sudden variations in uric acid production may be due to the
breaking up of leucocytes and the conversion of their nuclein
into uric acid. It has been shown by many observers that
there is an increase of uric acid excretion following a temporary
or permanent leucocytosis. Now we know that in the forma¬
tion of pus and in the other phagocytic actions of the leucocytes

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS, [Jan.,

a certain number become hors de combat . This is quite to be
expected in phthisis, with its pus-containing cavities and its
virulent bacteria, and their attendant virulent decomposition
products ; and if urea aids in the creation of uric acid which
draws usually upon these leucocytes, it is clear that more of
them are left free to attack the bacilli and its products than
would have been the case if no increase of urea had been added
to the forces of the blood.

2. That it is a certain destroyer of the bacilli tuberculosis we
know from the experiments of Harper, who states that (a) a i
per cent, solution of pure urea added to a virulent culture of
the bacillus tuberculosis inhibits the growth of the bacillus in
the test-tube in the incubator, and that (b) a 3 percent, solution
of urea used in the same way not only inhibits the growth but
kills the bacillus (7). We know that the blood usually contains
*015 per cent, of urea, and the conditions of the body are so
different to those of an incubator that it is probable that a
solution of urea which outside the body kills the germ may in
the body, with the assisting power of the leucocytes, who are
now especially free for phagocytic purposes, act as a direct
destroyer of the bacillus. That it acts as a solvent on the
bacillus has not yet been demonstrated, but the results of the
researches of Dr. Ransom (Oxford) read before the British
Medical Association in July last show that connective tissue was
readily dissolved by urea solution, that the myelin sheath of
nerve was rapidly altered and presented appearances similar to
those of degeneration, that gelatine was readily dissolved in it,
that coagula formed on heating solutions of native proteid were
dissolved, and, finally, that a dead frog placed in a saturated
urea solution soon became translucent and fell to pieces.

3. That it acts as an alterative to the cell ; it may do so in
the same way that mercury and iodide remove the masses of
round-celled growths in syphilis. The urea may hasten the
life processes of the young cells so much that the cells
disappear in the form of products, or, as is commonly ex¬
pressed, are absorbed. Such cells are found around the tuber¬
cular nidus(36). Again, the natural disposition of all tissues is to
return to the normal; the protoplasm of the cells supplied with
the urea is probably induced to return to its normal state, for
we do not find urea so extensively distributed through the
body as it is for no useful purpose.

Digitized by v^.ooQLe

1903]

BY J. LOUGHEED BASKIN, L.R.C.P.

4. That it acts as an anti-toxin. We know that there are
anti-bodies in the blood. If we treat an animal by injections
of a bacterial poison we get a blood serum, which, like the
anti-diphtheritic serum, neutralises this poison ; if we inject
bacteria into an animal we get a serum which kills the same
kind of bacteria ; if we inject blood-corpuscles from one animal
into another we get a serum which dissolves this kind of blood-
corpuscle ; if we inject milk of one animal into another we get
a serum which coagulates ttyis sort of milk, and so on. To
speak more generally, by injections of many different foreign
cells and foreign substances we get sera which counteract in
some way the foreign body injected ; we get antagonistic sera,
anti-sera ; the action of these sera we ascribe to substances
which we term anti-bodies (20).

In ordinary health we breathe in innumerable bacilli of
various kinds, we swallow them in our food, and yet we don’t
contract the disease which they may produce under other con¬
ditions. Why? Probably because of these anti-bodies. Now
the blood is, so to speak, a standard solution possessing
special characters which no other solution possesses, and
not least amongst the uses it is put to by the body is that of
being a medium for the conveyance of such substances as urea,
carbonate of sodium, white corpuscles and red corpuscles, and
their oxygen. And it is probable, as we have seen, that the
formation of uric acid from urea and glycocine can allow the
leucocytes a freer hand ; that they take advantage of this
opportunity to assist in the formation of anti-bodies. And that
they may do so is feasible from the results obtained by
Besredka, who found that the smallest quantities of leucotoxic
or leucocyte-killing serum would cause an increase in the
number of leucocytes in the blood ; and the fact found by
Cantacuzene that the smallest quantities of haemo-preparing
serum stir up the production of new erythrocytes, and referred
to by Dr. Max Gruber in the ‘ Harben Lectures’ for 1901.

Bibliography and References.

1. Report of the Tuberculosis Committee, 1902.

2. Niemeyer, Practice of Medicine^ vol. i.

3. ‘Practical Choice of Climate in Phthisis,* W. Gordon, M.D.,
Lancet , June, 1901.

4. Messrs. Merck, Manufacturing Chemists, Dresden, Letter on
‘ Synthesis of Urea.*

XLIX. 5

Digitized by v^.ooQLe

TREATMENT OF PHTHISIS IN ASYLUMS. [Jan.,

5. Goulstonian Lectures, 1897, Arthur P. Luff, M.D.

6. Lancet, December 7th, 1901, June 15th, 1901, March 9th, 1901,
Brit. Med. Joum., October, 1902, ‘Pure Urea in the Treatment of
Tuberculosis,* Dr. Henry Harper.

7. Letter on ‘ Bacteriology of Phthisis and the Treatment of Tubercle
Cultures with Urea,* Dr. H. Harper.

8. Landois and Stirling, Physiology (last edition), vol. i.

9. ‘Zomotherapy in Phthisis/ Practitioner , July, 1901.

10. Sir Dyce Duckworth, ‘Treatise on Gout,* 1889.

11. Fagged Practice of Medicine, articles on ‘ Gout * and ‘ Phthisis/

12. Croonian Lectures, 1886, P. W. Latham, M.D., Lancet,
April 3rd, 10th, 17th, 24th, May 1st

13. Comptes Rendus, 1896, pages 185—187.

14. Lumleian Lectures, 1883, Sir Alfred Garrod.

15. Croonian Lectures, 1892, Sir William Roberts.

16. Text-book of Physiological Chemistry, Halliburton.

17. E. A. Schafer Text-book of Physiology , article on ‘ Urine/ by Dr.
Gowland Hopkins.

18. British Medical Journal , 1899, page 64, ‘Zoological Distribution
of Tuberculosis/

19. Brit. Med. Journ ., August 3rd, 1901, Dr. Buck at Congress on
Tuberculosis.

20. Harben Lectures, 1901, ‘ Bacteriolysis and Haemolysis/ by Pro¬
fessor Max Gruber, M.D.

21. System of Medicine, Allbutt, vol. iv.

22. Manual of Bacteriology, Muir and Ritchie, 2nd edition.

23. Essentials of Chemical Physiology , W. D. Halliburton.

24. The Practice of Medicine, Frederick Taylor, M.D.

25. T. S. Clouston, M.D., ‘ Treatise on Mental Disease/

26. ‘ Variations in the Phosphates and Urea of Urine/ E. G. Clayton,
F.C.S., Lancet, September 6th, 1902, page 656.

27. Journal of Mental Science , April, 1901, page 231.

28. Insanity and Allied Neuroses, George H. Savage, M.D., article on
‘ Phthisis and Insanity/

29. Dictionary of Psychological Medicine, D. HackTuke, M.D., article
on ‘ Insanity of Phthisis/

30. W. Bevan Lewis, Text-book on Mental Diseases.

31. Organic Chemistry, Emerson Reynolds, M.D., T.C.D.

32. Pharmaceutical Chemistry, J. Attfield.

33. Text-book of Chemistry, I. Remsen.

34. Materia Medica and Therapeutics, article on ‘ Ammonia/ J.
Mitchell Bruce, M.D.

35. Materia Medica and Therapeutics, article on ‘ Ammonia/ Sir W.
Whitla, M.D.

36. Introduction to Pathology and Morbid Anatomy, T. H. Greene.

37. Lancet, August 16th, 1902, page 420.

38. Lancet, September 20th, 1902, ‘ The Causation and Prevention of
Phthisis/ Dr. Byrom Bramwell.

39. ‘ Uric Acid as a Factor in the Causation of Disease,’ A. Haig.

40. Clinical Research Association.

Digitized by ^.ooQle

1903.] ALKALINITY OF BLOOD IN MENTAL DISEASES.

The Alkalinity of the Blood in Mental Diseases. ( l ) By
Robert PUGH, M.D.(Edin.), Assistant Medical Officer,
London County Asylum, Claybury.

During the past year I have been engaged in a research
on the reaction of the blood in various forms of mental
disease. Whilst this and previous similar researches by other
workers have not so far contributed largely to our knowledge
of the pathology of mental diseases, several important results
have been obtained which have a direct bearing upon the
treatment of these diseases, especially that of epilepsy. I will
shortly describe the method used in the research, the physi¬
ology and pathology of the blood-serum, and the variations
which the alkalinity of the blood undergoes in various forms
of mental disease.

Method .—Under normal conditions the reaction of the human
blood is alkaline. The alkalinity is due to the presence of two
salts, bicarbonate of soda, NaHCO s , and disodic phosphate,
Na 2 HP 0 4 . These two salts are acid salts, and are readily
dissociated when brought in contact with litmus, forming a
coloured salt. Thus the blood is an alkaline fluid in virtue of
these two salts, which are bases in combination with very
weak acids.

Up to the present time various investigations have been
carried out and different methods used to estimate the
alkalinity of the blood. The earlier investigators used the
titration method with the organic acids. Zuntz (1) titrated with
phosphoric acid, Lassar (2) with oxalic acid. These methods
were improved upon by Landois (3) and this has been in
extensive use; the objections to this method are that for
clinical purposes it is too elaborate, that too much blood is
required, and it takes too much time. The method used in
this investigation is that introduced by Wright (4). This method
has obvious advantages over the others, and these are, the
quantity of blood required is small; the red blood-corpuscles
are completely separated from the serum ; the alkalinity can
be tested in a few hours, during which time the stable equili¬
brium of the serum and plasma is fixed—and from a clinical
point of view the alkalinity of the serum is the more important,
because it comes into such close contact with the tissues, and

Digitized by v^.ooQLe

ALKALINITY OF BLOOD IN MENTAL DISEASES, [Jan.,

may be taken as an index to the changes taking place in the
circulating blood.

The method requires a brief description. The necessary
apparatus consists of a couple of glass tubes for receiving the
blood, which is drawn off from the thumb; of one or two
capillary pipettes for measuring and mixing the serum with
the titrating acid ; and of half a dozen watch-glasses. The
blood-tubes and the capillary pipettes are made by drawing
out pieces of ordinary glass tubing, after heating in a flame.
The necessary reagents consist of (a) red litmus paper ;
and (£) a series of dilutions of a standardised solution of
sulphuric acid.

The thumb is cleansed with soap and water, and sterilised
with a 5 per cent . solution of formalin ; a solution of carbolic
acid is inadmissible, as it interferes with the reaction of the
blood. The thumb is pricked with a blunt-pointed instrument,
and a copious supply of blood is obtained.

The tube must be filled in such a manner that one of the
ends may remain perfectly free from the blood. The ends of
the tube are then sealed up in the blowpipe flame ; the tube is
inverted and suspended for a period varying from three to
twenty-four hours. A capillary pipette is inserted into the
serum, and the serum is allowed to flow in until it occupies
2 cm. of the stem of the capillary pipette ; then a mark is made
with a blue pencil. The end of the pipette is now quickly
inserted into a solution of acid of a known strength, and the
acid solution allowed to run in until the lower end of the serum
column runs up to the blue mark. In this way an equal
quantity of serum and an acid of known strength is obtained.
The contents of the tube are blown out on to a clean watch-
glass and thoroughly mixed with the end of the pipette. This
process is repeated until the contents of the tube are thoroughly
mixed. Finally, a series of drops is blown on to the surface of
the litmus paper, the reaction is noted, and if the neutral point
has not been accurately estimated, fresh titrations are carried
out with acids of greater or less strength until the neutral
reaction is obtained.

The alkalinity has been returned as the amount of H 2 S 0 4
in i c.c. of acid, which would exactly neutralise i c.c. of
blood-serum. Thus, by the result, alkalinity 1*385, is meant,
that 1000 c.c. of a solution containing this amount of H 8 S0 4

Digitized by v^.ooQLe

1903.] BY ROBERT PUGH, M.D.(EDIN.). 73

would exactly neutralise the alkaline properties of 1000 c.c. of
the blood-serum.

Physiology .—The alkalinity undergoes a diurnal variation,
being lowest in the morning, gradually rising in the afternoon,
becoming less again in the evening (5). It is increased during
digestion owing to the passage into the circulation of sodium
carbonate, which is formed by the production of HC 1 acid
from the sodium chloride in the cells of the stomach.
It is decreased after severe muscular exercise, owing to the
entrance into the circulation of the acid products of muscular
metabolism, e . g . 9 sarco-lactic and carbonic acids. Apart from
these two conditions, the alkalinity is maintained at a constant
level, and may be taken as an index to the amount and
activity of oxidation within the tissues, between the blood and
the various tissues ; also upon it depends the activity, the
well-being, and the fighting power of the leucocyte. Recent
observations tend to suggest that there is a relationship between
the alkalinity and immunity, that the higher the alkalinity
the more resistent is the individual to disease from bacterial
infection.

Pathology .—Numerous observations are recorded noting the
changes in the alkalinity in disease. These changes are con¬
stant, and manifest themselves in a lowering of alkalinity,
probably owing to the presence in the blood of acid products,
lactic, uric, and butyric acids.

1. In diseases of the blood. —Simple anaemia; pernicious
anaemia ; leucocythaemia.

2. In febrile and cachectic conditions .—The diminution in fevers
is probably due to the insufficiently oxidised acid products
formed by the tissue destruction.

3. In all toxic conditions .—In diabetes, and especially in
diabetic coma ; in uraemia, jaundice, gout, and rheumatism.

4. In certain fnental diseases .—Especially in epilepsy (6) and
general paralysis (7).

In obtaining the normal alkalinity, control cases have been
selected from the staff of Claybury Asylum—the physicians,
clerks, and attendants. Care was taken to avoid the times
during which the alkalinity is said to vary, e. g . 9 after food and
after severe muscular exercise. Blood was taken at a stated
time, 11 a.m., on successive days from each case; the highest
yalue obtained was 1*806, the lowest 1*538. In all, twenty

Digitized by v^.ooQLe

74 ALKALINITY OF BLOOD IN MENTAL DISEASES, [Jan.,

cases were examined, and these cases showed an average of
i•662. The reason why the control cases are not taken from
one class is to show the constancy of the alkalinity—that in
spite of the different conditions of living, such as diet, habits,
etc., the alkalinity is maintained at a constant value, and varies
within physiological limits.

Epilepsy .—Blood was taken from each patient at 11 a.m. on
successive days.

a. During the inter-paroxysmal period. (By this is meant a
minimum interval of seven days between the seizures.)

b. During the aura.

c. After the paroxysm , a period varying from ten minutes to
twenty-four hours after a fit.

Forty cases were examined.

I will select one case, and describe shortly the changes in
the alkalinity:

A. B—, aet. 18. Duration of epilepsy, four years ; bodily
condition fair.

Family History. —Father intemperate, died of acute Bright’s
disease, aged 36 ; mother alive and healthy; six children, four
boys, two girls. Patient is the fifth child ; the youngest child
is also an epileptic.

History of Fits. —Developed his epilepsy when nine years of
age. His mother states that he had a fall on his head when
six. On an average has seven fits a month ; grand mal ; two
minutes before a fit his right eyelids twitch. Recovery from
mental confusion takes place in two hours.

Inter-paroxysmal alkalinity, 1*538. Fit, 8 a.m.; blood taken
at 11 a.m.; alkalinity, 1*385; blood taken at 2.30 p.m.;
alkalinity, 1*538.

Blood taken 60 seconds before a fit—alkalinity, 1*26

£ hour after a fit

i*i 8

1 ..

1*26

2 hours

!'43

1 *48

24 »

1-58

These results show clearly that the alkalinity of the blood
undergoes marked variations in epilepsy. These variations are
constant, and manifest themselves in a diminution.

1. The average alkalinity during the inter-paroxysmal period
is lower than the average of the control cases.

Digitized by v^.ooQLe

1903-] BY ROBERT PUGH, M.D.(EDIN.). 75

2. There is a sudden and pronounced fall immediately prior
to the onset of the fit.

3. There is a further diminution after the fit is over.

The Diminution in the Inter-paroxysmal Period. —All the
cases studied showed this diminution, with the exception of two
senile cases. The lowest values of the alkalinity obtained
during this period were from cases suffering from gastric
catarrh and constipation. This diminution may be explained
by the gradual accumulation of toxines of an acid nature in the
blood, or it may be the result of deficient metabolism of the
body tissues generally.

The fall immediately prior to the onset of the fit is difficult to
account for, also the time at my disposal is too short to deal
with the matter fully.

The further diminution after the fit is over is easily
explained ; it is apparent soon after the fit is over, and lasts
for some hours. The alkalinity gradually rises, the rise being
more marked in the first hour; the return to the normal varies
in the different cases, and on an average takes from five to six
hours. This diminution is directly due to the acid products of
muscular metabolism, e.g ., carbonic and sarco-lactic acids
generated during the violent tonic and clonic spasms of the
epileptic seizure. This phenomenon is physiological, and is
seen, though in a less degree, after muscular exercise. The
diminution is scarcely perceptible in cases of petit mal. The
variations in the fall met with in the different cases depend upon
the number of fits, and the duration and severity of the muscular
spasms. These facts, together with the appearance of the fall
after the spasms are over, and the gradual rise to normal, seem
to prove that this diminution is muscular in origin.

Dementia Paralytica. —Twenty-three cases were examined,
and these were classified according to the different clinical
types of the disease.

1. Juvenile General Paralysis .—Two cases.

2. Ordinary Chronic General Paralysis. —Cases with dimin¬
ished knee-jerks, dilated pupils, and not subject to con¬
vulsive seizures. Eight cases.

3. Acute General Paralysis ,— Cases which run a rapid
course, pupils contracted, knee-jerks exaggerated, and subject
to convulsive seizures. Eight cases.

4. Tabetic General Paralysis. —Five cases.

Digitized by v^.ooQLe

76 ALKALINITY OF BLOOD IN MENTAL DISEASES, [Jan.,

The examination of the blood of these groups of cases was
very instructive, and all showed a low value of alkalinity, much
below the average of the control cases; in fact, the highest
value obtained in some of these cases, and these were the
juvenile general paralyses, was below the lowest physiological
limit of the normal alkalinity. The diminution varied in the
different groups ; the acute cases (Group 3) showed the greatest
diminution, the juvenile cases (Group 1) the least. The
lowering of the alkalinity in this disease is constant, well
marked, and varies according to the type, duration, and
progress of the disease.

The lowering of alkalinity by concurrent diseases, and by
the products of muscular metabolism, is ruled out in this
disease, although these factors may cause a slight and tran¬
sient diminution in the early stages. The diminution may
be regarded as a phenomenon directly associated with
general paralysis, due to bio-chemical, abnormal metabolic
and degenerative changes taking place in the central nervous
system. This persistent lowering of alkalinity may have a
different origin from the various degrees of diminution met
with in epilepsy, though the factors referred to in the case of
the former probably act in the latter. The additional factor in
the diminution is probably the general auto-toxaemia which
occurs in the progress of this disease. This general auto-toxae-
mia manifests itself by the presence of choline, neurine and
glycero-phosphoric acid in the circulation. This is supported
by the fact that more choline is found in the blood of cases
suffering from acute neuronic degeneration, in which class of
cases the alkalinity is lower than in the more chronic variety
of the disease. Other factors which tend to maintain a low
value of alkalinity are—deficient excretion of the neuronic
products by the kidneys ; deficient neutralisation by the secre¬
tions of glands ; and the relative incompetence of the leucocytes.
The most marked diminution in this disease occurs in con¬
nection with the convulsive seizures, and the more acute the
case the greater the diminution. In two of the cases, where
the blood was taken after seizures occurring a short time before
death, the alkalinity was found to be very low compared
with the reduction found in cases of status epilepticus . The
cause of this somewhat marked lowering before death is
probably the terminal auto-intoxication which occurs in

Digitized by v^.ooQLe

>903]

BY ROBERT PUGH, M.D.(EDIN.).

practically all the cases of the disease which do not die
suddenly from some accidental cause, such as pneumonia
and cardiac failure alone, or following a sudden series of
seizures.

Dementia .—Ten cases were examined. These included the
different varieties of dementia. All the cases were in good
bodily condition.

Secondary Dementia .—Six cases. Alkalinity, 1662,
1731, 1*662, 1*59, 1*662, 1*662.

Senile Dementia .—Three cases. Alkalinity, 1*59,
1*662, 1*662.

Organic Dementia .—One case. Alkalinity, 1*662.

The alkalinity in these cases does not undergo any marked
variation, but varies within physiological limits. Observations
were carried out on the blood of these patients after manual
labour. They were sent out to work on the farm, and
immediately on their return their blood was taken and tested ;
the alkalinity was found to be lowered below the lowest
physiological limit.

Mania .—In this disease fifteen cases were examined, of
which ten were cases of acute mania and the remaining five
were cases of chronic mania.

In the acute cases, and especially those who suffered from
intense motor restlessness, the alkalinity was reduced. This
diminution varied according to the restlessness of the case ; the
more restless the patient the greater the fall, and as the
patient became quiet there was a gradual rise of the alkalinity
to normal. During comparative repose the alkalinity remained
within its normal limits.

The chronic cases did not show a lowering of alkalinity, and
it was maintained at a fairly constant value, except during
periods of excitement, when there was a slight lowering of
alkalinity.

Melancholia .—Ten cases were examined. Of these eight
were acute cases ; they were very miserable and depressed ;
the remaining two were chronic cases.

The alkalinity in these cases was fairly constant, and varied
within the normal limits. One case showed a persistent
diminution ; the writer is of opinion that this bears no relation
to the disease, and is explained by the fact that the patient
suffered from mitral disease and chronic rheumatism.

Digitized by

Google

78 ALKALINITY OF BLOOD IN MENTAL DISEASES, [Jan.,

Conclusions.

1. The alkalinity of the blood is physiological in chronic
mania , melancholia , and dementia.

2. It is lowered in cases of mania, during the period of
excitement.

3. It undergoes marked variations in epilepsy , e.g .:

a . It is below normal during the inter-paroxysmal
period.

b. It undergoes a sudden and pronounced fall imme¬
diately prior to the onset of the fit.

c . It undergoes a further diminution after the fit
is over. This after-diminution depends upon the length
of time, the severity of the muscular spasms, and the
degree of the alkalinity in the inter-paroxysmal period.

d. There is a gradual return of the blood to its
normal alkalinity, which takes place in five to six hours.

e . There is a relationship between the degree of
the alkalinity and the onset of fits, e.g., the higher the
alkalinity the less liable is the patient to have a fit.

f. It is impossible to elevate and maintain the
alkalinity within physiological limits for any appreciable
length of time by the administration of drugs.

4. It undergoes a diminution in dementia paralytica. This
diminution is constant and well marked, and is probably due
to the products of neuronic degeneration in the circulation.
The variations in the diminution met with depend upon the
type, progress, and duration of the disease.

References.

1. Zuntz, Centralblatt fur die Medicinischen Wissenschaften , 1867.

2. Lassar, Archiv fiir die Gessammte Physiologic , Bona, 18.

3. Landois, Rial Encyclopedic , iii, p. 161,‘1885.

4. Lancet, vol. ii, 1897, p. 719.

5. Schafer’s Physiology , vol. i, p. 719.

6. Charon et Biche, Archives de Neurologic , 1897, p. 24.

7. Lui, Rivista Sper. di Freniatria , 1898, p. 1.

Digitized by v^.ooQLe

Table I .—Showing the Alkalinity during the Aura and varying periods after the Epileptic Seizure.

1903.] BY ROBERT PUGH, M.D.(EDIN.).

Digitized by v^.ooQLe

8 o

ALKALINITY OF BLOOD IN MENTAL DISEASES. [Jan.,

Table II .—Showing the Alkalinity in the various Clinical Types
of Insanity and of Dementia Paralytica.

Case.

Type.

Alkalin¬

ity.

Alkalin¬

ity.

Chronic G.P.

1-48

1*48

1-538

1*48

148

x *43

i*43

x *43

1 59

1538

i'43

x *43

>•385

•831

After a severe convulsive seizure.

1-48

i- 4 8

Juvenile G.P.

1662

1*662

Acute G.P.

1'43

x '43

1-385

•6925

After numerous seizures.

>•385

1-385

1*26

*5935

After seizures, and just before death.!

1385

*5935

ii fi ii

x *43

1*26

1*18

*831

After a slight seizure.

x 9

Tabetic G.P.

1*48

„

x *59

1-538

i*43

x *43

1*48

i- 4 8

1*48

Dementia.

Secondary D.

1*662

1*48

After severe muscular exercise.

x 73 x

1-538

11 ff ii

1*662

1*48

tt ft n

i*59

1-385

>f if fi

1*662

148

a n if

1*662

1*48

Senile D.

x *59

1-48

1* fi fi

1*662

x *43

1* 11 if

1*662

1*48

f* 11 n

Organic D.

1*662

1*48

11 n 11

Mania.

Acute Mania

1*662

1*48

After a period of excitement.

1*662

x ‘73 x

x *59

24 hours after a period of excitement.

1*662

x *59

1-48

Acutely maniacal.

1*662

x *59

1*662

1*48

x *59

x *43

3 hours after a period of excitement.

x *59

Chronic Mania

x 73 x

1*662

1*48

After a period of excitement.

1*662

x *59

Digitized by t^.ooQLe

1903]

ABNORMALITIES OF THE PALATE.

TABLE II— continued.

Case.

Type.

Alkalin¬

ity.

Alkalin¬

ity.

ELANCHOLIA. |

Acute Mel.

1*662

i 2

i *59

r 4 8

Mitral disease chronic rheumatism.

1 3 '

1*662

i *7 3 i

1 4

i *7 3 i

1*662

1 5 1

99 I

i *59

1 6 1

i *59

1*662

1731

Chronic Mel.

1*662

”

r 59

1*662

C 1 ) Prepared for the Autumn Meeting of the South Eastern Division, held at
Chiswick House, October 29 th, 1902 .

The Abnormalities of the Palate as Stigmata of De¬
generacy . By E. H. Harrisson, M.B., B.C., B.A.(Cantab),
Acting Assistant Medical Officer, Claybury Asylum.

The study of, in many cases trivial, bodily variations and
deformities has for many years attracted much attention from
a large field of workers, and in no part of this sphere has this
study been more elaborated than in that including the criminal
and the lunatic. As examples of these studies may be
mentioned the numerous papers which have been written,
giving copious and precise details concerning the anatomical
configuration, the complexion, the shape of the ear, nose, etc.,
and the physiological eccentricities in certain types of criminal.
Of these variations and deformities none have been more
thoroughly studied, and at the same time been the subject of
more discussion and difference of opinion, than those connected
with the shape, size, and general development of the palate.

Owing to the exceptional opportunities enjoyed by the
author at Claybury during the past few months, it has been
possible for him to add a further contribution to this subject
which, owing to difference of method, etc., has, in his opinion.

Digitized by t^.ooQLe

ABNORMALITIES OF THE PALATE,

[Jan.,

enabled him to throw more light on the subject. In this
connection he wishes to express his deep gratitude to Dr.
Robert Jones, of Claybury, for his kindness in allowing him to
make full use of the ample material in the asylum, and also for
his valuable advice.

Very many authors have written on the abnormalities of
the palate. Some thirty years ago Dr. Down(*) appears to
have first called attention to the existence of a narrow palate
in idiots, his observations being founded on a study of 200
cases.

A little later Dr. Norman W. Kingsley, an American dentist,
examined the palates of 200 of the idiots on Randall’s Island.
He differed in his conclusions from Dr. Down, and even on
continuing his investigation he only found that from 5 to 10
per cent . of the patients suffered from any reasonable degree of
palatal abnormality. He concluded that the palates of idiots
did not differ to any appreciable extent from those of the
ordinary patients who came to him for treatment The
conclusions drawn by these observers seem to have been
arrived at by simple naked-eye inspection only, and it is
probable that their contrary conclusions are due to this cause,
as without some system of measurement it must be difficult or
impossible to obtain data which can serve for the formation of
reliable statistics. It is the experience of the writer that even
after careful and repeated examination of casts it is no easy
matter to locate a doubtful case in any of the coarsely defined
types of palate, and consequently it is easy to understand how
different persons, when examining palates in living individuals,
may arrive at almost opposite conclusions. In Dr. Talbot’s
opinion measurements are necessary for the formation of
accurate statistics, but he considers that they do not adequately
give the shape or contour of the palate, but only its size.

Dr. Walter Channing (*) found great difficulty in discrimi¬
nating the palates of idiots from those of school children, which
he had taken as his standard of the normal. His conclusions
are as follows:

1. Two fifths of the palates of idiots are of fairly good shape.

2. Palates of normal individuals may be deformed.

3. In the idiot it is a difference in degree and not in kind.

4. In either case it shows irregular development anato¬
mically.

Digitized by v^.ooQLe

1 9°3>]

BY E. H HARRISSON, M B.

«3

5. Palates of average children and idiots under eight years
of age probably do not, in the majority of cases, markedly differ.

6. There is no form of palate peculiar to idiocy.

7. The statement that a V-shaped or other variety of
palate is a “ stigma of degeneracy ” remains to be proved.

Dr. Claye Shaw, in a paper in the Journal of Mental Science
in 1876, came to the following conclusions :

1. There is no necessary connection between a high palate
and the degree of mental capacity of the individual. Some
idiots have the flattest and most symmetrical palates, whilst
many with strong individuality of character have highly arched
palates.

2. There is a general relation between the shape of the
palate and that of the skull as to length and breadth.

3. A narrow pterygoid width is invariably associated with a
high palate, as is also a narrow skull.

4. The width at the first molars is almost invariably less
than or equal to the inter-pterygoid width, and is only very
rarely greater.

5. The arching of the palate has nothing to do, as regards
height, with premature synostosis of the skull base.

6. The differences in the palatal measurements of various
mouths are so slight and so various that it is difficult to see of
what service a palatal investigation can be in affording a clue
to the mental faculties.

Dr. Ireland, in The Mental Affections of Children , 1898,
page 53, gives such names as “saddle-shaped, vaulted, keel¬
shaped, lambdoid ” to the palates of genetous idiots. He states
no actual reasons for this, but appears to have gained a general
impression that palates of this kind exist in idiots of this
variety. He is, as a whole, strongly inclined to think that
these palates are especially common in idiots, and he thinks
41 that this deformity is extremely rare with people of ordinary
intelligence” (page 53).

Dr. Clouston (*) refers to this subject in The Neuroses of
Development (1891). He regards a change in the normal shape
of the hard palate as a very interesting and, in his opinion,
“ very important morphological accompaniment of many of the
developmental neuroses. . . . The importance of this

change consists, not in any direct effects of the palate bad or
good, but in the indication as to brain constitution which it

Digitized by v^.ooQLe

8 4

ABNORMALITIES OF THE PALATE,

[Jan.,

affords.” Dr. Clouston thought his assumptions amply borne
out by some investigations he made on 604 of the general
population, 286 criminals, 761 persons with acquired insanity,
44 epileptics, 171 persons with adolescent insanity, and 169
idiots and imbeciles. He was enabled to proceed in this rapid
manner because he “ thought it impossible to express the
differences and agreements in size and shape of a series of
irregular ovoid cavities, like the hollow of the palate in different
cases, by lines across or round special parts of them. . . .

After very careful consideration he considered that the simplest
and the best way was to adopt a classification that most
of them (the palates) seemed to him to fall into naturally.”
He divided them into three groups, of the “ typical,” the
“ neurotic,” and the “ deformed.”

Other writers, as for example, Talbot,( 4 ) Peterson,( 8 ) and
Charon,( 6 ) hold more or less similar views to those of Clouston
and Langdon Down.

The above references to previous writers on the subject suffi¬
ciently explain the present state of opinion on this subject, and
the writer will now proceed to describe his own investigations.

The method he has adopted for the preparation of casts of
the palate employed during the research will first be referred to,
and this will be followed by a description of the types of
patients made use of, and of the general method adopted.

A classification of palates will then be given, and this will
be followed by a tabulated account of his results and con¬
clusions. It may be added here that the author began this
research without any preconceived ideas as to the conclusions
at which he might arrive; and the work, though carried out on
perhaps rather narrow lines, should be, if anything, more trust¬
worthy on this account.

The relatively small number of patients made use of is, he
hopes, more than compensated for by the extreme care with
which the examination of each has been conducted, in spite of
the difficulties which have arisen owing to the mental condition
of the subjects.

Owing to the impossibility of accurately measuring the
palate in a living individual, it was necessary to take plaster-
of-Paris casts of the upper jaw and palate of the patients, upon
which the subject matter of this thesis is based.

The method of obtaining the casts is that used by dentists

Digitized by v^.ooQLe

I9°3-]

BY E. H. HARRISSON, M.B.

and the instruments and materials required are: Impression trays
of various sizes, Godiva composition, and fine plaster of Paris.

The patient is placed in a dentist’s chair,’'and an impression
tray is chosen which fits the teeth and palate. The tray being
selected, it is filled with the Godiva composition, which has
been previously softened by immersion in hot water, and the
impression of the teeth and palate is taken. Great care must
be exercised in order that the surface of the composition is
smooth, and that the tray is inserted carefully without injuring
or indenting the composition. The surface of the filled tray
must be held parallel to the plane of the cutting edges of the
teeth, and then the tray must be pressed firmly and evenly
upwards until the teeth are buried and the composition bulges
backwards over the tray below the soft palate. It is kept in
this position without releasing the pressure until the com¬
position is set firm and hard, which result usually occurs in
from two to three minutes, and then with gentle to-and-fro
movements the tray is loosened and removed from the mouth.

From the above description it will be seen that in order to
obtain a satisfactory impression it is necessary to gain the com¬
plete confidence of the patient, and this is naturally extremely
difficult when the operator happens to be dealing with insane
patients. Consequently several failures were met with, but by
dint of perseverance impressions were satisfactorily obtained
from no less than fifty-six patients. After an impression has
been obtained the tray and composition are carefully and
thoroughly washed. A mixture of plaster of Paris is then
made and poured slowly into the wet composition, care being
taken that the plaster flows to the bottom of every tooth im¬
pression and covers the palate evenly. A pedestal is then
made and the whole is inverted on it and left for half an hour
in order to ensure complete hardness of the plaster. The tray,
composition, and plaster are then placed in boiling water until
the composition is again softened, when the tray is pulled
steadily away, and the remaining composition is afterwards
removed from the plaster cast with the fingers, beginning at
the teeth and ending in the middle of the palate.

Having given the method by which the casts were obtained,
it is necessary to say a few words about the patients and how
they were chosen.

As complete development of the palate and teeth does not

XLIX. 6

Digitized by

Google

ABNORMALITIES OF THE PALATE,

[Jan.,

occur until the age of 22 to 25 years is reached, and after the
age of 40 senile changes begin to make their appearance, it
was considered necessary and expedient that the patients
should be between the ages of 2 5 and 40 years, and therefore
patients between those ages were chosen. Secondly, the case¬
books were gone through seriatim for this purpose, and each
case was chosen within these limits in all instances where a
family history had been taken. Thirdly, only males were
used, as it was found that they were not so troublesome as
females, and were more easily persuaded to submit to the
necessary operations.

It will thus be seen that the cases under consideration
include all varieties of insane patients, the only guide to selec¬
tion being the existence of a family history and an age of from
25 to 40 years (this being entirely irrespective of the shape or
size of the palate).

Careful examination of the fifty-six casts resulting in con¬
fusion only, it was found absolutely necessary to classify them
by actual measurements. The excellent system of measure¬
ment suggested by Dr. Goodall ( 7 ) was found to be much too
long and tedious for the purposes of the present investigation.
After much labour had been expended in careful comparison
of the different types, it was found that the following three
measurements were in all probability the most useful :—(1)
The transverse diameter was taken between the outer edges of
the second molar teeth ; (2) the depth of the palate was
taken at the level of the second molar teeth, measuring from
their cutting edges ; and (3) the depth of the palate was also
taken at the level of the first bicuspid teeth, again from their
cutting edges.

Having taken these measurements, it was found necessary to
obtain the average measurements of the palates of a number of
normal individuals. The same measurements were con¬
sequently made on twenty-one skulls chosen from the museum
of the London Hospital. The skulls were those of Europeans
and Americans, and were of about the average size and shape
of that of an ordinary well-developed man.

The measurements so taken were found to vary slightly,
namely, the transverse diameters at the level of the second
molar teeth varied between 68 mm. and 54 mm., and the
average of the twenty-one was 60 mm. The depth at the level

Digitized by v^.ooQLe

1 903]

BY E. H. HARRISSON, M.B.

of the second molar teeth varied between 2 5 mm. and 17 mm.,
the average being 20 mm. The depth at the level of the
first bicuspid teeth varied between 16 mm. and 12 mm., the
average being 13$ mm.

Now, in comparing the depth of palates taken from dried
skulls with that of casts of palates taken from living individuals,
the thickness of the soft parts, namely, the muco-periosteum,
must be taken into consideration, and for obtaining this thick¬
ness the muco-periosteum was stripped from half of the palates of
some patients in the post-mortem room of the Claybury Asylum,
and was found to average 2 mm.; therefore the average depth
of the normal palate at the level of the second molar teeth
must be taken as 18 mm., and that at the level of the first
bicuspid teeth as 11£ mm.

The measurements of the casts of the palates varied con-
siderably' in all diameters, and from a consideration of the
figures it was seen that the palates may be divided roughly
into four different types, namely, (1) the high narrow ; (2) the
high broad ; (3) the low narrow ; and (4) the low broad.

On examining the casts from a general point of view it was
soon seen that some palates slope gradually upwards from the
incisor teeth to the highest point, whilst others slope more
abruptly ; and in determining with some degree of accuracy the
amount of the slope, the depth at the level of the first bicuspid
teeth was found to be of considerable importance. On com¬
paring the measurements of the casts at this level with those of
the skulls, it was found that palates can still further be divided
into (1) those with a gradual slope backwards from the incisor
teeth ; (2) those which slope backwards more abruptly; and (3)
those with a normal slope backwards. Hence the types of
palates found in the fifty-six insane patients examined become
twelve in number.

Other differences were observed in a small number of the
casts, namely, a few were seen to be oblique or asymmetrical,
and others were found to have small projections (tori) (one or
more in number) along the median line.

Now, in considering the question of abnormalities of the
palate as stigmata of degeneracy, the evidence afforded by the
plaster casts may best be taken by a consideration of the
different types found in order: firstly, with regard to the
number of patients with palates of each particular type ;

Digitized by v^.ooQLe

88 ABNORMALITIES OF THE PALATE, [Jan.,

secondly, with regard to the mental condition of such patients ;
thirdly, with regard to the number of such patients who are
married ; and fourthly, with regard to the number of such
patients who have a distinct family history of insanity. In
connection with this last consideration it must be stated that in
the majority of cases the family history is not very accurate in
all details, and only deals with the more gross and obvious
forms of mental disease, which, in most cases, have ended
fatally. It is common knowledge that very often it is extremely
difficult to obtain a complete family history owing to the
ignorance and wilfulness of the friends, who refuse to admit that
a relative was in an asylum for a certain time and recovered.

Before referring seriatim to the different types of palate, and
classifying the various patients according to their mental con¬
dition, it is desirable to shortly, in order to avoid confusion,
define the different words employed for the latter purpose.
Two different uses are made of the word “ amentia,” ( 8 ) which is
employed in the phrases “ ordinary amentia,” and “ high-grade
amentia.” The former of these is used to indicate the mental
condition of patients who are congenitally feeble-minded, but
who are not idiots or very low imbeciles, neither of which
classes of patient has been employed during the present inves¬
tigation. The latter term, namely, “ high-grade amentia,” refers
to cases of insanity which have not from birth shown distinct
feeble-mindedness, but where, at maturity, this is present to
some extent, and is associated with various insane habits, and
with an absence of a tendency to develop dementia. These
patients thus possess a somewhat slighter degree of degeneracy
than do the former. The remaining patients have been
grouped under the terms “chronic insanity with dementia,”
" dementia of the third grade,” and “ dementia paralytica.” The
first of these phrases is employed to indicate the mental condition
of patients who are suffering from any of the ordinary varieties
of mental disease, but who have developed little more than
clinically appreciable dementia or secondary feeble-mindedness.
The second refers to the mental condition of that large class of
patients who may be conveniently grouped under the term
“ chronic lunatic.” They show any of the very numerous
common symptom-complexes of mental disease in association
with a well-marked degree of dementia. This class of patient,
like the preceding, is in a stationary mental condition, and it

Digitized by v^.ooQLe

1903.]

BY E. H. HARRISSON, M.B.

might perhaps with advantage be noted here that practically all
the cases used during the present investigation are in a fairly
stationary mental condition, this having been thought desirable
in order to enable a reasonably accurate diagnosis to be made
for the purpose of classification. In order that this intention
might be carried out without any sorting out of cases, the patients
were chosen from the earlier admissions, the later case-records
not being used. The third of the terms employed, namely,
41 dementia paralytica,” is synonymous with the term “ general
paralysis of the insane.” There is only one patient of this
kind, and he is a very chronic case with slowly progressive
dementia.

The different types of palate will now be considered
seriatim —

1. Of the high narrow palate which slopes suddenly from
the incisor teeth, there are seven examples. Of these, three
belong to patients suffering from dementia of the third grade,
two belong to patients suffering from chronic insanity with
dementia, and two to patients suffering from high-grade
amentia. Two of the above patients are married, and
hereditary insanity existed in one case.

2. Of the high narrow palate which slopes gradually back¬
wards from the incisor teeth, there are two examples. Of these,
one belongs to a patient suffering from ordinary amentia, and
the other to a patient suffering from chronic insanity with
dementia. Neither of the above patients is married, and here¬
ditary insanity exists in one of them.

3. Of the high narrow palate with a normal slope back¬
wards from the incisor teeth, there are two examples. Of
these, one belongs to a patient suffering from high-grade
amentia, and the other to a patient suffering from dementia
of the third grade. Neither of the above patients is married,
and there is hereditary insanity in one case.

4. Of the high broad palate which slopes suddenly back¬
wards from the incisor teeth, there are four examples. Of
these, two belong to patients suffering from dementia of the
third grade, one from chronic insanity with dementia, and one
from dementia paralytica. One of the above patients is
married, and there is hereditary insanity in one case.

5. Of the high broad palate which slopes gradually back¬
wards from the incisor teeth, there are seven examples. Of

Digitized by v^.ooQLe

90 ABNORMALITIES OF THE PALATE, [Jan.,

these, four belong to patients suffering from dementia of the
third grade, one from chronic insanity with dementia, one from
high-grade amentia, and one from ordinary amentia. One of
the above patients is married, and hereditary insanity exists
in four cases.

6. Of the high broad palate with a normal slope backwards
from the incisor teeth, there are five examples. Of these, one
belongs to a patient suffering from dementia of the third grade,
two from chronic insanity with dementia, and two from high-
grade amentia. Two of the above patients are married, and
hereditary insanity exists in three cases.

7. Of the low narrow palate which slopes backwards from
the incisor teeth suddenly, there are five examples. Of these,
three belong to patients suffering from dementia of the third
grade, one from ordinary amentia, and one from high-grade
amentia. Two of the above patients are married, and there
is hereditary insanity in two cases.

8. Of the low narrow palate which slopes backwards
gradually from the incisor teeth, there are five examples. Of
these, four belong to patients suffering from dementia of the
third grade, and one from ordinary amentia. One of the
above patients is married, and hereditary insanity exists in
two cases.

9. Of the low narrow palate with a normal slope backwards
from the incisor teeth, there are four examples. Of these, one
belongs to a patient suffering from dementia of the third
grade, two from chronic insanity with dementia, and one from
ordinary amentia. None of the above patients is married,
and hereditary insanity exists in four cases.

10. Of the low broad palate which slopes backwards
suddenly from the incisor teeth, there are three examples. Of
these, one belongs to a patient suffering from dementia of the
third grade, one from chronic insanity with dementia, and one
from ordinary amentia. None of the above patients is
married, and hereditary insanity exists in two cases.

11. Of the low broad palate which slopes backwards
gradually from the incisor teeth, there are four examples. Of
these, two belong to patients suffering from chronic insanity
with dementia, and two from high-grade amentia. Three
of the above patients are married, and hereditary insanity
exists in three cases.

Digitized by v^.ooQLe

Digitized by boo i

JOURNAL OF MENTAL SCIENCE, JANUARY, 1903.

No. 20. — High, uarrow, deop in front.

No. 50. -Low, narrow, deep in front.

No. 48. narrow, average in front. No. 13.—Low, narrow, average in front.

No. X. -High, narrow, shallow in front. No. 17. — Low, narrow, shallow in front.

To illustrate Dr. Hahriksox'x paper.

Half anil I>a n ifhsaii, I,til.

Digitized by VjOOQIC

Digitized by

" /

Digitized by

JOURNAL OF MENTAL SCIENCE. JANUARY, 1903.

No. 9. — High, broad, deep in front. No. 47.- Low, broad, deep in front.

o. 3S. -High, broad, average in front. No. 40.—Low, broad, average in front.

jlggMgK m

f W5r? m

1 ^

. t Mf

■M y '

jmf /

■ xS-^V

1. High, broad, shallow in front. No. 10. — Low, broad, shallow in front.

To illustrate Dr. Hauhisson’s paper.

Digitized by

1903 -]

BY E. H. HARRISSON, M.B.

12. Of the low broad palate with a normal slope backwards
from the incisor teeth, there are eight examples. Of these,
four belong to patients suffering from dementia of the third
grade, two from chronic insanity with dementia, one from high-
grade amentia, and one from ordinary amentia. One of the
above patients is married, and hereditary insanity exists in
six cases.

Having examined the palates seriatim , and considered the
patients to whom they belong with regard to their mental con¬
dition, family history, and civil state, it is interesting and
instructive to note that of the thirty patients with marked
heredity there are nineteen with broad palates and eleven
with narrow palates. There are eleven with high palates and
nineteen with low palates, measuring at the level of the second
molar teeth; and there are six deep at the first bicuspids, fourteen
average at the first bicuspids, and ten shallow at the first
bicuspids. Therefore, in the casts of fifty-six patients chosen
indiscriminately, the type of palate most commonly found with
well-marked heredity is the low broad palate, which is shallow or
of the average depth at the first bicuspids. With regard to civil
state, the married patients with low palates are seven in number,
and those with high palates are six in number; and the com¬
monest type amongst these is the low broad palate which is
of the average depth at the first bicuspids.

The mental condition of the fifty-six patients will now be
referred to. There are seven patients suffering from ordinary
amentia , of which

1 has a palate of the type high narrow, shallow in front.

and therefore the type of palate most commonly found in
patients suffering from ordinary amentia is the low narrow
palate which is shallow in front.

There are ten patients suffering from high-grade amentia, oi
which

2 have palates of the type high narrow, deep in front.

1 „ „ „ „ „ average „

„ broad

low narrow, deep
„ „ average

„ „ shallow

,, broad, deep

„ „ average

Digitized by v^.ooQLe

ABNORMALITIES OF THE PALATE,

[Jan.,

2 have palates of the type high broad\ deep in front.
i „ „ „ „ „ shallow „

i „ „ „ low narrow , deep „

1 „ „ „ „ broad , average „

2 h >» n ji » shallow „

and therefore the type of palate most commonly found in the
high-grade atnents of the series is the high broad palate which
is of the average depth in front.

There are fourteen patients suffering from chronic insanity
with dementia , of which

2 have palates of the type high narrow , deep in front.

2
2

„ „ shallow

„ broad y deep

„ „ average

yy yy SkollOW

low narrowy average
„ broody deep

„ „ average

.. „ shallow

and therefore the type of palate most commonly found in the
patients suffering from chronic insanity with dementia is either
high or low broad of average depth in front.

There are twenty-four patients suffering from dementia of
the third gracUy of which

3 have palates of the type high narrow , deep in front.

average

broody

deep

average

shallow

low narrow y

deep

average

shallow

broad

deep

average

and therefore the type of palate most commonly found in the
patients suffering from dementia of the third grade is the low
broad or low narrow which is deep in front.

There is one patient suffering from dementia paralytica^ and
the type of palate in this case is the high broad palate which
is deep in front.

Certain very interesting and important conclusions are at

Digitized by v^.ooQLe

I 9°3-]

BY E. H. HARRISSON, M.B.

once obvious on examination of the preceding remarks and
tables. As has been stated, in the patients whose family
histories show a gross hereditary taint of insanity the type of
palate which is most common is the low broad palate, which
is shallow or of the average depth at the first bicuspids .

It is known that mental disease is more obviously hereditary
as its degree is more marked. For example, the very highest
degree of heredity is seen in the case of idiots and severe
imbeciles; the degree is less in adolescent cases and in
ordinary chronic lunatics of the maniacal or delusional types,
and it is still less in toxic and other cases who either recover
or pass on into dementia. Lastly, there are many mild and,
in many instances, recoverable cases in which the symptoms
are very slightly beyond a permissible degree of eccentricity,
and in which the only traceable heredity is seen in similar but
less severe eccentricity in the case of near relatives. Under
these circumstances the fact cited above regarding the type of
palate which has been found during this investigation to occur
most commonly in cases with a gross heredity of insanity is of
importance, as this type of palate should be approximately
that found in the most degenerate group of patient. A study
of the above tables shows that this is the case. In the ordinary
aments the type of palate is a low narrow one which is shallow
in front; in the high-grade aments it is high and broad, and
of average depth in front ; in the cases of chronic insanity
with dementia it is either high broad or low broad, and of
average depth in front; and, finally, in the cases of dementia
of the third grade it is low broad or low narrow and deep in
front.

Hence, the palate of insane heredity is essentially a palate
which is shallow or, at any rate, of the average depth in front,
whatever its other characteristics may be.

A large proportion of the palates, however, are not of this
type, as many are deep in front, and especially those of the
cases of dementia of the third grade; and it is consequently
necessary to suggest a cause for this variety of deformity.
The most probable is a general physical degeneracy, associated
in many cases with defective dental development, with rickets,
scurvy, or congenital syphilis, etc. This is supported by the
fact that such palates are not uncommonly seen in the
“ weakling ” or in the youngest member of an otherwise healthy

Digitized by v^.ooQLe

ABNORMALITIES OF THE PALATE,

[Jan.,

family with no definite hereditary history of mental disease,
and in persons of this type who show no signs of mental
aberration. It also commonly occurs in the children of
persons of alcoholic habits, or who suffer from phthisis or
other similar “ diathetic diseases.”

The conclusions drawn during the present investigation may
be briefly summed up as follows :

1. Abnormalities of the palate are common in the insane.

2. These abnormalities may be roughly classified into two
large groups, of which the former contains the palate of the
hereditary psychopath and the latter the palate of the general
degenerate.

3. The former palate is variable in its general type, but as
a whole is shallow, or, at any rate, of the average depth in
front.

4. The latter palate is also variable in its general type, but
is in the main characterised by an increased depth at the
level of first bicuspids.

Tables showing Measurements of the Palates in their several

Types .

No. of patient.

Transverse diameter.

Depth at and molars.

Depth at 1st bicuspids.

High, Narrow,

Deep in Front.

52 mm.

24 mm.

15 mm.

55 mm.

21 mm.

20 mm.

58^ mm.

22 mm.

17 mm.

58! mm.

20 mm.

19 mm.

55 mm *

22 mm.

15 mm.

53 mm *

20 mm.

15 mm.

5 i

59 mm.

22 mm.

20 mm.

High, Narrow, Average in Front.

32 I

50 mm.

20 mm.

13 mm.

52 mm.

22 mm.

13 mm.

High, Narrow, Shallow in Front.

54 mm.

23 mm.

I 10 mm.

8 !

56 mm.

22 mm.

1 12 mm.

High, Broad,

Deep in Front.

65 mm.

21 mm.

19 mm.

65! mm.

24 mm.

19 mm.

60 mm.

23 mm..

20 mm.

62 mm.

20 mm.

16 mm.

Digitized by v^.ooQLe

I 9°3-]

BY E. H. HARRISSON, M.B.

( No. of patient.

Transverse diameter.

Depth at and molars.

Depth at 1 st bicuspids.

High, Broad, A

verage in Front.

61} mm.

21 mm.

i|mm,

70 mm.

25 mm.

13 mm.

62 mm.

21 mm.

13 mm.

67 mm.

23 mm.

14 mm.

61 mm.

22 mm.

13 mm.

High, Broad, Shallow in Front.

65 mm.

25 mm.

10 mm.

61 mm.

25 mm.

11 mm.

62k mm.

21 mm.

9 mm.

62 mm.

244 mm.

11 mm.

64 mm.

21 mm.

11 mm.

60 mm.

20 mm.

10 mm.

60 mm.

23 mm.

10 mm.

Low, Narrow,

Deep in Front.

55 mm.

17 mm.

19 mm.

57 mm.

15 mm.

17 mm.

53i mm.

15 mm.

18 mm.

58 mm.

18 mm.

15 mm.

53 mm.

16 mm.

15 mm.

Low, Narrow, Average in Front.

S 7 i mm-

17 mm.

13 mm.

55 mm.

16 mm.

12 mm.

4 »

50 mm.

14 mm.

48} mm.

16 mm.

13 mm.

Low, Narrow, Shallow in Front.

51 mm.

19 mm.

9 mm.

52! mm.

12 mm.

10 mm.

524 mm.

12 mm.

10 mm.

58I mm.

194 mm.

10 mm.

54 mm.

18 mm.

11 mm.

Low, Broad, Deep in Front.

60 mm.

18 mm.

16 mm.

60 mm.

15 mm.

16 mm.

59 mm.

17 mm.

20 mm.

Low, Broad, Average in Front.

63! mm.

18 mm.

13 mm.

63 mm.

18 mm.

14 mm.

61 mm.

174 mm.

13 mm.

59 $ mm.

15 mm.

12 mm.

62 mm.

18 mm.

12 mm.

63 mm.

18 mm.

12 mm.

63 mm.

17 mm.

13 mm.

66 mm.

18 mm.

13 mm.

Low, Broad, Shallow in Front.

60 mm.

17 mm.

9 mm.

60 mm.

17 mm.

10 mm.

62 mm.

17 mm.

11 mm.

61 mm.

15 mm.

11 mm.

Digitized by v^.ooQLe

INSANITY FROM HASHEESH.

[Jan.,

( 1 ) Langdon-Down, “On some of the Mental Affections of Childhood and
Youth,” Journal of Mental Science , 1887.—( 2 ) Walter Channing, Journal of
Mental Science, 1897, p. 72.—(*) Clouston, Neuroses of Development , 1891, pp.
42—45.—( 4 ) Talbot, Irregularities of the Teeth and their Treatment , Philadelphia,
1890.—(®) Peterson, 11 The Stigmata of Degeneration,” States Hospital Bulletin ,
1896, vol. i, No. 3.—(•) Charon, Thhse de Paris, 1891.—( 7 ) Goodall, Journal of
Mental Science, October, 1897.—( 8 ) Bolton, On the Histological Basis of Amentia
and Dementia (in press).

Insanity from Hasheesh.Q ) By John Warnock, M.D.,

Medical Director Egyptian Hospital for the Insane, Cairo.

Before describing this disease as it occurs in Egypt at the
present day, let me give a few historical notes of the use of
Cannabis Indica, of which hasheesh is the local preparation.
For this, and much other information contained in this paper,
I am indebted to the report of the Indian Hemp Drugs Com¬
mission of 1893. This valuable report was drawn up by a
committee appointed by the Government of India, and in its
pages a very full account of the use of hemp drugs in India is
to be found. Unfortunately it appears that no lunacy expert
sat on the Commission, and in my opinion its findings as to the
relations between hemp drugs and insanity are not conclusive.

Mr. Grierson quotes references to hemp drugs in Sanskrit
literature as early as 1400 b.c., i.e. 3300 years ago, or about
the time of Rameses I in Egypt. In the tenth century of the
Christian era, hemp drugs are mentioned as having medicinal
properties.

In the Makhzan-el-Adwiya, Cannabis Indica seeds are
spoken of as “ stimulant and sedative, imparting first a great
heat and then a considerable refrigerant effect. The leaves
make a good snuff for deterging the brain; the juice of the
leaves, applied to the head as a wash, removes dandruff and
vermin; drops of the juice thrown into the ear allay pain and
destroy worms and insects. It checks diarrhoea, is useful in
gonorrhoea, restrains the seminal secretions, and is diuretic/’
As to evil effects, the writer says :—“ Afterwards the sedative
effects begin to preside; the spirits sink, the vision darkens, and
weakness and madness, melancholy, fearfulness, dropsy, and
such like distempers are the sequel, while the seminal secretions

Digitized by v^.ooQLe

BY JOHN WARNOCK, M.D.

1903]

dry up.” Its habitual use causes “ weakness of the digestive
organs, followed by flatulency, indigestion, swellings of the
limbs and face, change of complexion, diminution of sexual
vigour, loss of teeth, heaviness, cowardice, depraved and wicked
ideas, etc.”

Ibn Beitar first recognised an insanity from its use, a.d. 1235.
Makrizi, writing in the fourteenth century on Egypt, states that
in 780 Hegira very severe ordinances were passed in Egypt
against the use of the drug. The famous garden in the valley of
Dijoncina was rooted up, and all those convicted of the use of
the drug were subjected to the extraction of their teeth; but
in 799 Hegira the custom re-established itself with more than
original vigour. Makrizi writes :—“ As its consequence, general
corruption of sentiments and manners ensued, modesty dis¬
appeared, every base and evil passion was openly indulged in,
and nobility of external form alone remained in these infatuated
beings.”

No doubt many other references to hasheesh might be found
in Arabic literature, and perhaps its popular use in Egypt may
be traced back further than 540 years.

So much for the historical aspect of the subject. Let us now
consider the use of hasheesh in the present day, especially in
Egypt.

Besides contrasting hasheeshism and alcoholism, I propose
to compare the effects produced by the use of Cannabis Indica
in Egypt with Indian experience, as reported by the Indian
Hemp Drugs Commission. As to the physiological action of
Cannabis Indica, the following experiments are noteworthy:

Dr. Marshall, of Cambridge, records as symptoms (Allbutt’s
System of Medicine ):—Dryness of the mouth, paraesthesia
and weakness in the legs, an inhibition of self-control; the
subject wandered about and felt very happy, the time-sense
became impaired, “ minutes seemed like hours.” The subject
laughed and seemed to see the comic side of things; there
were lucid intervals which occasionally seemed voluntary; the
speech was slurring and the gait ataxic; there was no sleepi¬
ness observed. The pulse increased in rate, sensibility was
lessened, the face became ashy pale, the pupils reacted and
were somewhat dilated; there were no hallucinations.

In other experiments there was sickness, loss of time-sense,
debility, and increase of appetite.

Digitized by v^.ooQLe

98 INSANITY FROM HASHEESH, [Jan.,

In the Indian Report on Hemp Drugs , 1894, I find the
following:

O’Shaughnessy records the effects of Cannabis Indica on
dogs, chiefly stupor and paralysis.

Lauder Brunton describes :—Delirium, hallucinations, sleep,
gaiety, restlessness, loss of space- and time-senses, anaesthesia
and paraesthesia, dilatation of pupils, increase in the amount of
the urine.

Experiments on cats by Dr. Evans are also quoted: .

Small doses of the drug were given by the mouth to cats.
Ataxic and paretic phenomena resulted, tremors, rocking
movements, and alterations in the muscular sense.

Dr. D. D. Cunningham made interesting experiments on a
monkey, which was compelled to inhale smoke from Cannabis
Indica habitually for eight months with the following results :

The animal plainly suffered from hallucinations of sight, and
it acquired a positive liking for the drug. Although its appetite
decreased, it put on fat. The inhalation usually made the
animal drowsy and unsteady in gait; occasionally convulsions
and unconsciousness resulted. It is important to note that the
hallucinations persisted after the other symptoms of intoxica¬
tion had disappeared.

At the autopsy a deposit of fat was noticed in the abdomen
and pericardium. As this deposition of fat occurred in spite of
loss of appetite and loss of body-weight, it appeared that
Cannabis Indica actually caused a diminution in the waste of
the body tissues, and thus had a dietetic value.

There seems reason for believing that Cannabis Indica has a
peculiarly toxic action on certain individuals. In the British
Medical Journal of October 3rd, 1896, the case is mentioned of
a boy of twelve years of age who suffered from grave toxic
symptoms after a dose of ten minims of the pharmacopoeial
tincture of Cannabis Indica thrice daily; yet similar doses
from the identical preparation given to another child pro¬
duced no bad effects. Other similar cases have been recorded
from time to time, and one wonders whether this peculiar
susceptibility of certain individuals to the toxic action of
moderate doses of Cannabis Indica may not partly explain
why in this country, where many thousands smoke hasheesh,
only a comparatively few suffer from grave toxic symptoms.

Let us now examine the results of the use of hasheesh in

Digitized by v^.ooQLe

1903 .] by JOHN WARNOCK, M.D. 99

Egypt, where large quantities are used by the inhabitants of
the towns, although the importation of the drug is prohibited
by law. The fact that about sixteen tons of hasheesh were
confiscated during the year 1901 gives some indication of the
extent of its use. Most of the drug is consumed by smoking in
the gozeh and in cigarettes, but a considerable amount is
eaten in pill form and in sweetmeats, magoon, etc.

The usual reason given by patients for using hasheesh is
that it induces a general feeling of pleasure and content. It is
also alleged that it increases the appetite for food, also the
sexual appetite, and relieves feelings of lassitude and depression.
When eaten in pills and sweetmeats it seems to be taken
chiefly for aphrodisiac purposes.

Probably, as in the habit of opium, alcohol, coca and tobacco,
etc., hasheesh is primarily employed on account of its
euphoric effects on the nervous system. The need for some
such agent exists in almost every race of human beings,
especially among the males; local conditions of climate and
topography, race traditions, etc., cause variations in the agent
selected.

Popular opinion disapproves of the use of hasheesh. Even its
moderate use is condemned by the better class of Egyptians;
the habit is considered as degrading as secret drinking is with
us. The low associations of the habit are partly responsible
for the ill-favour with which it is regarded, but without doubt
the real reason for its condemnation is the fact that hasheesh
users degenerate morally, and therefore all decent people feel
bound to hold up the habit to reprobation. From a religious
point of view the use of hasheesh is prohibited just as much
as alcohol by the Mohammedan creed (Koran, chapters ii
and v).

Hasheesh appears, nevertheless, to be used by certain
Mohammedan religious teachers (fikkis) as largely as by laymen.

The diagnosis of insanity from hasheesh depends on the
history of the case and the patient’s statements. The police
certificate frequently gives information as to the existence of
the habit; but unless this is confirmed otherwise, such evidence
is disregarded in making the diagnosis of hasheesh insanity.

The discovery of hasheesh in the patient’s clothing, or con¬
cealed in his ears or mouth, occasionally betrays the nature of the
case. On admission every male patient is questioned with regard

Digitized by v^.ooQLe

IOO

INSANITY FROM HASHEESH,

[Jan.,

to hasheesh, and a report made on the amount he takes and his
attitude towards the charge; excited protests and denials of the
habit are known by experience to indicate a hardened hasheesh
smoker. As the mental state of the patient improves, he is
again questioned about hasheesh, and before discharge he is
invited to give full details of his habit. By comparing the
repeated statements and by noting his knowledge or ignorance
of the various details of hasheesh smoking, such as the price of
the gozeh, the different qualities of the drug, etc., it is not
difficult in most cases to form an opinion as to whether the
case is one of hasheesh. The evidence of relatives is occasionally
of use, but is less reliable than the repeated cross-examination
of the patient; numbers of the Cairo cases are known to be
frequenters of hasheesh cafes from being seen there by hospital
employes.

Insanity from hasheesh belongs to the toxic group of
insanities, and, like insanity from alcohol, opium, cocaine, etc.,
has an exogenous toxic cause.

The clinical types of hasheesh insanity vary, but before
describing them it will simplify matters to enumerate those
met with in alcoholic insanity as follows:

1. Ordinary alcoholic intoxication, short in duration; with
symptoms of excitement and violence, stupor, exaltation, and
various ataxic and paretic phenomena ; occasionally real tran¬
sitory mania.

2. Delirium tremens, of longer duration; numerous hallucina¬
tions, especially visual; oblivious restless delirium, melancholic
in tone; delusions of fear; motor phenomena, tremors, etc.;
usually curable.

3. Alcoholic mania of various degrees of acuteness; no com¬
plete delirium, hallucinations chiefly auditory; maniacal,
changing delusions of exaltation or persecution, restlessness
and violence; no tremors usually; often curable.

4. Chronic alcoholic mania, including alcoholic mania of per¬
secution; suspicion, jealousy, hallucinations of hearing and
taste; delusions about tortures, machines, conspiracies, poison¬
ing, wires, etc.; there may be ideas of grandeur or altered
personality; often suicidal and homicidal impulses; motor
and sensory phenomena occur; usually incurable.

5. Alcoholic dementia, often with gross organic brain-lesions,
or with hemiplegia, paresis, etc.; loss of memory, mental

Digitized by v^.ooQLe

BY JOHN WARNOCK, M.D.

IOI

1903.]

facility, loss of interest, dull, apathetic demeanour; various
motor and sensory phenomena occur.

6 . Dipsomania .—This term is used to express the craving for
alcohol, and nearly all the foregoing types occur as the results
of giving in to this craving. Between his outbreaks of mania
or delirium tremens, the dipsomaniac usually shows some
mental and physical impairment, especially in the direction of
blunted moral feeling. He is usually a practised liar, reckless
in his methods of obtaining money to gratify his craving, care¬
less of the claims of relations on him, lazy, dishonourable,
often shameless, and often incurable.

Non-nervous results of alcohol .—Almost every organ in the
body shows pathological results of alcoholism which need not
be enumerated here. Now let us consider the result of using
hasheesh. Insanity from hasheesh gives the following types :

1. Temporary intoxication .—The smoker of hasheesh becomes
dull and drowsy, he feels pleasantly exalted, and the worries of
life are temporarily blotted out; fatigue is no longer felt; he
is at peace with the world. The drug acts as a stimulant and
sedative. This state is to be observed among the habitues of
hasheesh cafes; such cases do not come to the asylum, though
patients recovering from the graver forms of hasheesh insanity
often describe what were their feelings during temporary
intoxication. Pleasant half-waking dreams, not unlike those
of the opium taker, gently occupy the mind, and often the
individual feels that he is temporarily some important personage.
The active excitement of alcoholic inebriety is uncommon, but
if the hasheesh smoker is annoyed or interfered with during
his dreams he is liable to become irritable and excited, and to
show loss of self-control. A staggering gait makes the condi¬
tion not unlike that of alcoholic intoxication, while the pleasant,
dreamy state approaches that of the opium smoker.

Contrasting the three intoxications, one may say that the
mental pose of the hasheesh smoker is more “ subjective ”
than that of the alcoholic, and less so than that of the absorbed
opium user. The alcoholic is the most “objective” and
demonstrative of the three.

2. Delirium from hasheesh, which is accompanied by hallucina¬
tions of sight, hearing, taste, and smell, often of an unpleasant
kind. Delusions of persecution often occur. The idea that
the subject is possessed by a devil or spirit is common. Great

xux. 7

Digitized by v^.ooQLe

102

INSANITY FROM HASHEESH,

[Jan.,

exaltation and the belief that the individual is, a sultan or
prophet may occur. Suicidal intentions are rare. The restless¬
ness and sleeplessness of these cases are marked features, but
usually they do not approach the unending chatter and
continual busy movements of the subject of delirium tremens,
nor is the absorption in delirious ideas and hallucinations as
complete as in the latter. The motor phenomena of delirium
tremens, tremors, and ataxy are absent; although some stagger¬
ing is occasionally noticeable, usually the patient is active and
quick in movements. The physical exhaustion and gastro¬
intestinal and hepatic disorders of delirium tremens do not
occur. Hasheesh delirium is a less grave state both physically
and mentally. Some cases are stuporous in type.

3. Mania from hasheesh .—This varies in degree of acuteness
from a mild short attack of excitement to a prolonged attack of
furious mania ending in exhaustion or even death. Most
cases are exalted, and have delusions of grandeur or of
religious importance; persecutory delusions occur frequently,
and provoke violence towards others, but not suicide. Rest¬
lessness, incoherent talking, destructiveness, indecency, and
loss of moral feelings and affections, are all ordinary symptoms.
A certain impudent dare-devil demeanour is a character
istic symptom. Hallucinations are not so marked as in
alcoholic mania, but those of hearing and taste are not un¬
common ; delusions of being poisoned are often based on the
latter variety. A few cases are more melancholic than maniacal
in demeanour, and exhibit extreme depression and terror with
hallucinations of hearing (threatening voices, etc.). There is no
pathognomonic symptom of hasheesh mania, but the transitory
nature of many cases is often a guide.

4. Chronic mania from hasheesh, including a form of mania or
persecution. Many of these cases are not distinguishable from
ordinary chronic mania. Hallucinations are not so frequent as
in alcoholic chronic mania. The patient is a happier, less
worried individual than the alcoholic chronic maniac. The
morose, suspicious, jealous demeanour of the alcoholic, his
belief in machines, invisible wires, and mysterious tortures are
absent, also his motor and sensory troubles. His suicidal and
homicidal tendencies are also usually wanting.

5. Chronic dementia from hasheesh describes the final stage of
the preceding forms. We find no motor or sensory symptoms.

Digitized by

Google

BY JOHN WARNOCK, M.D.

1903 ]

103

as in alcoholism ; there are loss of memory, apathy, degraded
habits, and loss of energy, as in ordinary chronic dementia.

6. The term cannabinomania may be employed to describe the
mental condition of many hasheesh users between the attacks
of the above forms. The individual is a good-for-nothing, lazy
fellow, who lives by begging and stealing, and pesters his
relations for money to buy hasheesh, often assaulting them
when they refuse his demands. The moral degradation of these
cases is their most salient symptom; loss of social position,
shamelessness, addiction to lying and theft, and a loose,
irregular life, make them a curse to their families. While in the
asylum they are notorious for making false charges, refusing to
work, and quarrelling. Some deny using hasheesh, but others
boast of its stimulating effects. They often have an inordinately
high opinion of themselves. They are loud in their complaints
of oppression by the police, and emphatically protest their
innocence of any misdeeds. Irritability, unconcern as to the
future, loss of interest in family, malingering, continual
demands for cigarettes, urgent petitions for release, fervent
promises of reform, emotional outbreaks when refused their
demands, garrulity, abusive threats alternating with extreme
servility, are all marks of this state. These patients do not
often ask for hasheesh while in the asylum, but occasionally
procure it by stealth, though the craving for it does not appear
to be so keen as that of a dipsomaniac or a morphinomaniac.
No phenomena of " deprivation ” are noticeable, as in the latter
disease, and therefore the cessation of the habit should be easier
than in the case of alcohol or opium, and I believe that it is
actually easier.

In the early stages these individuals are usually regarded as
criminals, and their moral lapses land them in gaol. Later on,
when their intellectual impairment becomes more marked, they
are sent to the asylum.

The similarity between this condition and that of the dipso¬
maniac is evident; many of the differences are probably due to
racial peculiarities.

Contrasting generally hasheesh insanities with those pro¬
duced by alcohol, the following points stand out:

1 . Suicidal intentions are common among alcoholics, rare
among hasheesh cases. How far this may be explained by
differences in race and religion one cannot say, but it is to be

Digitized by v^.ooQLe

104 INSANITY FROM HASHEESH, [Jan.,

borne in mind that suicide is rare among the insane of the
Arab race and Mohammedan religion.

2. Hasheesh, in Egypt, seems to be a more important factor
in the production of insanity in that country than alcohol is
in England.

3. As a cause of crime, hasheesh appears to be as important
in Egypt as is alcohol in England.

4. The use of hasheesh, unlike that of alcohol, is not followed
by any characteristic anatomical lesions, and no physical
disorders are known to result from it. I have not found
asthma and bronchitis to be specially common among hasheesh
smokers; only the physical disorders and lesions met with in
the idiopathic insanities occur in insanity from hasheesh. The
only exception to this rule being the staggering gait of hasheesh
intoxication and delirium.

Let us now consider how far the hasheesh habit is affected
by Government regulations:

In Egypt the drug was totally prohibited in 1868, then
allowed to be imported on paying duty in 1874. In November,
1877, all hasheesh was confiscated.

In March, 1879, the importation and cultivation of hasheesh
were prohibited by Khedivial decree.

In March, 1884, a decree prohibited the cultivation, sale, or
importation of hasheesh under penalty of a fine of two to eight
pounds Egyptian per oke, the drug to be confiscated and sold
for export within fifteen days, a quarter of the price so
obtained to be divided among the informers and seizers of the
hasheesh. The decree of May, 1891, modified the preceding :

The cultivation of hasheesh was prohibited under a penalty
of £E5 o to £Eioo per feddan. The mere possession of
hasheesh became an offence, and the penalty was raised to
£Eio to £E5 o per kilogramme, with a minimum fine of
££2.

In June, 1892, the Court of Appeal of the Mixed Tribunals
decided that the preceding decrees did not apply to foreigners.

In April, 1895, the Native Appeal Court decided that the
fine inflicted might be less than £E2.

In January, 1895, an arrete was promulgated, by which the
keepers of public establishments (cafes, etc.) were prohibited
the sale of hasheesh under a fine of 25 to 100 p.t ., the drug to
be seized and confiscated. Three condemnations of a cafe

Digitized by v^.ooQLe

105

I903-] . BY JOHN WARNOCK, M.D.

keeper within six months were to entail the closure of the
establishment.

In May, 1900, the preceding arrite was modified by the addi¬
tion of one to seven days’ imprisonment to the fine. The
judge in every case will order the confiscation of the hasheesh
seized, as well as the apparatus employed in its use. When
the offence is the permission of hasheesh smoking on the
premises, the shop must be in every case closed for a month.
After two convictions the shop will be permanently closed.
For the offences of selling hasheesh or providing it for smoking,
one conviction is to be followed by permanent closure of the shop.

Numerous convictions are obtained under these arretes , and
the importation of hasheesh along the Mediterranean coast is
carefully watched, many tons of the drug being ahnually con¬
fiscated ; yet the use of hasheesh still continues on a large scale,
though not so openly as in former years, and every one who
wants to smoke hasheesh seems to have no difficulty in obtain¬
ing it. The number of hasheesh cases admitted into the
asylum shows an annual diminution, and one hopes that the
strenuous efforts now being made to suppress the habit will
gradually reduce the asylum admissions from this disease to a
small figure.

It is to be noted that the abuse of hasheesh, like that of
alcohol, is sometimes only a symptom of incipient insanity.

It has been suggested that if the use of hasheesh were
entirely prevented in Egypt its place would be taken by
another euphoric agent, probably alcohol. Would this change
be for the better ? I am inclined to answer in the negative.
Alcohol is in other countries such a fertile cause of crime and
insanity that its substitution for hasheesh in Egypt would
probably result in a worse state of things. Alcohol also seems
to have a specially deleterious effect in warm climates and on
Oriental races. Probably the wisest policy in Egypt will be to
keep the use of hasheesh within bounds without entirely pre¬
venting it.

The present system of nominally prohibiting hasheesh, while
a large amount is smuggled into the country and smoked in
spite of the decrees, may eventually bring about the necessary
amount of restriction by raising the price of hasheesh, and
rendering its immoderate purchase beyond the means of the
majority of habitual hasheesh smokers.

Digitized by v^.ooQLe

106 INSANITY FROM HASHEESH, [Jan.,

Opium, which is so largely used in India, apparently with
little evil effect, is taken to some extent in Egypt; but I have
seldom met with insanity among the lower classes attributable
to its use. Probably the substitution of the opium habit for
that of hasheesh would be an improvement.

In the Report of the Royal Commission on Opium 9 1895, the
conclusion is reached that “the temperate use of opium in
India should be viewed in the same light as the temperate use
of alcohol in England. The use of opium does not cause
insanity. It does not appear responsible for any disease
peculiar to itself.”

The popular use of hemp drugs is known to exist in Turkey,
Greece, Egypt, India, and some of the tropical parts of
America, Trinidad, British Guiana, and probably elsewhere.

In most of these countries it is used chiefly as a euphoric
agent, but in India the hemp plant is considered to be holy by
the Hindoos. Mr. J. M. Campbell, of Bombay, gives interest¬
ing details of the worship of the plant.

The Ascetic Mahadev is believed to inhabit the leaf of
Cannabis Indica (called bhang in India). The preparation of
bhang is a religious process accompanied by prayers and
incantations. Its use cleanses from sin and atones for evil
deeds. It destroys disease and keeps off evil. It brings luck,
and is therefore used at weddings, on going a journey, etc.
Bhang is much used in temple rites as an offering to Shiva.
Vishnu worshippers drink bhang before Baladev. The goddess
of smallpox, Shitaladevi, is propitiated by libations of bhang.

The North Indian Mohammedans show much respect for
bhang, the spirit of the plant being that of Elijah or Khizr.

Certain Indian sects are devoted to the use of bhang, and
drink it at their festivals, believing it to cure all diseases and to
bring the user into harmony with the infinite.

Indian policy in regard to hemp drugs has been directed
towards “ restraining the use and improving the revenue by the
imposition of suitable taxation; ” “ discouraging the consump¬
tion by placing restrictions on the cultivation, preparation, and
retail, and imposing on their use as high a rate of duty as can
be levied without inducing illicit practices; ” “ limiting the
production and sale by a high rate of duty, without placing the
drug entirely beyond the reach of those who will insist upon
having it.” The Commission approve of this policy, and con-

Digitized by v^.ooQLe

I9°3-] BY JOHN WARNOCK, M.D. IO7

demn the proposal to prohibit the use of the drug in India.
They formed the opinion that there is a legitimate use of the
drug, generally among the poorest of the population, and this use
should not be rendered impossible. As to Burmah, they find
that prohibition has been a failure; that the drug is largely
smuggled into the country; that all who want it (chiefly Indian
immigrants) can get it illicitly; and that the Burmen do not
take to the habit, though they evidently have many oppor¬
tunities to do so. The Commission say that the present illicit
traffic in Burmah is demoralising to the Indians and to the
Government servants, who are powerless to deal with it. It
would be better to license this use of the drug under proper
control and taxation than to maintain an unworkable pro¬
hibition ; however, the sale of the drug should be restricted to
Indians, Burmen being still prohibited its use.

The actual restrictions on the use of hemp drugs vary in the
different provinces of India; they include the control of the
cultivation, manufacture, and taxation of the drug.

Retail and wholesale vendors are licensed, and the possession
of more than a certain amount of the drug is illegal.

The Commission, discussing the various provincial systems,
approves of a combination of a fixed duty with licence fees for
the privilege of vend; the control of cultivation; and the limita¬
tion of the number of licensed shops.

Let me now briefly quote from the Indian Hemp Drugs
Commission’s Report in 1894 :

Vol. i, p. 186: “ On the whole, the weight of evidence is to the
effect that moderation in the use of hemp drugs is not injurious.

“ The temptation to excess is not so great as with alcohol.”

Vol. i, p. 263: “ In regard to the physical effects, the Com¬
mission have come to the conclusion that the moderate use of
hemp drugs is practically attended by no evil results at all. The
excessive use does cause injury, but does not cause asthma. It
may indirectly cause dysentery, and may cause bronchitis.”

Vol. i, p. 264: “ The moderate use of hemp drugs produces
no injurious effects on the mind.

“ The excessive use indicates and intensifies mental instability;
it tends to weaken the mind; it may even lead to insanity. It
has been shown that the effect of hemp drugs in this respect has
hitherto been greatly exaggerated, but that they do sometimes
produce insanity seems beyond question.

Digitized by v^.ooQLe

108 INSANITY FROM HASHEESH, [Jan.,

“ Moderate use produces no moral injury whatever. For all
practical purposes it may be laid down that there is little or no
connection between the use of hemp drugs and crime.”

Page 239: “Out of 1344 admissions to the asylums of
British India during 1892, there are shown to be only ninety-
eight cases (or 7*3 per cent) in which the use of hemp drugs
may be reasonably regarded as a factor in causing the in¬
sanity.”

Let us compare the evidence of other observers :

In British Guiana , Dr. T. Ireland reported {British Medical
Journal , September 10th, 1893) that insanity from Indian hemp
is common there; that it causes asthma, and results in acute
mania, melancholia, and chronic dementia.

In the Journal of Mental Science , January, 1892, Dr. W. S.
Barnes, formerly superintendent of the Lunatic Asylum of
British Guiana, is quoted as stating that the smoking of
hasheesh is a common cause of insanity, often combined with
alcohol. “ These patients are the most acutely insane amongst
the inmates of the public asylum. The mania is fierce, and
they are recklessly violent and regardless of consequences,
recalling frequently to one’s mind the furor of epilepsy. When
the form of the disease is melancholia their mental distress is
profound, and they require careful watching. The earlier
attacks are usually very curable; but they return again and
again unless the drug is given up, and at each recurrence
recovery becomes less likely. In most cases hallucinations are
a very marked feature, and appear to occupy the patient’s mind
so fully and vividly as to render him almost unconscious of his
actual surroundings.”

In the Journal of Mental Science , January, 1894, “ Return East
Indies, Consumption of Ganja,” Blue Book, is described the use
of Indian hemp in India. It is said to produce pleasant excite¬
ment, torpor, depression. Large doses cause mania with
hallucinations and delusions. Its use is a serious evil, and is
a great cause of insanity in Bengal.

In the Journal of Mental Science , January, 1894, Surgeon-
Captain J. H. T. Walsh, Superintendent of Calcutta Lunatic
Asylum, relates two experiments with hasheesh on men. One
on swallowing large doses became a little excited, and felt very
happy, laughing ; the other became drowsy and giddy.

He quotes Indian Asylum Reports from 1862 to 1892, show-

Digitized by v^.ooQLe

1903.] BY JOHN WARNOCK, M.D. 109

ing that Indian hemp is credited with causing a large amount
of the insanity occurring in India.

Dr. Hutchinson, of Patna Lunatic Asylum, India, 1868, thus
describes hasheesh cases :—Conjunctiva congested, pupils
generally contracted, peculiar leery look, gait unsteady, great
volubility, much laughter or singing. There may be a tendency
to rush onwards blindly. No unpleasant after effects. He also
describes the maudlin intoxication of ganja smokers, and notes
their dark purple lips.

Dr. Wise, of Dacca Asylum, 1872, mentions religious mendi¬
cants called Rumawat, who smoke much ganja without ill
effect. Between 1882 and 1892 Indian hemp caused 25 to 35
per cent . of the insanity in Bengal asylums.

Dr. Walsh thinks that hemp drugs produce only a temporary
insanity. If insanity lasts more than ten months he thinks
hasheesh was only a contributing cause.

In the report for the year 1899 of the Bengal asylums, it is
stated that 45 out of 220 cases admitted were due to the use of
Cannabis Indica.

In Egypt, statistics are available since the year 1895.
During the six years 1896—1901, out of 2564 male cases of
insanity admitted to the Egyptian Asylum at Cairo, 689 were
attributed to the abuse of hasheesh, i. e., nearly 27 per cent .
Very few female patients used hasheesh, and it is noteworthy
that insanity is more than three times as common among
the hasheesh-using sex as among women, who, comparatively,
seldom use the drug.

I think this difference in the insanity rate between the sexes
is significant, and goes a long way to prove the importance of
hasheesh as a cause of insanity among Egyptian men. Let it
also be remembered that in England insanity is more frequent
among women than among men (35 to 31).

My experience does not confirm the Indian Commission’s
belief that Cannabis Indica only sometimes causes insanity. In
Egypt it frequently causes insanity. As to whether excessive
use of hemp drugs is commoner here than in India I can give
no opinion, but many thousands use it daily here. Probably
only excessive users, or persons peculiarly susceptible to its
toxic effects, become so insane as to need asylum treatment.
Whether the moderate use of hasheesh has ill effects I have no
means of judging, and this paper is now read to elicit the

Digitized by v^.ooQLe

I IO

CLINICAL NOTES AND CASES.

[Jan.,

opinions oi my colleagues in Egypt, whose daily practice must
give them opportunities of studying the effects of the ordinary
use of hasheesh. I should be grateful for information on this
question.

I have never met with dysentery or bronchitis as the direct
result of the use of hasheesh.

Again, in my experience, I find that persons insane from
hasheesh have a proneness to commit crimes, especially those
of violence, and I have a strong suspicion that much disorderly
conduct results from hasheesh smoking, just as alcohol among
Europeans leads to such misconduct.

To sum up, the use of Cannabis Indica in Egypt seems to
have graver mental and social results than in India, and is
responsible for a large amount of insanity and crime in this
country.

( J ) Extracts from this paper were read at the Egyptian Medical Congress at
Cairo in December, 1902.

Clinical Notes and Cases.

A Case of Cysticercus Celluslosce Causing Insanity .(*)
By R. Sinclair Black, M.A., M.D., D.P.H., Medical
Superintendent, Government Hospital and Asylum, Robben
Island, Cape Colony.

T/ENIA SOLIUM is common enough in this country in man,
but its cystic stage is, I think, met with very infrequently; that
is the reason I bring this short paper before the meeting in
order to elucidate whether cases of the following kind are met
with in any frequency in South Africa.

The so-called cysticercus is, of course, the cystic stage of the
Tania solium , its larval condition, which, before developing into
the adult sexual tapeworm, must be taken into the alimentary
canal of an animal. How does the cyst or bladderworm get
to those inner parts of the body in which it is found, so to
speak, imprisoned ? It is believed that the outer shell of the
ovum is digested by the gastric fluid, and that the emergent

Digitized by ^.ooQle

I903-] CLINICAL NOTES AND CASES. I I I

embryo bores its way through the intestinal walls, getting into
the stream of the blood, whereby it is carried and deposited in
this or that organ.

It is stated that the cystworm is seldom met with in an
animal that is liable to the corresponding cestoid worm ; but
this occasionally happens, as in the case of man, the cyst of
the tapeworm being an occasional, though rare, inhabitant of
the human body. How does this happen ? Possibly one or
more of the ripe joints of the tapeworm may ascend into the
stomach, where the embryos are set free by the digestion of
their cases ; or a pod may be broken by accident or violence
while yet within the bowel; or some of the eggs may chance
to be swallowed by man. In any of these cases the liberated
embryo pursues its natural instinct, migrating in the usual way,
and gets fixed in the uncongenial soil of a wrong animal.
This condition is the only known instance in which man is
liable to the larval and mature form of a cestoid entozoon.

Fagge states that as a bladderworm the parasite is most
frequently observed in the eye and the brain ; but it is very
likely, he says, that it is really most frequently present in the
muscles and subcutaneous tissue, where, however, it is apt to
escape notice. He states that it is often solitary, or present in
small numbers. It is remarkable that patients with tapeworms
do not more frequently become affected with bladderworms. As
a matter of fact very few of those who have a tapeworm
become affected with cysticerci; but conversely von Graafe
found that among thirteen patients with cysticerci in the eye
five had tapeworms.

This bladderworm is found, as you are aware, chiefly in the
pig, being the cause of measly pork ; but it is found occasionally
in the monkey, dog, and other animals. In the pig it occurs
principally in the connective tissues, between the fascicles of
the voluntary muscles, and also in the liver and brain.

Cysticerci are the most frequent parasites of the human eye.
Da Costa says that they cannot as a rule be diagnosed, except
they be in a position in which they can be seen or felt, or if the
little tumours they occasion in the subcutaneous tissues are extir¬
pated and examined. In the brain, he says, the chief symptom
is violent and rapidly increasing epilepsy. That cysticercus
as a cause of insanity is very uncommon may be taken from the
following:—In the proceedings of the British Neurological

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

I 12

[Jan,

Society no mention is made of cysticerci in the brain. Gowers
alludes only casually to it; Beevor not at all.

In Leuckart's Parasites of Man an excellent account will
be found of the development and frequency of cysticercus in
parts of Europe, where the subject has been scientifically
investigated.

There is a pretty full account written by Collins, of New
York, in Twentieth Century Practice and his description fairly
tallies with the following case.

Ford Robertson, in his new book on mental pathology,
makes no mention of it.

The writer in Twentieth Century Practice devotes half a
dozen pages to cysticerci and echinococci as affecting the brain.
He states that the former are more common than the latter. In
some cases, he says that there are no symptoms at all; in others
there are various psychoses, such as hysteria, hypochondriasis,
and acute mania; and in others the symptoms of brain tumour
occur ; he adds that the symptoms vary very much from time to
time. He describes various motor symptoms, and says that
they may resemble Jacksonian epilepsy. He admits that it is
impossible to diagnose the disease, except inferentially, from
any multiple cerebral tumour ; but I think that if cysticerci
were noticed in the eye with such irritative brain symptoms,
diagnosis might be made of cysticerci on the brain.

In Niemeyer’s Practice of Medicine six lines are devoted
to the subject.

The subject, therefore, is of some interest on account of its
rarity.

In the Robben Island Asylum this condition existed in a
patient named S—, a Kaffir criminal lunatic, who, with two
other natives, was concerned in the murder of a child by
throwing it from a railway carriage. On admission he was
classed as suffering from acute mania ; he was noisy, and had
a staggering gait; occasionally his sight was bad, no doubt
from the presence of cysticerci within the eyeball. He was
admitted on May 12th, 1899, and died, after a series of
epileptiform fits, on December 7th, 1900.

The case from admission steadily progressed from bad to
worse. After observing him for some time I classed him as a
general paralytic. He was quite incoherent, had a staggering
gait, was dirty, destructive, and often shouting in his single

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

”3

room at night; he had frequent epileptiform convulsions
not confined to one side or the other. Sometimes he appeared
to be in great pain, and threw himself about. I several times
had to administer hyoscine hypodermically. The case steadily
got worse, and he ultimately became generally paralysed ; con¬
vulsive seizures occurred at intervals, and in one series of these
he died.

Post-mortem examination showed excess of cerebro-spinal
fluid, general congestion of cerebral vessels, congestion of
lungs, liver, and kidneys, thickening of mitral valves. Over
the frontal region of the cerebrum, numerous cysticerci, adher¬
ing to the pia mater and embedding themselves in the grey
matter of the brain, were scattered. Over the motor area,
particularly about the fissure of Rolando, they were very
numerous, covering the whole surface with small semi-trans¬
parent vesicles about the size of a pea ; when one of these was
taken out it showed a white spot on the surface—the head of
the cystic worm.

Over the sensory area of the brain the cysts were infrequent,
as also at the base of the brain ; they were, however, very
deeply embedded in the walls of tho lateral ventricles, the
ventricular surface of the optic thalamus and the corpus striatum
being studded thickly with these cysts.

In the fourth ventricle the condition was very interesting ;
five cysts hung by delicate pedicles from the fine membrane
lining the exposed surface of the ventricle, and floated about
in the cerebro-spinal fluid ; the cerebellum was free.

The cysts all seemed to have origin from the pia mater,
having evidently been carried in a swarm by the blood-vessels
to the sites in which they took root as ova and grew into
cysts. There must altogether have been several hundreds of
these cysts in the cerebrum, and it was impossible to separate
the membrane from the surface of the cerebrum without tearing
the brain to pieces. The mental state of the patient was amply
explained by the condition of the brain.

The cysts were all of nearly the same size, one eighth to a
quarter of an inch in diameter. Some seemed older than
others, with thick walls; others were apparently more recent,
with transparent walls.

In the body generally, wherever the muscle was cut into,
cysts were found lying between the fascicles of the muscles.

Digitized by v^.ooQLe

114

CLINICAL NOTES AND CASES.

[Jan.,

The cysts in the muscles of the body appeared much fresher
than many of those in the brain, being all plump and semi¬
transparent ; the head of the bladderworm being very dis¬
cernible. They were particularly abundant in the intercostal
muscles, and were also present in the diaphragm. They were
found sparsely in the muscle of the heart, and in the connective
tissue under the pericardium.

I did not observe them in the cutaneous connective tissues,
or in the lungs, liver, or spleen, but they were found in the
connective tissue round the kidneys.

Altogether there must have been several thousand of these
cysts in the body generally, and the pain suffered by the un¬
fortunate man must have been acute and prolonged, only
mitigated by the profound dementia resulting from the gross
cerebral lesions.

Though I recognised the condition at once on making the
post-mortem examination, I did not, till I read up the literature
of the subject, recognise the great interest of the case, and I
very much regret that I did not carefully search the intestinal
tract for tapeworms, or the eye for cysticerci, as I would other¬
wise have done. I may, however, say that I had frequent
occasion to see the dejecta of this patient when visiting him in
his single room, and I never noticed any evidence of tapeworm.

In the ‘Report of Asylums for Cape Colony* for 1899 I
observed that my friend Dr. Conry, medical superintendent of
Fort Beaufort Asylum, had a very similar case ; I conse¬
quently wrote to him regarding it, and he furnished me with
the following interesting notes, which he has kindly given me
permission to read to you. The case tallies very closely with
my own.

I am sure the Society would consider it of interest if other
cases of this kind could be reported.

W. B—, admitted to Fort Beaufort Asylum from Grahamstown
January 23rd, 1899, suffering from epileptic dementia.

Notes taken from the Case-book.

January.—Is excitable and has a difficulty in understanding what is
said to him ; speech slow and laboured; epileptic fits not frequent

March.—Excited if spoken to; wants to go home; quarrelsome;
fits not frequent.

June.—Excited and incoherent if spoken to; quarrelsome; inclined
to be violent.

Digitized by

Google

1903.] CLINICAL NOTES AND CASES. 11 5

September 5th.—Vacant-looking ; quarrelsome; tries to bite ; fits
much more frequent.

September 10th.—Fits more severe; difficulty in swallowing; unable
to answer when spoken to.

September 20th.—Unable to answer when spoken to; lies in a semi¬
conscious state; cannot swallow; fed per rectum ; fits continuous day
and night

September 30th.—Dead.

Post-mortem notes. Autopsy made thirteen hours after death .

Body well nourished; head well shaped. On removing calvarium
dura mater non-adherent, all blood-vessels very full and prominent,-
longitudinal sinus bulging. On removing the dura mater, vessels still
very prominent, pia arachnoid friable, surface of grey matter very soft
and pinkish-looking, the least touch causing the convolutions to peel off.
The pia arachnoid could not be removed without loosening the surface
of the convolutions. When the pia mater was removed the convolu¬
tions did not look grey, but pinkish. The brain presented numerous
small masses, nodules of a semi-cartilaginous feel, resisting the knife;
they were about the size of an ordinary pea, and were numerous
throughout the cerebrum and cerebellum. They were not in the spinal
cord. They were in the walls of the ventricles, and could be seen and
felt protruding from the surface. They had a pinkish tint, probably
from the colour of their investing membrane; internally they were white,
and firm in character. They appeared to be dried-up cysts ; they could
be easily separated from the brain tissue. The cysts were not shrunken ;
the contents must have become dry, as the cyst sac was full. There were
also numerous cysticerci studded throughout both cerebrum and cere¬
bellum. There were a good many in the ventricles, some attached by
thin pedicles, a few floating loose. They were about one quarter inch in
diameter, almost transparent, and showed a white spot at one point in
their walls. They floated easily in water. Occasionally two were attached
together by a thin pedicle. Their membrane was tough ; it required a
firm squeeze to rupture the cyst. There were no cysts found in any
other part of the body.

(*) Read before the Cape Town Branch of the British Medical Association.

A Case of Cysticercus Cellulosce of the Brain. Re¬
ported by Dr. W. C. SULLIVAN (with the permission of the
Prison Commissioners).

D. R—, aet 27, butler, of Italian nationality, resident in England for
past eight months, married, two children, the younger aged six weeks;
in prison for petty larceny.

Nothing special in family history. No illness of note in patients
own antecedents, except that two years ago he is said to have had a
“ fit,” in which spasm of right hand and arm preceded loss of conscious-

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

[Jan.,

116

ness; there was subsequent aphasia and paresis of the right side, but
these symptoms cleared up completely within about two days, and
patient has had no nervous troubles since. He is not known ever to
have suffered from tapeworm.

Owing to difficulties of language, slight mental defect might, of
course, have passed unnoticed; but marked enfeeblement of intellect
was quite excluded by his general demeanour and his ready adaptation
to his surroundings.

The first symptoms of illness appeared on October 24th, six weeks
after patient’s admission to prison. On that date he complained of
headache, which did not present any special characters, and was not
accompanied by fever. During the two following days the headache
continued, still without other symptoms and with normal temperature.
On October 27 th, however, the patient stated he had had rigors during
the night, that the pain in the head had become much more severe,
and that his vision was dim. His temperature was 102*5° F.; pulse
64 ; there was marked retraction of the head; pupils were contracted,
equal, and did not react to light or on convergence ; Kernig’s sign was
present on both sides. There was a very profuse discharge of sero-
purulent fluid from the right ear. This, the patient stated, had com¬
menced the evening of the previous day. The sediment from this fluid
examined under the microscope showed taenia hooklets. The patient
rapidly became delirious, appeared to become totally blind, and had reten¬
tion of urine. At noon he had a slight attack of general convulsions,
followed by a phase of co-ordinated movements of clutching the throat
and pulling the nose. After that time he remained in a state of coma,
with sighing and irregular breathing ; temperature remained at 102° F.,
and pulse about 68. Two hours later he died by sudden respiratory
failure.

Post-mortem examination .—The thoracic and abdominal organs were
healthy ; there was no trace of tapeworm in the intestines.

On removal of the calvarium several rounded impressions were visible
on the inner surface of both parietal bones, the bony tissue where it
was most worn being little thicker than parchment. These depressions
corresponded to prominences produced by cysts in the subdural space.
The dura mater was healthy, and was nowhere adherent to the cyst wall.
It presented, however, a spicule of ossification on the right side close
to the superior longitudinal sinus, and at this point was adherent to the
pia mater over the ascending parietal convolution. Several cysts pro¬
jected on the surface of the brain, especially in the larger fissures.
At the base of the brain was a large quantity of thin purulent matter
bathing the pons and medulla and extending along the sheaths of the
cranial nerves.

The dura over the pars petrosa appeared healthy. There was no
perforation of the tympanic plate. On opening the middle ear the
cavity was found to be filled with thin purulent matter similar to that
within the cranium. The mucous membrane and ossicles appeared
normal. The mode of communication between the tympanic cavity
and the subdural space could not be determined. The cysticerci were
those of Tania solium .

Digitized by v^.ooQLe

I903-]

OCCASIONAL NOTES.

II 7

Occasional Notes.

Lunacy Law Reform in relation to the Treatment of Incipient

Insanity .

The accuracy of the description of the present legislative
provisions for the insane as the Lunacy Act has often been
questioned, and there, indeed, seem many well-founded reasons
for believing that they would have been more correctly
described as the Lunatic Act.

The Bill on which this Act was founded was introduced at a
time when John Bull (as Dr. Merrier recently remarked) was
suffering from considerable mental disturbance excited by the
Weldon case. The disorder took the form of morbid fears
about the liberty of the subject, with delusions of suspicion
against the medical profession. The Bill, as originally intro¬
duced, affords ample evidence of these symptoms, but for¬
tunately several years of delay intervened (during which the
sufferer had to some extent recovered) before this insane Bill
became lunatic law.

The animus against the medical profession was well shown
in the clause in the original Bill which excluded medical men
from taking charge of single cases of insanity. An ex-convict,
an habitual drunkard, or even a lunatic, was (and is still) at
liberty to take charge of such cases, while all medical men (unless
struck off the register for infamous conduct) were disqualified.
That such a clause should have been introduced in two
successive Bills is evidence of the spirit of the framers, and is
confirmed by the extreme severity of the penal provisions of
the Act against medical men. Throughout the Act lunatics
are treated as veritable, and their doctors as probable, criminals.

The alleged lunatic was always spoken of as bein^
“accused 99 of insanity* of being “ incarcerated ” in an asylum,
and so on; whilst under the existing Act power is given to
the magistrates to order these sick persons before them, to
delay their proper medical treatment for days and weeks, even
to override the written advice of two medical men, and to
virtually discharge the patient after admission to hospital
(asylum). This last power was recently exercised, resulting
xlix. 8

Digitized by v^.ooQLe

OCCASIONAL NOTES.

[Jan.,

118

in the suicide of the patient, whilst the other powers of delay
have led to homicide, homicidal violence, or suicide. The
magistrates, on the whole, however, have acted with astonish¬
ing discretion, and have rarely exercised the powers given them
in the Act to practise as transcendental lunacy physicians.

The criminality of being mentally sick necessarily involves
criminality in those who are accessory to the crime. Hence
the Act provides that any person undertaking for payment to
take charge of an invalid against whom mental disorder can
be even alleged, is (by Sec. 315) guilty of a misdemeanour.
The liberty of the subject, which this Act was designed to
protect against the utterly improbable possibility of a sane
person being detained in an asylum, is outraged in the grossest
manner in three different directions— viz., by delaying and
deterring sick persons from obtaining treatment under certifi¬
cates ; by forcing certification on others before they need it;
and by preventing medical men and nurses from the legitimate
exercise of their vocation in treating these invalids.

Bad laws are badly obeyed, and the lunacy law, being harsh,
unjust, and absurd, is no exception to the rule. To the intense
popular objection to being considered a lunatic (which is
evidenced throughout our literature, and by a hundred con¬
temptuous phrases in the vernacular) has been added the equally
wide-spread dislike to magisterial interference. Hence a much
more universal desire to escape the meshes of the law; and
this is aided by the fear that has been established in medical men
by the penal threats of the Act, and by incomplete protection
against prosecution for certifying insanity.

The manifold hardships and gross interference with the treat¬
ment of mental diseases in their early stages, as a result of the
existing law, formed the subject of a discussion at the Carlisle
meeting of the British Medical Association in 1896, when a reso¬
lution was passed leading to the formation of a conjoint
Committee of the British Medical and Medico-Psychological
Associations. This Committee was ultimately received as a
deputation by the Lord Chancellor, who adopted into his Bill,
almost without alteration, a clause moulded on that in the
Scottish Act. This clause provides for the treatment of
incipient and unconfirmed insanity for a period of six months
without certification, and for notification of the fact to the
Lunacy Commission.

Digitized by

Google

1903 .] OCCASIONAL NOTES. II9

Sir William Gowers, at the November meeting of the
Medico-Psychological Association, read an address pointing
out this defect in the law, and recommended much the same
amendments. His testimony is all the more valuable from
its being arrived at independently, he being apparently un¬
acquainted with the Lord Chancellor’s adoption of this clause
four years ago.

Treatment of incipient and unconfirmed insanity provided
in this clause if it becomes law, will need to be supplemented
by some regulations in regard to the character and qualifica¬
tions of the persons undertaking it Ignorance may be worse
than cruelty, and the incipiently insane person who is well fed,
well clad, and tenderly neglected in the nursing-home bed or
the genteel back parlour until hope of recovery is lost, is really
subjected to the most grievous neglect. Under existing
conditions such neglect, it is to be feared, is of but too
common occurrence.

A considerable number of those engaged in the treatment of
unconfirmed insanity are highly qualified for the work by
experience or special aptitude, but there are many not so
qualified. There seems, indeed, to be a very wide-spread
popular opinion that when all else has failed a " patient ” may
be taken who, like the Hibernian pig, will not only “ pay the
rint,” but something more.

The housing accommodation of incipient cases is not always
the best that could be desired. There is often no opportunity
for private exercise, so that the patient is unduly confined to
the house, or, to avoid inconvenience to other inmates, to bed.
To escape the attention or the annoyance of neighbours, and
to overcome the noise of the locality, sedatives are often
unduly resorted to, while the patient is frequently allowed to
indulge many kinds of ill habits unchecked and uncontrolled
except by chemical means.

Uncertified care may therefore be either the best or the
worst form of treatment, and may bring either salvation or
utter ruin to the patient. Such treatment should not be left,
as at present, to be undertaken by any person, however
unqualified, and under any conditions, however unfitting.

The notification of treatment would enable the Lunacy
Commission to obtain information which they have now no
means of acquiring, and of framing regulations which would

Digitized by v^.ooQLe

120 ' OCCASIONAL NOTES. [Jan.,

tend to obviate the present very serious irregularities. This
would entail much labour, and would necessitate that increase
in the personnel of the Commission which has long been
required.

The Lord Chancellor has shown himself so much interested
and so open-minded on lunacy questions, that direct represen¬
tations to him would be much more practical and successful
than to put the whole lunacy law into the hands of a Royal Com¬
mission. A Royal Commission, indeed, may be regarded as the
Western equivalent of the car of Juggernaut. Fanatics rush to
prostrate their crude ideas beneath its ponderous examination
wheels, happy ever after in having them recorded in the
report. Hence the conclusions of the Commission are
commonly a compromise of extreme rather than a composite of
all views. From such a result we may pray to be delivered.

The lunacy law wants reform on many points, but first it
is necessary to persuade those concerned in legislation that
the medical profession is not in a conspiracy to shut up all the
community in asylums, but, on the contrary, is really desirous
of doing good to the insane; that the insane are not criminals,
but sick persons needing the most careful, skilful, and tender
treatment, especially in the early stages of the disease.

The Legislature needs also to be taught that these sick
persons have a right, equally with other sick persons, to obtain
necessary treatment, without the delay of a moment by legal
procedure, and that to sacrifice this right to the fantastic fear of
a hitherto uncommitted crime is a disgrace to our national
character for common sense and humanity.

In Scotland, where the law is sane, and has not a quarter of
the safeguards and none of the terrific threats against medical
men found in the English law, no case has arisen in which any
person has been proved to be illegally detained. The late
Lord Shaftesbury vainly pointed out that no such case had
ever occurred in England.

The liberty of the subject bogey should be relegated to a
legal limbo, and lunacy legislation should be based, not on
panic and prejudice, but on common sense and justice.

If the present Lord Chancellor is approached in a suitable
manner, we believe that English lunacy matters may yet be
dealt with by “ sane law in a sane Act.”

Digitized by v^.ooQLe

1 903-]

OCCASIONAL NOTES.

121 .

Insanity and Life Assurance.

The life assurance of the insane was recently dealt with by
Dr. Poore in his Presidential Address to the Life Assurance
Medical Officers’ Association, and in the discussion Dr. Savage
suggested the possibility of the formation of an association for
the assurance of the insane.

Dr. Poore pointed out that every life might be insurable if
the statistics necessary to form conclusions of its probable
duration were forthcoming, and that in regard to the insane in
asylums more complete age and post-mortem statistics were
available than for any other class of the community. He
expressed the opinion that when a person had been in an asylum
for some years, and the mental condition had become chronic,
the life is probably a good one from the assurance point of view.

Asylum life, with its freedom from worries, dietary irregu¬
larities, etc., no doubt does prolong the life of many patients,
even when suffering from associated physical disease. The
asylum post-mortem table often affords examples of this pro¬
longation of life in connection with an extent of heart, kidney,
and liver disease such as are rarely seen elsewhere.

Asylum inmates, indeed, when chronic and not affected with
progressive disease, such as general paralysis, epilepsy, or
phthisis, have a good expectation of life, and even when the
insanity is accompanied by bodily disease it is probably about
as good as in a sane person suffering similarly.

Asylum statistics (Table No. IV) show that patients live
on for half a century and more after admission, and it will be
seen by a study of this table in reports of large asylums how
very regular is the proportion of survivals after the first four
years from admission.

Statistics such as these demonstrate that a general average
would not be difficult to calculate on such chronic cases, but
an equitable estimation of prospective life would need to be
based on a careful examination of the individual case.

Discharge from the asylum, as Dr. Poore pointed out, would
tend to shorten life, but we trust that this would never become
an argument in favour of detention, but would only be regarded
as an extra risk—from the standpoint of life assurance.

Digitized by

Google

122

OCCASIONAL NOTES.

[Jan.,

Liberty of the Lunatic .

The public from time to time is sadly distressed by the
occurrence of crimes committed by lunatics whose lunacy has
in many cases been known and recognised prior to the criminal
acts. Unless, however, the lunatic has previously inhabited
an asylum, the occurrence is accepted as in the natural course
of things, and in no way regarded as an avoidable event.

This Journal has frequently had occasion to comment on
this subject, and there can be little doubt that some at least of
these cases might be prevented by an alternative to the present
legal procedure in putting an insane person under control.

Lunacy certification rests on the fact of a medical man being
able to put into writing a description of facts indicating
insanity observed at the time of the interview, and this at
present is the essential evidence on which a lunatic can be
restrained.

Lunatics, however, may, and often do, decline to be inter¬
viewed by a medical man; they may decline to speak or do
anything in his presence, or may control all expression of their
insanity. Moreover, a continuous or occasional insanity ot
conduct may exist which does not show itself sufficiently
during an interview to form the basis of a certificate.

Such lunatics, although their insanity is manifest to their
friends and relatives, may remain uncontrolled for days, weeks,
or months, and not infrequently prove their insanity by their
criminal acts, thus shocking the community and furnishing
startling head-lines for the newspapers.

The law has surely a hiatus here. Ample evidence of con¬
tinuous insanity might be obtained from lay persons, and
(apart from the certification interview) from medical men
Without the certificate, however, no restraint is possible in
private cases, but amongst the poor, by stretching the law, the
patient is often taken to the workhouse.

This difficulty is an additional argument in favour of recep
tion-houses. If these were established, power might be given to
the magistrates to order the detention therein of persons in
regard to whom satisfactory pritnd facie evidence of insanity
had been adduced (apart from medical certificates). Some
such provision would save many lives and much suffering.

Digitized by v^.ooQLe

1 903]

OCCASIONAL NOTES.

123

Tuberculosis Committee Report.

The statistical tables of this report have been subjected to
very severe adverse criticism, which certainly has a basis of
justification.

We cannot but wish, however, that the criticism had been
addressed to this Journal rather than to the pages of a
contemporary.

The statistical differences thus pointed out are fortunately
not of vital importance, and in no way vitiate the conclusions
of the report, which is a contribution of the utmost value.

The incident emphasises the desirability, in all statistical
matters of an original character, of obtaining the criticism
and advice of a skilled statistician.

Insane Poor under Private Care.

The contribution on the above subject by the Secretary of
the Scotch Board of Lunacy, at the recent Belgian Congress,
is a valuable description of this mode of treatment as at present
carried out in Scotland.

Mr. Spence objects to the term “ boarding out ” as applied
to the system, as giving the erroneous impression that “ the
essence of the method lies in removing patients from asylums.”
Private Care is certainly a non-committal and better term.

The statistics show that no fewer than 2631 persons are thus
provided for, 1597 being placed singly with relatives (954) or
strangers (623), while 1054 are in 477 houses licensed to
contain two, three, or four patients.

Two thousand homes, therefore, are found in Scotland in
which these cases can be satisfactorily placed; and this fact
suggests once more the oft-repeated inquiry whether some¬
thing of the same kind cannot be carried out in England.

The difficulties would be much greater, and there is little
doubt that this mode of care could not be carried out to the
same extent as in Scotland. That it is practically non¬
existent in England leads, however, to the conclusion that
this is due to its never having been satisfactorily tried.

The reasons why private care of the poor cannot be carried
out have been so often discussed that it is useless to repeat

Digitized by v^.ooQLe

124

OCCASIONAL NOTES.

[Jan.,

them, but this report suggests a desire to see a really vigorous
and determined attempt at imitation on this side of the border.

In the millennium, when the English Lunacy Commission is
strengthened in its medical element, this may, perhaps, be
again attempted; at present it is obviously impossible for the
three medical commissioners to add to their present work the
inspection of a few thousand additional honjes.

Hospital and Asylum Training of Mental Nurses.

Discussion has recently arisen in regard to the introduction
of hospital-trained nurses into asylums, and the experiment has
even been tried of placing them in charge of wards without
having had previous experience of the insane. With careful
selection and enthusiastic co-operation, this has even worked
satisfactorily.

Extraordinary conditions must be carefully excluded in
dealing with large ordinary affairs. The question is really
whether the ordinary hospital nurse is as good for asylum work
as the nurse trained in the asylum. To this question we
believe that the majority of medical superintendents would give
an emphatic negative.

Attendance on the insane, at its best, demands a much higher
quality of intellect and of personal character than is ever
required by hospital nursing, and the extent of experience is of
much greater value and importance.

The asylum nurse has to deal with the disordered working of
the most complex function of life ; the hospital nurse is
principally concerned with material details of a routine
character.

Self-control, alertness, sympathy, patience, cheerfulness,
sense of justice, keenness of observation, discrimination, firm¬
ness, courage, promptness, initiative, are only a few of the
characteristics demanded of a mental nurse; the majority of
these qualities may be absent from the hospital nurse without
detracting from the efficient performance of her duties.

Whatever may be the actual average of individual education
and capability of the two classes at the present time, there can
be no doubt that the asylum nurse has scope for a much higher
ideal, even if it is rarely attained.

Digitized by v^.ooQLe

OCCASIONAL NOTES.

125

1903]

The public and even the profession need to appreciate that
although some cases with slight mental symptoms (which are
merely epiphenomena) may recover under unskilled nursing,
such care may often do infinite harm when there is serious dis¬
order. Many epiphenomenal cases, from want of proper dis¬
crimination, are unnecessarily removed from home, and by
their recovery encourage the belief that skilled nursing is not
needed in mental disorder.

There have been, and no doubt still are, many indifferent
mental nurses, but there is a wide gulf between the hospital
and the efficient mental nurse.

The high personal qualities demanded of asylum nurses,
which are too frequently passed over as a matter of course,
cannot be too forcibly and publicly insisted on, both to over¬
come the prejudice that survives from a time when asylum
keepers were untrained and uneducated, and to draw to the
service people of a higher grade.

Lunacy Prophecy .

A contemporary reports a Detroit “ doctor and scientist,”
“after a careful investigation of existing conditions,” as asserting
that “ 260 years hence everyone in the United States will be
insane.” The population by that time will amount to a few
hundred millions, so that this prophecy affords an opening for
much speculation. Imagination paints the General Paralytic
Progressive Party contesting with the chronically Hallucinated
Conservative faction.

Religion would certainly be the province of an epileptic
priesthood, with many melancholic devotees.

Paranoia would add interest to philosophy, while confusional
cases would probably revel in metaphysics.

Literature and science would be the province of the idiot
savants , whilst the labour of the community would no doubt fall
to the dements.

Similar predictions were no doubt made some fifty years ago
in regard to criminality, but fortunately they are not being
fulfilled. Eternal hope suggests that perhaps lunacy may not
continue to progress by leaps and bounds, and that three
centuries hence America may not be more mad than England
at the time of Hamlet.

Digitized by v^.ooQLe

126

REVIEWS.

[Jan.,

Part II—Reviews.

The Fifty-sixth Report of the Commissioners in Lunacy > fune, 1902.

Apart from the points raised by a consideration of the statistical
tables, the following are among the more important topics we notice
touched upon in the current report.

Fees from Improper Sources received by Relieving Officers for the
Certification of Pauper Lunatics .—In view of certain instances of this
having come to their knowledge, the Commissioners publish a circular
letter from the Secretary of State to Clerks to the Justices for Petty
Sessional Divisions, drawing the latter’s notice to the intention of
certain sections of the Act.

The Re-classification as Private Patients of those admitted into
Asylums as Paupers .—Allusion is made to the interpretation of the law,
that where there is ground for believing a pauper patient in an asylum
to be possessed of sufficient property to maintain him as a private
patient, he should be at once re-classified as such. The Commissioners
express their appreciation of the present position so created, and are
considering if any, and what, amendment of the law could be introduced
into a new Lunacy Bill with a view to its improvement.

We would suggest that on the grounds of equity, before a patient is
adjudged a proper person to be classified on the private list, it should
be proved that his means can refund not only the cost of his main¬
tenance, but contribute to the rate of the upkeep of the fabric of the
asylum, and for any payments still due in regard to the original cost
incurred in building the asylum. In this connection it would be very
desirable to substitute the word “ rate-paid ” for “ pauper.”

Provision and Enlargement of Asylum Cemeteries .—It is pointed out
that a recent change in the law makes it necessary now to obtain the
approval of the Local Government Board before the Secretary of State
can give his consent as required by the Lunacy Act.

Examination at Police Courts of Patients for purposes of Certification .

-—It appears there are still some thirty-one places where this objection¬
able practice is still more or less in vogue. The Commissioners
enumerate them, and rightly again animadvert on the continuance of
such a custom.

County and Borough Asylums.

The number of these at the time of writing the report had by the
opening of the new asylum for West Ham reached eighty. Some few
years ago the Board published a supplementary Blue Book containing
the plans of several of the most recent asylums. If it is not practicable
to include in their Annual Report lithographic plans of any asylums
opened during the previous year, we feel assured that the regular
appearance of such a supplement, say every five years, would be very
welcome.

Digitized by v^.ooQLe

1 903]

REVIEWS.

127

The condition and management of these institutions are stated to
continue almost without exception to be highly satisfactory. The
patients* dietary, particularly the mode of serving of the meals, is the
main point in which room for improvement is most commonly noticed.

Post-mortem Examinations. —The names of seven asylums in which
such has been held in every case of death are quoted. These asylums
are certainly to be congratulated on their success in these highly
necessary examinations, but their being thus signalled out is a little
unfair towards several others, whose zeal in this respect was not a whit
less, but who were unable to attain such completely satisfactory
figures, owing to the deceased patients’ friends lodging an emphatic
embargo against any autopsy being held. How far this objection could
be legally maintained is a point upon which we should like to see an
authoritative expression of opinion.

Following upon a statement of the proportion of deaths in which a
post-mortem examination was held, is commonly a statement as to the
number, if any, of coroners’ inquests. We would here venture to
deprecate such a statement as “ It is satisfactory to record that since
the last visit of our colleagues, more than nineteen months ago, no
coroner’s inquest has been held, ...” which we read in the report of
one of the county asylums. In our opinion there is an element of
danger in such a remark ; the obtaining of satisfactory verdicts deserves
congratulation rather than the occurrence or absence of inquests.

Zymotic Diseases .—Those of which instances are reported are influenza,
scarlet fever, erysipelas, diphtheria, enteric, tuberculosis, dysentery, and
diarrhoea. The last two are the only ones which call for notice here,
and in none can the case-incidence with any advantage be quoted, owing
to the variation of the interval between the Commissioners’ visits.

Dysentery. —The returns justify a statement that the mortality from
colitis, enteritis, and diarrhoea is a growing one. Comparing the
returns for 1892 and 1901, the proportion of “dysenteric” deaths to
deaths from all causes has rather more than doubled itself, whether
estimated by a reference to all the asylums or to only those from which
“ dysenteric ” deaths were reported. In order to gauge more definitely
the extent to which these diseases are prevalent in asylums, the Com¬
missioners have initiated a plan, based upon the scheme adopted by
the London asylums, to ensure the registration and the half-yearly
notification of all cases of diarrhoea amongst staff and patients. We
are very sanguine that this may pave the way to more drastic prophy¬
lactic measures. We understand that a somewhat similar registration
of all cases of tuberculosis also exists in the London asylums. That
this will ere long receive general adoption we earnestly hope.

Tuberculosis in the year 1901 accounted for 1215 of the deaths in
the county and borough asylums, which is 15-8 per cent, of the total
deaths from all causes. It is not quite clear whether these figures and
those with reference to dysentery are taken from the table of deaths in
Appendix A (Table XIV), in the compilation of which it is permissible
to assign only one cause of death in each case, or from the statutory
notices of death sent to the Commissioners; the latter would, of course,
give much more complete and accurate figures.

The Weekly Maintenance Pate shows the marked advance of 1 id. a

Digitized by v^.ooQLe

128

KE VIEWS.

[Jan.,

head per week on the weekly rate for the year ending March 31st,
1900. This would appear to be mainly due to a general all-round
rise in contract prices, but especially to the great increase in the price
of coal.

Registered Hospitals .

The Commissioners emphasise the importance of the functions these
perform, and repeat their regret that there are no signs of the urgent
need of greater accommodation for educated persons of small means
being met by public philanthropy. They are fourteen in number, and
on the 1st January, 1902, there were 2535 patients and 87 voluntary
boarders therein.

Institutions for Idiots.

These are stated to continue maintained in a generally satisfactory
condition, despite the unsafe position of the law regarding them.

State and Criminal Institutions . Metropolitan and Provincial
Licensed Houses. Single Patients. Lunatics in Workhouses.

The remarks made under these headings do not call for comment here.

Statistical Tables.

Table I gives the number on the first day of the year of all lunatics
of whom the Commissioners had cognizance and their distribution,
differentiating also between private, pauper, and criminal patients.
These figures are given at intervals of ten years from 1859 to 1889, and
for each of the years 1893 to 1902 inclusive.

Table II deals with the same years and gives the ratio per 10,000 of
all notified lunatics (again differentiating them into private, pauper, and
criminal) to the whole population estimated to the middle of the year,
and in the last column the number of persons in the whole population
to each lunatic.

The former table shows that on January 1st, 1902, the Board had
official knowledge of 110,713 lunatics, 45*5 per cent, of whom were of
the male sex. In 1869 the corresponding total was 53,177, which in
the last thirty-three years has therefore rather more than doubled itself.
Such a statement has, of course, no sociological value until the figures
are expressed in terms of the whole population. It is, however, of some
interest to work out the different rates at which this increase has pro¬
ceeded. It thus appears that the number of lunatics on January 1st,
1859, was 36,762, and had increased to 53,177 on January 1st, 1869, at
an annual average rate of 4*4 per cent.; between 1869 and 1879 the
average rate of increase was 3*1 per cent. ; and 2 per cent, between 1879
and 1889. For the years between January 1st, 1893, and January 1st,
1902, the annual rates of increase have respectively been 2*2, 2*5, 2*1,
2*5, 2*9, 2-6, 2*9, 1*4, 1*2, and 2*6 per cent., giving an annual average
rate of increase for the last decade of 2*6 per cent. The reader is
naturally struck by the particularly low rates during the years 1899 and

Digitized by v^.ooQLe

REVIEWS.

129

1903 .]

1900. There axe several factors which would have to be examined
before any reliable explanation could be arrived at. The time spent in
so doing would, however, to a considerable extent be thrown away, owing
to the fact that the above figures merely represent a census of insane
population on a given day in the year, instead of daily averages. If a
column expressing the latter could be added to Table I, the value of
this table from a statistician’s point of view would be immensely
increased. As a matter of fact Table IV does give the daily averages
for most of the distributing columns, omitting, however, those “in
workhouses” and those “residing with relatives or others.”

Similarly, if it could be found possible to calculate Table II from
figures expressing a daily average instead of a census, its results would
be much more convincing. As it stands, it indicates a present ratio of
33*55 lunatics to 10,000 of the whole population, as compared with
18 67 in 1859; or, expressed in terms of the number of sane persons to
every lunatic, there are now 298 compared with 536 in 1859. How far
these figures would require to be amended, if calculated on daily
averages, it is impossible to say without the data; but looking forward
to Table IV, and working out the annual rate of increase per cent . on
each year’s figures, the following are the results :—4*1, 2*1, 27, 4, 3*2,
3*5, 2*8, 1 *5, and 3*1, which suggests a curiously greater degree of
fluctuation in the rate. There can be no doubt, however, that, as the
Commissioners point out, the advance in the ratio has been almost
entirely in the pauper class; indeed, the ratio in the private class seems
almost stationary. They suggest that possibly more insane of the better
social classes are now treated privately without notification to the Board.

Table III is an extremely important and valuable one. It gives the
admissions , classifying them into private, pauper, and criminal, into
institutions for lunatics (except idiot establishments) for the same years
as Tables I and II, rightly omitting from them transfers and admissions
due to lapsed orders, and sets forth the ratio of these per 10,000 to the
whole population. It shows that the total admissions in 190a were
20,769, being 6*4 per 10,000 total population, to which amount the
ratio has advanced from 5*83 in ten years, and from 471, which was the
ratio in 1869.

The question that at once presents itself is whether this growing ratio
means that insanity on the whole is increasing. There are several other
explanations which would require to be borne in mind before admitting
such an unpleasant one. For instance, a fall in the number of persons
in the general population below the age of fifteen, during which period
insanity is uncommon, other conditions remaining unchanged, would
bring about a rise in the ratio; and conversely the ratio would equally
tend to rise were there an increase in the general population of persons
at an age-period which is specially prolific in cases of mental breakdown.
Or again, an explanation for an increased ratio would be forthcoming
were it found that it was a growing practice to certify and send into
asylums cases which in former years were nursed at home or allowed to
remain in workhouses; we have here, of course, in our minds senile
cases, and we are familiar with the frequent wail of superintendents that
their asylums are being made a receptacle for such in an alarmingly
growing manner. These considerations show the necessity—well enough

Digitized by v^.ooQLe

130

REVIEWS.

[Jan.,

known to most of us—of having the means to compare the number of
our cases, divided according to age-periods. Such is at our disposal in
Table XX, which is divided into eight age-periods, quinquennial
between 15 and 35, decennial above 35. It deals with the admissions by
means of a yearly average during five years. The table in the present
report refers to the years 1896 to 1900 inclusive, and it is very instruc¬
tive to compare the ratios for its eight age-periods with those in the
same table in the 1899 report, which has reference to the years 1893 to
1897 inclusive. This comparison shows that under 15 years of age, and
from 15 to 19, the ratio was stationary; that in each of the periods 20 to
24, and 25 to 34, there was an advance in the ratio of o*i; while in the
periods 35 to 44, 45 to 54, 55 to 64, and upwards of 65, the advances
were respectively o’6, 0*8, 0*9, and i*i. But these figures require still
further sifting, for the ratios themselves vary widely in the different age-
periods, from 0*2 under 15 to 14*3 in the 65 and upwards column ; so
that the above advances must, for purposes of comparison, be worked
out as percentages, and will then read : 1*5, i*o, 4*8, 6*2, 7*2, and 8*3.
In other words, in the period 20 to 24 the ratio advanced only 1*5 per
cent ., as against 8*3 per cent . in the case of those 65 and upwards. So
far, then, it would seem that the senile period is the one in which the
advance in the ratio has been most noticeable ; but it is impossible from
the data at our command to say whether this is due to an increase in
the number of cases that really require asylum treatment, or to a
tendency to alter and enlarge the definition of this type.

There remains an appreciable advance in the ratio demanding con¬
sideration in the periods 35 to 44 and 45 to 54—periods that are, in
truth, of no small importance, for it is probably during them that life’s
stress and struggle press most severely, and we cannot afford to lightly
pass over any apparent rise in the proportion ot insanity occurring
during them. It has been stated by some that general paralysis is much
more prevalent than formerly, and, as these two periods yield more than
twice as many cases of this disease than all the other six combined, we
at once have at hand a very ready explanation. It probably, however,
must be discarded, for, were it the real one, we should expect the male
sex to supply considerably the greater share of the advance in the ratio.
Such, however, is not the case; indeed, as regards the chief period,
35 to 44, the very opposite prevails. An increase in these periods in
the number of “ not first attack ” cases would account for the advance
in the ratio without implying an actual increase in the proportion of
persons becoming insane. Unfortunately there is no table in which
“ first attack ” and “ not first attack ” cases are arranged separately
according to age, so that this last hypothesis must remain such.

This division of admissions into “ first attack ” and “ not first attack ”
cases we regard from the point of view of the vital statistician as highly
important. Since 1898 the Commissioners have included in Table III
a column expressing the ratio (per 10,000) of first admissions to the
general population. During 1901 it stood at 5*31, as against 6*4, the
already quoted ratio of the total admissions. So strongly do we feel
the value of this division that we would venture to urge that it be
adopted in all such statistics dealing with admissions, as age, cause
duration of malady, occupation, etc. And, indeed, with regard also to

Digitized by v^.ooQLe

REVIEWS.

i903]

131

recoveries, we believe that a similar separation of them into the same
two classes would prove a valuable reform.

The recovery rate , expressed in three terms, is given in Tables V and
VIII. Based on the number of admissions, it was 37*27 per cent . lower
than the averages for the ten years 1892 to 1902. We cannot see any
practical advantage in the methods of calculating recovery percentages
on either the total number under treatment or the daily average number
resident, and do not feel that anything is to be gained by quoting the
figures.

As a matter of fact no one can feel very satisfied with the foremost
mentioned, and at present the accepted, mode of expressing the recovery
rate, in that the percentage is based on the admissions of the current
year, while many of the recoveries refer to the preceding year, and
many of the current year’s admissions will not recover until the succeed¬
ing year. It is a pity the Commissioners’ tables do not include one
corresponding to Table IV of the Medico-Psychological Association.
It is a tedious one to compile, and, as at present found in asylum
annual reports, is rendered valueless by the necessary inclusion of
transfers; but, compiled by the Commissioners upon the statutory
notices of admission and discharge furnished to them, the table would
become decidedly valuable. At present the Blue Book affords us no
means of finding how many of the admissions notified to the Com¬
missioners in any given year have by now recovered.

The death-rate , expressed in two ways, is shown in Tables VI, VII,
and VIII. Calculated on the average number resident, it was 9*77 per
cent and 7*65 per cent, in terms of the total number under treatment.
Both these numbers are 0*37 less than the corresponding ones for 1900.
The Commissioners point out an important diminution in the death-
rate during the past thirty years, and are sanguine that in partial ex¬
planation of this may be held the better nursing in, and the improved
sanitary conditions of, asylums.

Causes of Insanity .—We share with the Commissioners considerable
diffidence in drawing any conclusions from this table. That such
should be necessary is exceedingly unfortunate, for its importance
obviously cannot be over-estimated. No doubt this is partly explicable
by the fact that in compiling it, personal equation comes more strongly
into force than in any other table. Take, for instance, venereal disease
(syphilis): it is an assigned cause in 3 per cent . of the 9230 male
admissions, of whom 11*5 per cent . are stated to be general paralytics.
Most of us to-day will agree that, if looked for, evidence or history of
syphilis can be found in at least 50 per cent . of the cases of general
paralysis, so that, on these considerations alone, the above percentage
of 3 must be much below the mark. And this can only be so because
either the evidences of the disease have been overlooked, or because
the recorder did not happen to think it was actually a cause. It should
be clearly understood that its presence ought to be recorded, leaving
to a subsequent study of the figures the decision as to its causal relation.

The Report concludes with an allusion to the deep loss the Board
has sustained in the death of Mr. J. D. Cleaton. He had been a
member thereof for thirty-seven years.

Digitized by v^.ooQLe

REVIEWS.

132

[Jan.,

Forty-fourth Annua/ Report of the General Board of Commissioners in
Lunacy for Scotland , 1902.

The number of people coming for the first time under the official
cognizance of the Lunacy Authorities in the United Kingdom in 1901
was 22,922. This, taken as an index of the amount of occurring lunacy
of the country, represents a distinct step in the backward direction
when compared with immediately preceding years. It means that there
has been a percentage increase of fresh cases of mental breakdown
amounting to 4*96, as compared with 0*94 in 1900 and 1*39 in 1899,
the average annual increase of population meanwhile being approxi¬
mately 1 per cent . In 1900 the increase was under what it would have
been if the proportion to population had remained the same; in 1901
the increase is out of all proportion to the increase of population.* The
average daily number of fresh cases, which in 1898 was 58, in 1889 59,
and in 1900 60, rose to 63 in 1901. There must be some reason for
the fact that 1901 had, as compared with 1900, three more fresh
lunatics added every day to the official list.

In reviewing the Report for 1900 the opinion was expressed that the
existence of the danger which was then threatening the Empire had
been productive of an increased mental stability and a stiffening of the
moral character, but that that improvement was not likely to be per¬
manent, and the returns of the year under review appear to support the
correctness of that prognostication. “ Jeshurun waxed fat and kicked ”
is just as true now as it was in Mosaic times. No sooner is the
imperial security assured than self-restraint becomes loosened and
mental stability diminished. This throwing-off of restraint makes
itself felt in many ways and through all ranks of society. Staid, sober
citizens, business men, members of the Stock Exchange, and wearers
of silk hats go for the time being clean “off their headsthere are
“ Mafekings ” and peace rejoicings; London’s stock of champagne is
drained in one single night; “ Peace ” meetings are broken up in riot
and bloodshed. If such is the conduct of the usually orderly and law-
abiding section of society, what can be expected from others ? The in¬
stability of the unstable is heightened ; the criminality of the criminal
is increased. Law, order, and sanity cease for the time being to be
characteristics, and that too while war is still to be waged for another
half-year.

It might, with some show of reason, be held that these alarmist views
are contradicted by the facts related in the Scottish Lunacy Report.
In England, whose population increases in nearly the same ratio as
that of Scotland, the percentage increase of first admissions in 1901 is
6*44; and in Ireland, where there is an annual decrease of 0*5 per cent .
in the population, these have increased 1 *66 per cent .; while in Scotland
the total number is less by 9, or 0*33 per cent. y than in 1900. This,
however, may be looked upon rather as an illustration of a difference
between the Scottish character and that of England and Ireland, a
difference which expresses itself by a lesser readiness to be betrayed
into effervescent emotionalism by passing events, however exciting. The
steadying effects of the temporarily trying time through which the
Empire has been passing were longer in making themselves felt in

Digitized by ^.ooQle

REVIEWS.

153

»9°3]

Scotland, and the reaction which has set in elsewhere has not yet
manifested itself. The returns of 1902 will in all likelihood witness to
this.

No special reference is made by the Commissioners to this, from the
sociological point of view, really the most important feature of the year,
viz., the actual diminution in the total numbers admitted for the first
time to the official register in 1901. The proportion of these per
100,000 of population rose from 52*6 in 1900 to 55*4 in 1901 for the
whole United Kingdom ; in England from 50*2 to 53-1; in Ireland from
61 *9 to 67*4; while in Scotland there is, by contrast, a fall from 60*8
t° 59 # *.

The statistics relating to general paralysis as a cause of death in
establishments reveal “a new and startling proportion,” and reflect
“ seriously upon the social health of a large section of the city popula¬
tion,” not only in Edinburgh, but throughout the whole of industrial
Scotland, which provided three fourths of the whole number of victims
of this disease. The following table is so sufficiently eloquent of a most
startlingly retrogressive tendency on the part of the Scottish race as to
call for no further comment.

Percentage increase or decrease (i)of total deaths, exclusive of general
paralysis; (2) of deaths due to general paralysis in 1901, as compared
with 1900.

Total deaths exclusive of

general paralysis. Deaths from general paralysis.

England .

- 49 •

.. — ri ..

. - 2 9 ..

. + l 6‘5 •

.. - 2 9

... + 12*0

Scotland .

“ 147 •

.. - 4*4 ••

. - 9*2 ..

1. + 4**® •

.» + 63.1

... + 45 * 2

Ireland

+ 96 .

.. - 15 8 ..

. ~ 3*2 ..

• + 13*3 •

... + 130

With regard to the “ boarding-out ” system, the figures for the year
indicate a continued tendency towards accumulation of pauper patients
in establishments, with a corresponding reduction in the numbers
accommodated in private dwellings. This decrease takes place mostly
in the case of those who are under the care of related guardians. While
the total number of pauper lunatics shows an increase of 2*4 per cent,,
those in establishments have risen 3*4 per cent, The decrease in the
number in private dwellings amounts to 1 per cent., those with relations
diminishing 3*3 per cent ,, and those with strangers only 0*3 per cent, A
possible explanation for this tendency, in addition to those adduced by
the Commissioners, may be found in an improvement in the conditions
of life, an improvement indicated by a fall in the pauper rate per
100,000 of population equivalent to 1 per cent,, which has taken place
during the year.

Considerable prominence is given to questions of medical treatment
and to the nursing of the insane, and frequent reference is made to the
“bed treatment” of acute cases. This system, which meets with
approval on the part of the Commissioners, but as to whose merits, as a
hard and fast rule, there is by no means unanimity of opinion, can
hardly be regarded as a modem discovery. In one asylum, it is
recorded, “ it has for many years been used as one of the ordinary forms
of treatment; ” and is it not recorded that Christian’s relations, thinking
that “ some frenzy distemper had got into his head, . . . with all haste
XLIX. 9

Digitized by v^.ooQLe

*34

REVIEWS.

[Jan.,

they got him to bed ” ? The spirit of progressiveness is very active in
the Scottish asylums ; some might, perhaps, think too much so, and that
there is some risk of the sense of proportion getting lost One looks for
indication of some result of a practical kind, some evidence that the
condition of the patients, for whose benefit all these improvements are
devised, is materially bettered. Perhaps it is unjust to judge of their
merits so soon, but it is not encouraging, after having high hopes raised,
to turn to the hard facts of the statistical table and to find that the abolition
of the single room, the supervision by the hospital-trained nurse of the
tried and experienced asylum attendant, the bed treatment, and the like,
have not resulted, so far, in any marked improvement either in the
recovery rate or the death-rate. The former was 38*6 per cent, of
admissions in Royal and district asylums in 1901, as compared with
38*3 in the preceding year, 37*3 in the quinquenniad ending 1899, and
38*6 in the preceding quinquenniad; and an analysis of Table X of
Appendix A reveals the fact that, though there has been a decrease in
the total deaths in 1901 amounting to 3*6 per cent., there have been
increases under those very headings in which improved methods of
treatment and nursing might be expected to give other results. The
increases we refer to are those of deaths within a year of admission,
which are 8*9 percent.; those from maniacal and melancholic exhaustion,
which are 217 per cent.; and those from suicides and accidents, which
are 17*6 per cent, more than in 1900. The desirability of securing and
retaining the services of suitable asylum attendants, upon whom
depend so largely the welfare and happiness of the patients, is strongly
emphasised by the Commissioners; and apparently this service is being
rendered more attractive, for the changes among the staff, though still
numerous, are considerably fewer than in the previous year. Voluntary
resignations were 12 per cent. less, but dismissals showed an increase of
16 per cent., and the number of those who absconded rose from nine to
twenty-nine. In this regard, it is difficult to reconcile certain statements
with certain facts relating to one asylum, of which it is reported that the
nursing arrangements “ possess many novel and interesting features
worthy of record,” and which, it is said, “ have been found to be most
beneficial, both as to the patients and staff.” If beneficial to the staff,
how is it that the reports covering a period of twenty-four months out of
the past three years record the resignation of 107 and the dismissal of
22, the corresponding numbers for three years ending 1895 being only
63 and 6 ? And with all these frequent changes, how can it be argued
that there is any benefit to the patients? Novel, certainly, all will
admit; savouring a trifle too much of the revolutionary, not a few will be
disposed to think.

One of the features of the Scottish Reports is the manifest evidence
which they bear of a far keener interest on the part of the Com¬
missioners in the lunacy affairs of that country than is found in
the English Reports. The reason for this is not far to seek. It is not
humanly possible for the English Commissioners to devote more time
and attention to the requirements of their office when the proportion of
registered lunatics per Medical Commissioner is somewhere about
37,000, the corresponding proportion in Scotland being 4000. Read¬
ing over the reports of visits to individual asylums, one cannot help

Digitized by t^.ooQLe

REVIEWS.

135

»903]

being struck by the kindly, almost personal interest which is evinced by
the Commissioners, by the hearty acknowledgment of zealous work on
the part of officials, especially the Medical Superintendents, and by the
encouraging and helpful suggestions which are offered, features certainly
not conspicuous in the Reports of their English brethren. And yet,
how well could it be otherwise ? And is not the argument strongly in
favour of one, at least, of Sir William Gowers’ contentions, viz., an
increase in the number of English Medical Commissioners ? If four
Medical Commissioners are considered requisite for the 16,000 registered
insane in Scotland, manifestly it is unjust that the interest and welfare
of the 110,000 in England should be entrusted to a Board on which the
Medical Commissioners number only three. If the 11,000 lunatics
resident in the twenty-six Royal, District, and Parochial Asylums in
Scotland get ninety-four days in a twelvemonth devoted to their visita¬
tion, their 77,100 fellows in the eighty English County and Borough
Asylums are unfairly dealt with in having only somewhere about 100
days devoted to their visitation, even taking into allowance that they
have the benefit of the Legal as well as the Medical Commissioner.

In the matter of the management of the lunacy affairs of their country
the Scottish Commissioners have always been to the forefront Only on
one point had we been waiting and hoping that once more the initiative
would have been taken by them, and that is the treatment of the whole
subject of lunacy on modem and rational lines, such as is being
attempted in recent times in the case of cancer and tuberculosis,
and which has done so much in the past in eradicating such diseases
as used to be prolific causes of mortality, viz., prevention. The credit
for this must be awarded to our own Association, which at last has made
a tentative suggestion to deal on these lines with one particular form of
insanity, that which is caused by syphilis. Perhaps, at the most, not
more than one tenth part of lunacy can be attributed to this caus£; but,
small as the matter is, it is a beginning, and the great point gained is the
recognition that the rational method of treatment is the preventative.
Why restrict the “ liberty ” of the subject only in the matter of syphilis ?
The principle once admitted is capable of much wider application. If
the Legislature, which is (too fondly, we think) being looked to more
and more in these days, is to be relied upon to devise means to ensure that
men and women shall not run the risk of syphilitic infection and the
subsequent possibility of general paralysis and its congeners, why should
it not, quite as logically, enact measures to ensure absence of mental
instability in the generations that are yet to come ? To what end all
the compilation of statistical tables by the Commissioners and asylum
authorities, if not to indicate the conditions under which lunacy is found
to prevail, and the directions in which the remedy for this admittedly
saddest of all human ills is to be sought? Leaving the pain and
misery on one side, the financial outlay cannot be regarded as other
than an unremunerative investment, simply a penalty (the magnitude
of which has been very forcibly brought home to at least one lunacy
authority in Scotland just lately) that Society has to pay for having
insane members, and the remedy lies not that way. If there is one
subject upon which the public do want enlightenment, it is the subject
of insanity. That public interest can be aroused was illustrated by

Digitized by v^.ooQLe

136

REVIEWS.

[Jan.,

the amount of attention which Sir William Gowers’ address at the
November meeting of our Association evoked, not only in the medical
world, but throughout the whole lay press from The Times even unto
Modem Society . Neither the Boards of Lunacy, nor our own Association,
nor asylum committees, do what might be done educatively in this
direction. A good deal might, we feel, be done in the direction of
popularising these, to most people, driest of Blue Books, the Lunacy
Reports. The thoughtful lay public has been induced to evince a real
interest in such a matter as crime, and if the lunacy returns were
modelled on lines similar to those, for example, on that subject and on the
latest Irish Census Reports, with illustrative charts, maps, and diagrams,
they would appeal more strongly, and so be productive of good in the
long run.

Fifty-first Report of the Inspectors of Lunatics ( Ireland ) for the Year
ending December 31 st 9 1901.

Once in ten years the census returns afford the opportunity of
correcting lunacy statistics, based on merely estimated population, by a
reference to the actual figures as obtained by the census. This
decennial revision prevents any material errors in the percentage
computations; but of course such computations for the intervening years
between successive census enumerations can only be regarded as
approximately correct, although perhaps too much exception is some¬
times taken to the accuracy of such calculations. Some estimate of the
amount of lunacy is desirable, and, as it is impossible to have a census
every year, for the greater number of years we must be content with
merely approximate results.

If, for a moment, we turn to the figures of the Census Commissioners,
we find that there was an absolute increase in the total number of
lunatics and idiots in Ireland of 3862 during the past decade, which is
equivalent to a rise of 18*2 per cent But as there was a decrease in
population of 5*2 per cent, in the same period, this figure understates the
relative amount of lunacy for the two census years. From the figures of
the census report the following table can be constructed:

Year.

Population.

Total number of
lunatics and idiots.

Ratio per 100,000
population.

Increase pe* tent.
per decade.

1851

6.552.385

9.950

ISa

1861

5,768,967

14.098

243

60 I

1871

54 * 2,377

16,505

3<>5

25 I

1881

5,174,836

>8,413

356

167 I

1 *891

4,704,750

si, 188

450

265 1

1901

4458.775

25,050

561

246

We have, therefore, to face the unpleasant fact that the lunacy ratio
in this country has increased during the past decade by close on 25 per

Digitized by

Google

REVIEWS.

137

1903 ]

cent , and that there is now one insane person for every 170 sane in
Ireland. In the previous decade the increase was slightly over this,
being 26*5 per cent. So far, therefore, from there being any indication
of an absolute decrease of lunacy, we can hardly even say that there is
any material reduction in the rate of its increase, although there may be
a small crumb of comfort in the fact that the 2 per cent difference in the
percentage increase of the last two decades is on the right side.

If we analyse the figures representing the aggregate amount of
insanity we find that, while lunacy has so largely increased, there has
been a notable diminution in the number of idiots, this class of the in¬
sane numbering less by 1027 than in 1891. There are few things more
puzzling than the fluctuations in the recorded number of idiots in
successive decades, as will be seen from the following table of the
figures of the last six decades:

Y«u. |

At large.

In asylums.

In prisons.

In workhouses.

Total.

1851

3563

202

X129

4906

l86l

5675

403

934

7033

1871 |

5147

410

1183

6743

1881 '

4548

1896

—

2195

8639

j , ®9 I 1

4077

99<5

—

1170

6243

| 1901 !

3272

763

—

1181

5216

The chief anomaly in this table is the decade 1871-1881. Accord¬
ing to the census returns, there was a total increase of 1897 idiots; the
number in asylums having, by one amazing bound, more than quad¬
rupled itself, rising from 410 to 1896, while those in workhouses had
nearly doubled, increasing from 1183 to 2195. It seems almost
incredible that the number of idiots for this particular decennium should
so vastly exceed that of any other antecedent or subsequent period.
During the following decade, 1881-1891, the number of idiots in
asylums and workhouses dropped to nearly one half. Another fact
revealed by these figures may, perhaps, help to throw a little light on
this rather mysterious circumstance. During the same decade, 1871-
1881, there was practically no increase in the number of lunatics (a rise
of eleven only), an incident wholly contrary to the experience of both
previous decades, for in each of the two preceding decades they had
increased by about 2000, and in each of the two succeeding ones there
has been an increase of about 5000. We have, then, this curious
condition of things:—Lunacy virtually stationary during a particular
decade; idiocy presenting a huge increase, followed in the next decade
by a reduction to about one half. The only possible explanation which
suggests itself is that a large number of insane patients were admitted to
asy lums and workhouses as idiots, and on a revised classification were
transferred to the category of lunatics.

The number of idiots, however, seems to be steadily diminishing, as
in the course of the past twenty years they have decreased by 3423, and
in the last decade alone by 1027. This fact is consonant with another,
that the number of insane under the age of fifteen has largely and con-

Digitized by v^.ooQLe

138

REVIEWS.

[Jan.,

tinuously diminished during each of the last four decades, viz., from
650 in 1861 to 385 in 1901 (see Census Report, 1901, Table 128,
p. 472). As there are very few cases of acquired lunacy under the age
of fifteen, it is a perfectly warrantable conclusion that the number of
congenital idiots is steadily decreasing — a ray of light through the
gloom.

Coming to the Inspectors’ Report, we find at the opening the usual
summary of the number and distribution of the insane under care in
establishments, which is as follows :

On ist January, 1901.

On ist January, 190a.

Male*.

Females.

Total.

Males.

Females.

Total.

In district asylums

8,912

7492

16,404

9» I 33

7,747

16,880

„ central asylum, Dundrum.

140

162

146

170

„ private asylums

325

384

709

' 323

409

732

„ workhouses

Single chancery patients in
unlicensed houses

l, 59 <>

2,215

3.805

1,560

2,186

3.746

102

Total

11,014

10,155

21,169

11,217

10,413

21,630

As shown here, there was a total increase of 461 during the year,
as compared with 306 in the previous year. But the increase is 33
below the average for the past ten years, viz., 494. The increase
in district asylums was 476, while in workhouses there was a decrease
of 59. In the year 1880 67 per cent, of the insane under care were in
asylums, 27 per cent, in workhouses, and 6 per cent, in private asylums;
in 1901 the corresponding ratios were 78, 17, and 5 per cent., showing
that there has been a gradual depletion of workhouse patients by their
transference to asylums. Until this process is completed we cannot
look for any finality in the “ increase of lunacy,” using the term in at
any rate one of its most common applications as denoting the aggre¬
gate of insane confined in asylums. As bearing upon this question, it is
to be noted that with one exception no attempt has been made to
establish auxiliary asylums for the reception of harmless and incurable
lunatics, as provided for by the seventy-sixth section of the recent Act.
The exception is Youghal, where disused industrial school buildings are
being converted into an auxiliary asylum in connection with the Cork
District Asylum. According to the Act, for patients of this class an
allowance of 2 s. per head per week will be made from the Local
Taxation Account, or half the capitation grant given in district asylums.
Possibly this fact may account for the reluctance of County Councils to
avail themselves of the provisions of the seventy-sixth section. And it
is a question whether for this, as well as for other reasons, it would not
be a preferable procedure to build annexes to existing asylums suitable
for the reception of such patients under the ninth section of the Act,
when the full contribution of 4 s. per week could be claimed. By a poor

Digitized by v^.ooQLe

I903-]

REVIEWS.

139

country like Ireland a reduction of the maintenance allowance of one
half is looked upon as a serious matter, and, judging by the apathy
hitherto shown on this head, it is very doubtful if this seventy-sixth
section will ever bear the fruit which the framers of the Act no doubt
expected.

In the table on page 15, giving the proportion of insane per 100,000
of estimated population, there seems no reason why in the census years
1881, 1891, and 1901 the actual and not the estimated population
should not be given. In a foot-note, variations in some of the figures
in this table from those in previous similar tables are explained by
stating that “ the population is estimated officially for the years between
those in which the census is taken, and is afterwards subject to
revision.” As the estimated population is still given for the above-
mentioned census years, one is tempted to ask—Where is the revision ?

The admissions in 1901 were 3572, of which 2821 were first admis¬
sions and 751 recurrent cases. The table on page 19 gives the admission
figures since 1880, and if we take the last four quinquennia and calculate
he rate of increase, we get the following result:

Period

ending

Average ist
admissions.

Increase
per cent.

Average re-
admissions.

Increase
per cent.

Average

Total.

Increase
per cent.

1886

2182

554

2736

1891

2312

5*9

636

14’8

2949

1896 1

2468

764

201

3232

1901

2735

108

549

28*1 •

3484

* Decrease.

From which it appears that there has been a large percentage increase
during the past five years in first admissions, this being io*8as compared
with 67 in the previous quinquennium ; whereas there has been a very
large decrease in the number of re-admissions, 28*1 per cent., as compared
with an increase of 20*1 in the five years preceding. The percentage
increase in total admissions was reduced from 9-5 to 77 in the same
period. It is not improbable that a good deal of the increase in first
admissions is due to transfers from workhouses, which, as a table on
page 13 shows, have increased in the past ten years from a ratio to total
admissions of 12*66 in 1891 to 20*13 I 9 ° I > or > if we take first
admissions alone, the ratio is higher still for 1901, viz., 21*3.

On the whole a study of these figures is not illuminating. He would
be a bold theorist who would attempt to found any deductions upon such
data. Mark, learn, and inwardly digest them as we may, they are
baffling and inscrutable, and give us no clue to the future. As well
interrogate the Sphinx of the Libyan desert.

And yet we are fain to cry “ How long ? ” Can nothing be done to
stay the advance of the destroyer ? As a matter of fact, very little is
done, except indirectly. The great temperance movement tends in the
long run to reduce insanity by limiting one of its most potent causes.
Education ought to be a powerful lever, if properly used, in the further¬
ance of the same great object. And if a tithe of the energy which has

Digitized by

Google

140

REVIEWS.

[Jan.,

lately been expended in heated altercations by rival religious and
political partisans on the subject of education had been applied to
the more useful and practical aim of ensuring that in every school
physiology, and even elementary psycholog)’, should be regularly taught
by competent instructors, a great step in advance would have been
made towards safeguarding the sanity of future generations. It is only
by instilling into the minds of children from their earliest years—and
this is quite possible and feasible—the great leading facts and principles
of life, and health, and sanity, that they can learn how to avoid the
pitfalls which they will meet in after years, and be enabled to exercise
an intelligent and well-balanced control over their appetites, passions,
faculties, and powers. And in this power of control lies the antidote
to insanity. Si jeunesse savait; but it doesn’t, and that’s the pity of it.

The recoveries show a percentage of 36*3 on the admissions, not
quite as favourable a record as that of the previous year. The average
recovery rate for the past four years was 36 *8 per cent . as compared with
38*4 for the previous five years, a considerable drop. Records of
recovery are, it is to be feared, not altogether reliable, as they depend
more or less on the views, as regards what constitutes recovery, of
individual medical superintendents. And it is certain that a large
number of the cases returned as recovered are not permanent recoveries ;
64*6, which is the recovery rate for males in Kilkenny Asylum, seems
inordinately high, judging from the average experience, and it would be
interesting to learn how many of these patients continued perfectly well
after a period of, say, six months from their discharge.

The average death-rate was 7*5, which is exactly the average of the
past five years. The death-rate in asylums fluctuates within very
narrow limits. One fourth of the deaths (313 out of 1257) were due to
phthisis. It is probable that this does not differ much from what
obtains outside asylums in Ireland, if the age at death were taken into
consideration; but, unfortunately, a really useful table giving the
mortality from each disease at successive age-periods has for some inscru¬
table reason been discontinued since 1900, and now only the average age
at death is given, which teaches nothing, if it is not actually misleading.
As regards the general population, where there are large numbers to work
upon, the average age at death may embody a truth and so be utilised;
but in asylums only a comparatively few patients die from any one
disease, and averages computed on meagre data of this kind are sure to
be unreliable. To take an extreme but quite possible case :—Suppose
of four deaths due to pneumonia that two occurred at the age of twenty-
five, and two at seventy-five; the average age at death here would be
fifty, and, as not one of the four even approximates to that figure, it
conveys an absolutely false impression. It would be a decided advan¬
tage if this table giving the mortality at successive age-periods could be
restored.

Four deaths occurred from suicide, seven from misadventure, and two-
from homicide, the casualties being nearly double those of the previous
year. Two of the suicides were by hanging. In one case the patient
suspended himself from one of the water-pipes in a sanitary annexe
which “ were fixed contrary to all the canons of asylum constr uction
inasmuch as they afforded an absolutely perfect facility for su icide

Digitized by ^.ooQle

1903 ]

REVIEWS.

141

No doubt; but how many facilities for suicide exist, and must exist, in
all asylums ? Every bedstead, every door or door-handle, every window-
shutter is a potential gallows; and the very next case, where the patient
suspended himself from the window-shutter, largely discounts the value
of the above criticism. The fact is that precautions of a merely
mechanical nature are only an infinitesimal protection. A determined
suicide will find facilities anywhere and everywhere. There is only one
certain precaution against suicide—vigilance; tireless, unceasing vigilance.
An insufficient staff is probably a more prolific source of untoward
incidents in asylums than all other causes put together, and in most of
the cases recorded the inspectors seem to have been of the same
opinion.

As regards zymotic disease, the amount of enteric fever and dysentery
is scarcely creditable to the asylums in which they occurred. . In
Richmond asylum five out of eleven patients attacked died from
dysentery, and in Castlebar nineteen out of forty-nine—an unusually
high mortality. It is not always easy to trace out the forts et origo of
these maladies. In Castlebar, however, it was sufficiently obvious, and
was evidently the sewage of the asylum, which discharges into a marsh
close at hand, which in wet seasons becomes a lake, emitting mephitic
and poisonous exhalations. This state of things, it is expected, will be
remedied before long. Castlebar is also stated by the inspectors to be
greatly overcrowded, having 610 patients with legitimate accommoda¬
tion for only 419. Additional accommodation is about to be provided.
But overcrowding in Irish asylums appears to be the rule rather than the
exception, for in no less than ten asylums it seems to have reached an
acute stage. With respect to two of these, Monaghan and Sligo, the
inspectors comment in strong terms. In the case of Monaghan, they
have “ each year called the attention of the committee to the very dis¬
graceful condition of overcrowding, but so far without avail; ” and as
regards Sligo, when the committee eventually moved in the matter, and
decided to enlarge the asylum, “ the County Councils of Leitrim and
Sligo refused to supply the funds for carrying out the work.” The ninth
section of the Act (sub-sec. 1) empowers the Lord Lieutenant, in the
case of councils refusing to do their duty (in providing sufficient accom¬
modation for the lunatic poor), to enforce compliance on the recalcitrant
bodies. The cases just mentioned would seem to be instances which
urgently call for His Excellency’s interference.

The total expenditure for the maintenance of pauper lunatics in
district asylums for the year under review was ^427,660 9 s. 3 d, y being
less by ^7843 2 s. 1 id. than in the previous year, although the daily
average was greater by 513. The reduction is attributed by the
inspectors mainly to the fall in prices of provisions, etc. The net cost
per head was £24 9 s. nd., which also shows a reduction of £1 3J. 7 d.
per patient

In private patients there was an increase of twenty-three, as compared
with ten in the preceding year, but the admissions numbered only one
more. Of latter years the admissions into Irish private asylums have
increased somewhat, but it is doubtful whether this indicates any
increase in insanity amongst the better classes. It may only mean that
a smaller proportion than formerly are sent to English and Scottish

Digitized by v^.ooQLe

1 4 -

REVIEWS.

Dan.,

asylums. A general improvement to a very material extent, judging by
the inspectors* reports, has been steadily in progress for some years
past in nearly all these institutions, and in some of the leading private
asylums in Ireland patients are now probably just as comfortably
located as they would be in any asylum.

The condition of the insane in workhouses continues to be anything
but satisfactory. Some few improvements have been effected in some
unions, but until the one radical improvement which is needed is
carried out, namely, the transference of every insane inmate to institu¬
tions properly equipped for such cases, their condition, it is to be
feared, is likely to be nothing else than deplorable, and a discredit, if
not a disgrace, to the country which permits it to exist.

O/d and New Investigations upon the Brain [Alte und neue Untersuch-
ungen ueber das Gehim]. Archiv fur Psychiatrie, Band xxxiv,
Heft i, und Band xxxv, Hefte 2 und 3.

In three elaborate articles, filling 181 pages, Professor Hitzig reviews
the methods and theory of the examination of the functions of the
brain practised during the last thirty years, and the inferences to be
deduced therefrom. He observes that the original experiments of
Fritsch and Hitzig still furnish the only facts which are beyond dispute.
He then considers the experiments by removing portions of the brain,
as practised by Goltz, Loeb, Luciani, and Tonnini. It is easy to excite
motions of one limb or of the facial muscles by the application of the
continued current; but it is only with great difficulty that we can induce
loss of motor power of one paw in an animal through the operative removal
of a circumscribed portion of the cortex. After the operation both limbs
on the same side are generally affected. Hitzig shows, by detailing five
observations, how often such experiments are vitiated by secondary
effusions of blood or softening, which injure the neighbouring and
subjoining part of the brain. Even in the removal of definite portions
the slightest invasion of the mechanism of a contiguous region can alter
the whole results of the experiment

Hitzig points out that Goltz began by stating that every portion of the
cortex had an equivalent function, while in 1879 observed that
animals after destruction of both parietal lobules showed a greater loss
of sensibility than those in which there was an equal removal of the
occipital lobe. On the other hand, a lesion of the occipital lobe entails
a more lasting injury to vision. Goltz, however, qualifies this admission
by the following sentence:—“ From my experiments I have arrived at
the conclusion that every section of the cortex of the brain shares the
function from which come willing, perception, representation, and
thought Every section, independently of the others, is connected with
all the voluntary muscles, and stands also in connection with all the
sensory nerves of the body.”

Hitzig remarks that this means that every section of the cortex of the
brain has an equivalent function with every other section. Probably
Goltz holds that although every part of the cortex has a connection with

Digitized by ^.ooQle

1903]

REVIEWS

143

every motor nerve and with every sensory nerve, nevertheless the con¬
nection is not equal, as some portions of the cortex have more connec¬
tion with some nerves than with other nerves. Hitzig reminds us that
the methods and theories of Goltz are not yet abandoned ; his follower
Loeb continues his experiments in the same line, and even takes back
his concessions. This physiologist found that in his vivisections of the
brain the prescribed injury to function did not follow while contrary
results occurred. He states that in the animals experimented upon,
when there were scanty bleeding and healing by the first intention, no
injury to vision was observed. Loeb confesses, however, that some¬
times hemiamblyopia did occur, which he attributes to especial
irritability of the brain.

Luciani and Tamburini, experimenting on dogs, found that loss of
motor power and impairment of sensibility followed extirpation of the
motor region, and that there was also disturbance of vision, which in
time passed away. The sensory motor zone thus indicated extended
from the apex of the frontal lobe and went over the so-called visual
region of Munk. Luciani and Seppilli found that injury to sight
followed extirpation of all parts of the cortex with the exception of the
under and inner sides of the hemisphere, which have been little investi¬
gated. In this estimate of the great extent of the cortex, of which
removal is followed by injury to the vision, these Italian physiologists
agree with Goltz.

They hold that the apprehension of seen objects is realised in the
middle portion of the cortex cerebri. There are separate spheres for
vision, hearing, smelling, and sensori-motor impressions, besides a
common area which lies within Munk’s visual region; here there is a
fusion of the special areas, a centre of centres. The extirpation of this
region in the brain of the dog, while it especially injures vision, also
affects hearing, smell, and touch.

Tonnini, who has made a large number of experiments, found that
in the dog injury to the motor powers was more apt to follow frontal
lesions, but might also follow sigmo-prefrontal, sigmo-parietal, and even
parietal lesions. The sigmoid region is not the only motor zone ; the
parietal area in its anterior half has at least an equal share in the hemi¬
plegia following such vivisections. Tonnini denies that the occipital and
temporal regions have specific functions ; but he admits that the central
parietal region of the hemispheres has more the function of a visual
and auditory centre, and perhaps of a complicated sensory centre.
Tonnini comes to the general conclusion that identical operations do
not always give the same results, while different operations, even in
adjoining regions, may give a group of symptoms of the same character.

Altogether, the results of the experiments of the Italians are difficult
to seize, and throw dubiety upon defined localisations in the brains of
animals.

Dr. Hitzig thinks that the reason why his first experiments with
electrical excitations on the cortex have withstood all criticism is that
he was careful to use only the weakest galvanic currents which could
bring on motor reaction: when stronger currents are employed combined
actions of several muscles ensue. Hitzig could only succeed in causing
contraction of single muscles with the induced current w'hen a w r eak

Digitized by v^.ooQLe

144

REVIEWS.

[Jan.,

one was used. If the strength was increased, combined actions of
groups of muscles always followed. With galvanic excitation applied to
one hemisphere Hitzig has produced contractions of all the muscles
on both sides. He is convinced that almost all the muscles of the
body are represented in both hemispheres, though in unequal proportion.

Dr. Hitzig combats at great length the explanation advanced by
Goltz and Loeb that the brain is an organ of inhibition, and that the
results obtained by removal of portions of the cortex are due to the
withdrawing lower parts of the encephalon from its regulating influence.
To say that because injury to a certain portion of the brain is followed
by inhibition of another part, therefore the normal function of the first
organ is to inhibit, seems an assumption. At any rate, they ground
their theory upon their observations of the slow renewal of the power
of limbs which at first seemed to be paralysed after removal of parts of
the motor zone in the cortex. Goltz and Loeb hold that the common
motions, such as walking and running , in dogs, are functions of the
subcortical ganglia, and cannot be destroyed by lesions of the cerebrum.
Goltz observed that dogs, after great lesions to the fore-brain, show an
increased impulse to move about, and assume an excited, angry, and
aggressive character; and dogs which have received great injury to the
hind brain become quiet, soft, and harmless, even when they have pre¬
viously been vicious. Thus these physiologists hold that as the anterior
portions of the brain are anatomically connected with the motor
apparatus, they serve to inhibit the outflow of energy into the muscles ;
when they are destroyed the inhibiting power ceases. When muscular
motions are excited through electric stimuli applied to the cortex, the
result is due to the indirect transmission of the excitation to the
“segmental ganglia.” On the other hand, the posteriors portion of the
cerebrum are more connected with the organs of the senses. They serve
to limit the excitations coming from the organs of the senses, so that
the animal can direct muscular motions to a certain object. If these
portions of the brain are destroyed the excitations pass into the motor
apparatus and inhibit it in its activity. It seems to me that the word
Hemmung may be sometimes translated inhibition, at other times
prohibition. Loeb denies that there are any centres in the cerebrum.
The exclusive function of the brain is to furnish an associated memory.
The loss of this memory follows after loss of the hemispheres. Animals
thus mutilated learn nothing. What we call consciousness is only an
accompaniment of the activity of the associating memory. The nervous
system is a regulating mechanism like the escapement of a clock, but it
is also a conducting medium which enables the peripheral organs to
work with precision. Much of what we to-day call functions of the
brain are really functions of the peripheral organs.

Hitzig combats Loeb’s neurological psychology both by reasoning and
experiments. He does not admit the general correctness of the disposi¬
tion of the dogs from which such sweeping inferences are drawn. He
asks for further explanations about the areas on the cortex from which
irritations can be propagated with such precision to the “segmental
ganglia ” below. Loeb calls these places of anastomosis or junction
“ Einmiindungstellen.” Hitzig observes that these are the first places in
which the axis-cylinders are developed, and experiments have shown

Digitized by v^.ooQLe

REVIEWS.

1903]

how they are affected by secondary degenerations, so it is difficult to
deny that they are important areas.

Hitzig makes use of inhibition so far as to admit that sensory lower
ganglia may be put out of function for a time by injuries not directly
applied to them, and that the terminations of centripetal nerves may be
temporally inhibited in their function by injuries to certain parts of the
cortex. More inquiry is needed as to the conditions under which these
inhibitions take place.

At the end of the first article Hitzig indicates the present state of our
knowledge, and what there is still to do. He holds the localisation in
the hemisphere as conclusively proved, but that there are questions
concerning the sensori-motor and visual functions which are still to be
resolved. Further research is needed to decide the issue between
Hitzig himself and the Italian inquirers about the localisation of certain
gyri in relation to single muscles and muscular motions. The functions
of the frontal lobe and the central representation of the muscles of the
trunk should be put beyond all doubt. There are still gaps in our
knowledge about the innervation from the cortex to the extremities ;
still more about the function of other cortical areas—for example, that
of the facial nerve. Here, also, new methods of inquiry are demanded.

The sensory functions are certainly impaired through lesions of the
motor zone in proportion to the extent of the injury. It is probable
that this zone serves for the formation of representation of sensation,
though it is not likely that this is the only region which is used for that
end. When portions of the cortex are removed the impaired motor
and sensory functions are never completely restored. Sometimes it is
difficult to find out these residual deficiencies, especially where the
injury to the cortex is not considerable. The apparent restitution is
partly owing to the disappearance of associated symptoms, and partly
to additional power given to the opposite hemisphere, and also to
increased conduction in the tract of the tegmentum.

Hitzig thinks that the area of the cortex which stands in relation to
vision has yet to be defined, and that a correct discrimination between
cortical lesions and indirect subcortical impairments of function has yet
to be made. Hitzig considers it highly probable that in the spinal and
cerebellar, perhaps also in the centres of the middle brain, there is a
gradual elaboration of movements and sensations therewith connected,
through which representations of movements of a lower order are
formed. These are recognised in consciousness as performed move¬
ments, without the processes through which they are executed being
perceived by the mind. Hitzig does not recognise sensory, visual,
auditory, or other such spheres, but only representations in which
images of these centres enter into consciousness.

In the third paper Hitzig considers the relations of the cortex and
the subcortical ganglia in the visual function of the dog. Here there
are three views to dispose of: that of Munk, who assigns the posterior
half of the cortex in the dog’s brain to the functions of seeing and hear¬
ing ; the view of Goltz, who assigns the loss of sight after operations to
inhibitions of the lower ganglia; and the observations of the Italian
school, who, though they allow that the injury to vision is the direct
result of lesions to the cortex, assert that this can be brought about by

Digitized by v^.ooQLe

146

REVIEWS.

[Jan.,

lesions affecting the greater part of the convexity of the brain. This is
confirmed by the experiments of Exner and Paneth cited in the article.

Hitzig’s own views are supported by twenty-two observations of ex¬
periments on dogs, which are given in detail and illustrated by wood-cuts.
He found that the simple exposure of the pia is followed by marked
injury to the convolutions lying below, and that there is often implica¬
tion of those contiguous. The uncovering of the membrane over the
motor zone led not only to motor impairments in the extremities, but
also, save in one case, to impairment of vision, and in all the cases to
impairment of the reflex movement of the eyelids. The uncovering of
the pia over the occipital lobe led in all cases to disturbances of vision
and of the reflexes of the eyelids, but not to injury to the motor powers.
The symptoms following such operations are of the same character as
those following extirpations of corresponding areas of the cortex. The
alterations in the nerve-tissues found after death explain these symptoms
without supposing any accidental injuries or mistakes in the conduction
of the experiment. Hitzig observes that surgeons opening the vault
of the cranium should be careful to replace the dura over the
part. He thinks that he has proved by his numerous experiments that
marked impairment of vision may be induced by a lesion to other
regions of the cortex than those assigned by Munk as the visual area.
Dr. Hitzig promises, in a future paper, to treat about the relations of
the other regions of the cortex to the sense of vision.

The articles which we have gone through are of value as showing us
not only what we know about the brain functions, but also as indicating on
what points we require further knowledge. Here no better guide could
be found than Professor Hitzig, who, while he has led the way in in¬
vestigations of the functions of the cortex, has been ever cautious that
his assent should not go beyond his evidence. It is almost comical to
read his complaint that Haeckel, in a recent report of our present
knowledge of the origin of the human race, gives Goltz and Munk as
the founders of our knowledge of the localisation of the brain without
alluding to Hitzig.

The Varieties of Religious Experience: a Study in Human Nature .
Being the Gifford Lectures on Natural Religion, delivered at Edin¬
burgh in 1901-2 by William James, LL.D., etc. London, 1902 ;
Longmans. Royal octavo, pp. 534.

On the principle that it is more blessed to give than to receive, the
professor of philosophy at Harvard shows a pardonable pride in having
been called across the Atlantic to give lectures to an audience in the
Old World. No Gifford lecturer has hitherto succeeded in attracting so
large and so appreciative an audience. Though Dr. James’s practice in
lecturing, his genial voice, and clear pronunciation contributed to this
success, the book under review will no doubt be read with interest both
in Europe and America. Deeply versed in the lore of philosophy, but
avoiding pedantic terms, and refusing to help his diction through other
men’s phrases, his sentences are permeated by thought and a rare
felicity of expression. He has that quality which the Romans called

Digitized by v^.ooQLe

REVIEWS.

147

1903 .]

disertus. Wary of belief, yet fair in statement, weighing the very dust
in the balance, the professor considers the religious faculty in all its
manifestations. Avoiding that sort of generalisation which includes too
much of the opinions of the author, James seeks to base his remarks
upon particular examples of religious experience as exhibited in auto¬
biographies, the letters of devout persons, and the lives of the saints.
With a good eye to effect he gives extracts from the sacred literature of
the Brahmins and Buddhists, and the Mussulman Sufis, with the same
philosophical equanimity as from the confessions of Catholic saints and
pious Protestants. This is sure to be distasteful to some people, who
will demur to accepting various metals under one religious stamp.
Dr. James himself observes that his concrete examples are drawn from
extreme expressions of the religious temperament.

There are chapters upon the reality of the unseen, the religion of
healthy-mindedness, the sick soul, the divided self and the process of
its unification, conversion, saintliness and its value, mysticism, and the
philosophy of religion.

We shall confine our criticism mainly to the passages in which the
author deals with those manifestations of the religious faculty which are
associated with mental derangement. It cannot be said that the pro¬
fessor, like too many of his colleagues, is unwilling to learn what
physicians can teach psychologists from the study of abnormal mental
action. We should rather say that he is too ready to admit some over-
hasty theories, and to found conclusions on unstable premises in these
fields of inquiry.

An unwary reader may take up from Dr. James that it is a current
belief amongst medical men that genius is a neurosis, as Moreau long
ago advanced, though James himself refuses to adopt this view.
“ There is,” he writes, “ of course no special affinity between crankiness
as such and superior intellect, for most psychopaths have feeble
intellects, and superior intellects have more commonly a normal
nervous system.” He cites Lombroso and Mr. Nisbet, the author of a
book which puts “the insanity of genius” in a popular form.
Mr. Nisbet was not a medical man, and knew so little of medicine that
he imagined that intermittent fever was a nervous disease; and Dr. James
might have told his readers that Lombroso’s theories have been attacked
and, as we think, refuted.

The learned author slides too rapidly past the studies which have
been made on the neuropathic symptoms of some leaders of great
religious movements. “The medical materialists,” he writes, “are
effective with their talk of pathological origin only so long as super¬
natural origin is pleaded by the other side, and nothing but the argu¬
ment from origin is under discussion.” Yet, in spite of all Dr. James
can say, with those who believe in a supernatural revelation the question
of origin is the key to the position. If the claimant to divine illumina¬
tion exhibit symptoms frequently associated with insane delusions, most
people will think that the credibility of his message is seriously injured.
In vain does Dr. James urge that the psychopathic temperament, with
its intensity, its fondness for metaphysical speculation, and its mysticism,
is favourable to the perception of religious truth. A lunatic may deliver
a message correctly, yet his testimony is always subject to suspicion*

Digitized by v^.ooQLe

REVIEWS.

148

[Jan.,

especially in matters on which one can have no experience. In reality
Dr. James gives away revealed religion. He lays down that a religion is
to be judged “ from its fruits, and not from its roots; ” that is, he con¬
siders the efficacy of religious faiths in promoting worldly order and
prosperity, and in leading their votaries to follow reason and virtue in
their earthly lives. But this is a criterion which the Christian, the
Brahmin, and the Mohammedan will all reject. The fruits which they
promise have to be gathered in an unseen world.

He observes that each religion at the outset must have satisfied the
aspirations and moral wants of its votaries, and when the standard of
morality or intelligence had risen above the old faith, that it sunk into
discredit. He claims for “our instincts and our common sense the
right of disbelieving peremptorily in certain types of deity.” “ When we
cease to admire or approve what the definition of a deity implies, we
end by deeming that deity incredible.” Yet, if such a deity exist, he
needs not our approval. “ The monarchical type of sovereignty was,” the
American author tells us, “ so ineradicably planted in the mind of our
own forefathers, that a dose of cruelty and arbitrariness in their deity
seems positively to have been required by their imagination. . . . But
to-day we abhor the very notion of eternal suffering inflicted, and the
arbitrary dealing out of salvation and damnation to selected individuals.”

Pascal, in his Pens/es, admits that the conception that unbaptised
children should be consigned to eternal torments is contrary to our
miserable ideas of justice; but the reason of the great geometrician
gave way under the terror of being himself subjected to the same
torments if he should disbelieve in the dogma taught by his Church. It
was not till historical inquiry loosened men’s faith that their minds
began to recoil against this article of belief.

In his appreciation of the value of saintliness Dr. James tells us that
Stoic, Christian, and Buddhist saints are practically indistinguishable.
In estimating the effects of different religions upon the community it
ought to be held in mind that religion is but one of many powerful
factors, and thus its effects are difficult to isolate. In India we have
the Mussulman and the Hindu living together. Some people who have
passed many years in the country think that the Mohammedan is better
than the Hindu, others the contrary, while many think the native
Christians worse than either. Here we have three very distinct religions
under much the same conditions.

Dr. James startled his Edinburgh audience by proclaiming his faith
in the mind-cure movement in America. “ The blind have been made
to see, the halt to walk, lifelong invalids have had their health restored,
the moral fruits have been no less remarkable.” Fatigue, pain, and
paralysis have been annulled by impressing on the mind that these
do not affect the soul, which, if it chooses, becomes supreme. The
instances of cure cited by the author are far from convincing. Going
along the road a man sprained his right ankle, when he recollected that
“ there is nothing but God; all life comes from Him perfectly. I cannot
be sprained or hurt.” He never felt it any more, and walked two miles
that day. We are inclined to believe that this person gave his tendons
a painful stretch without any rupture, and the effect naturally passed
quickly away. This is a thing which often happens. The next case is

Digitized by v^.ooQLe

I 9°3-J

REVIEWS.

149

a woman who felt pains, nausea, headache, and faintness, and went to
bed believing that she would have influenza. She felt a dominant idea
that all would be well, and when she woke in the morning she was well.
The other two cases given in the appendix do not seem any more
convincing. We leam from medical sources in the States of the
vagaries of Mrs. Eddy and her followers, and regret that so distinguished
a professor should have given them any countenance by classifying
them under the heading of “healthy-mindedness.” He defends the
mind-cure by the power of suggestion in some cases of disease. This
has, of course, been long admitted; from Pechlin to Hack Tuke many
books have been written upon the power of imagination and confidence
in a cure. These have been successful principally in functional nervous
diseases and in rheumatism; but such mental influences are varying
and uncertain, and can be rarely utilised in the treatment of disease.

In the course of his speculations Dr. James builds much upon the
subliminal consciousness of Myers, a modified form of the unconscious
cerebration of Carpenter. There are agents both physical and mental
which change our moods, prompt our thoughts, raise and depress our
spirits, increase our mental power and render us ready to receive this or
that set of ideas, and these influences act insensibly. There does not,
however, seem sufficient proof that any process of active thought or
exertion can be performed without consciousness. Some writers talk
of persons being unconscious in the active states of hypnotism or sleep¬
walking. So far from this being the case consciousness is intensified
and narrowed. In these abnormal conditions consciousness persists
more or less separated from memory, and those who are sparing of their
mental analysis may, on looking back, easily believe that consciousness
had not persisted because it had left no record in the mind. Dr. James
seeks to support his subliminal consciousness by the feats of hypnotisers
who claim that they can sometimes get their subjects to execute com¬
mands a month or so after without their counting the days or taking
any note of the lapse of time, and without their knowing wherefore they
are performing the prescribed action. This has, on the face of it, a
strong air of absurdity. We dare say that Dr. James, in the course of
his wide reading, will get writers on hypnotism to support all he wants,
and more than he wants; but he might have mentioned that on this
point they are not agreed. Bemheim, in his well-known book on
Suggestive Therapeutics , totally rejects the idea of any unconscious
mechanism in suggestion h longue echeatue , and he is supported in this
view by Krafft-Ebin^, Delboeuf, and Liegeois, who have all had much
practice in hypnotism.

It can scarcely be expected that the reader will find nothing to
disagree with in the course of the book, for it must be kept in mind
that Dr. James deals with much disputed questions. Nevertheless
his book has a pleasing stamp of originality. His great erudition
is kept in rule by a mature knowledge of human nature. If he
takes up a sceptical attitude, it is not because he prefers it, but because
he will not voluntarily eliminate opposing considerations. Sometimes
the views in one chapter seem out of accord with those in another,
and he has again and again to wam his readers to wait for his con¬
clusions. In the search for truth one does not sail upon a sea
XLIX. IO

Digitized by v^.ooQLe

REVIEWS.

[Jan.,

150

always smooth; there are currents and eddies. Sometimes he may
seem to veer; but he is willing to take the reader into the harbour,
if there be a harbour. Dr. James is decidedly on the spiritualistic
side. He is inclined to believe in telepathy and messages from the
dead, though not convinced. While admitting the reign of law
in the material world, he shows that prayer has its own sphere of
action. He is ready to recognise good in most religions, and thinks
that men will never agree to have the same creed, considering their
various antecedents, circumstances, tastes, and intelligence. One can¬
not read the book without recognising the enormous force of religious
ideas upon the human mind. William W. Ireland.

Clinical Psychiatry: a Text-book for Students and Physicians , abstracted
and adapted from the sixth German edition of Kraepeliris ‘ Lehr-
buch der Psychiatries By A. Ross Defendorf, M.D., Lecturer in
Psychiatry in Yale University. New York and London : Macmillan
and Co., 1902. Pp. 413. 16 Illustrations. Price 15*. net.

It is not our intention, in this notice, to attempt any review or
criticism of Kraepelin’s teachings, however tempting such a task
may be. His papers in the various Continental psychiatrical journals
have, from time to time, been abstracted and criticised in the pages of
the Journal of Mental Science .

Our object is chiefly to point out that there is now available
for English readers an excellent translation conveying clearly, con¬
cisely, and in a scientific way the principles of Kraepelin’s psychiatry,
which supplies a hitherto deplorable gap in English and American
psychiatrical literature. The work is well illustrated.

It is regrettable that, apart from the short abstracts provided in this
and a few other journals, foreign teaching and progress in our branch
of medical science is so completely neglected.

No asylum should be without its psychiatrical library, and this should
contain, among others, works conveying the teachings of the various
important schools and clinics which are now scattered throughout the
world. This means a series of faithful translations of monographs and
text-books similar to the one we now strongly recommend to our readers.

We hope this recent example will be more largely followed in the
future, and that, before long, there will appear a number of works which
will bring within the reach of English readers the main teaching of the
more important psychiatrical centres. J. R. Lord.

L'Art et la Medecine . Par le Dr. Paul Richer. One vol. 4to,
pp. 562 ; 354 illustrations (reproductions of works of art). Price
30 f. Paris : Gaultier-Magmer et Cie., 1902.

This book certainly contains a wonderful collection of the works of
art related to medicine, the majority being very careful reproductions of
the original paintings, with some representations of statuary, etc,

Digitized by v^.ooQLe

I903-] REVIEWS. 151

The demoniacs occupy nearly a third of the whole work, and are
profusely illustrated from the earliest ages of Christian art and from
paintings by renowned masters. The hysterical attitudes are, in many
instances, strikingly accurate ; but it is noteworthy that Dr. Richer con¬
siders Michael Angelo to have been more unsuccessful in his delineations
of this form of disorder than many less eminent artists. The descrip¬
tion of these appearances as depicted appears sometimes to require a
certain amount of imagination in the beholder, and probably some
observers would perceive epileptic appearances rather than hysteria.

The grotesque chapter is less satisfactory, but that devoted to idiots
and dwarfs is specially interesting to alienists. The examples of micro¬
cephaly are particularly good.

Chapters are also devoted to the blind, the lepers, etc., but these
yield in interest to that devoted to the sick and their doctors, which
illustrate many obsolete medicinal methods. The quacks do not
escape, although very few examples of the operation for removing
“ stones from the head,” so often painted by the Dutch school, are given
here.

The work is, indeed, a monument of labour and love of the subject,
and Dr. Richer is to be congratulated on the successful issue of his
arduous undertaking, and on having secured such great success in the
production of the illustrations.

The Making of Citizens: a Study in Comparative Education . By
R. E. Hughes, M.A.(Oxon.), B.Sc.(Lond.). The Contemporary
Science Series. Newcastle: Waller, Scott & Co., 1902. Octavo,
pp. 405. Price 6 s.

The author claims to have written this book for general readers. In
attempting to place before them a complete and accurate account of the
present position of education in the four principal countries of the world,
the author uses the published reports and statistics in illustration of
the system pursued in each country, and he certainly is successful in
giving a satisfactorily clear idea of the systems and their contrasts.

The part of the book that is specially interesting to the alienist is
that relating to the education of defective children, which is somewhat
unsatisfactorily brief and condensed. There is, however, a fairly full
description of the modes of education of the deaf mutes.

The tables of statistics on all subjects relating to the schools of the
four countries (England, France, Germany, and America) are very
valuable and interesting, as are the other facts brought together in the
book. They, however, offer little subject for criticism beyond the
recognition of the clear and instructive method of their arrangement.

With what is perhaps his most vital conclusion, viz., that we must be
“content to go on lagging behind the Teuton in intellectual capacity,”
and trust “ to our own special gifts,” a very distinct difference of opinion
must be expressed. With developmental education, in place of the
brain-stunting methods now in vogue, we believe that the Englishman
would be not only the equal but the superior of the German.

The book is a valuable addition to the literature of the education
question.

Digitized by vj<. OQle

152

EPITOME.

[Jan.,

Part III.—Epitome.

Progress of Psychiatry in 1902.

AMERICA.

By Dr. H. M. Bannister.

The past year has not been notable for any special events in
American psychiatry, though the usual amount of activity has existed.
There has been no retrogression, and signs of a better future ahead
as regards political control of charitable institutions have appeared in
quarters where they are most welcome. In Illinois, for example, where
for ten years past politicians have controlled the institutions, recent
events have made reform in this regard a political issue, and both
parties are, so to speak, tumbling ovq^ each other in their zeal to
utilise it to their own advantage. The scandal that excited this was
not abuse of patients or bad financial management, for neither of
these has been proven, but the assessment of employes for political
purposes, which has at last aroused the public conscience. The out¬
come can hardly fail to be good, and we may hope at least for a better
state of affairs than existed even before the politicians took control.
It is a slow work educating the public as to the political neutrality of
hospitals for the insane, but it is being done, and the prospect is that
they will before very long be as free from the abuses of partisan politics
in Illinois as in any of the older states of the Union. I have spoken
of this matter in previous letters, but it is right that I mention it again,
for it is the chief fault of our public institutions, and the one that is
more than everything else responsible for their failings.

The meeting of the American Medico-Psychological Association took
place this year in Montreal, and, as might have been expected, was a
success socially as well as in the character of papers presented and
their discussion. The medical organisations representing the specialists
here recognise no boundaries as between Canada and the United States,
and the Association, therefore, is no exception. The “ Chauvinism ” in
medicine, that formed the subject of Dr. Osier’s address before the
Canadian Medical Association at Montreal a little later, is certainly
not evidenced by the medical specialists, however it may be with the
general practitioners. It would be invidious, perhaps, to speak of any
one of the papers read as specially excelling in interest or scientific
value; they were all apparently well received, and aroused the usual
interesting discussions. It is possibly worth noting that not all were
from medical men; one was contributed by a prominent Methodist
clergyman, Dr. J. M. Buckley, who, however, is an honorary member
of the Association, and has written extensively on related subjects,
faith cures, hypnotism, etc., and takes an active interest in the insane
and defective classes generally. The choice of Dr. Blumer as President
of the Association was, I believe, a most satisfaciory one to all, and

Digitized by v^.ooQLe

1903-]

PROGRESS OF PSYCHIATRY.

153

a deserved tribute to one who has been among the foremost in every
movement for the advancement of scientific mental medicine in this
country during the past fifteen years, since he succeeded the late Dr.
John P. Gray in the editorship of the Association journal.

Speaking of faith cures and religious abnormalities generally, I might
here mention that the Canadian Government has a puzzling problem
in the Russian Doukhobors, who settled in Assiniboia. A large
portion of these, incited by some recent prophet, concluded that it
was not only wrong to keep domestic animals in subjection, but to
utilise their products in any way. They therefore turned their cattle
loose, burned their shoes and woollen garments, and set out on a
crusade to convert the world, inadequately clothed and provisioned.
The local government has had to forcibly interfere, and though the
Doukhobors are non-combatants as well as vegetarians in their princi¬
ples, they have exerted the most active type of passive resistance, and
have only been controlled by the use, it is reported, of some necessarily
pretty rough handling and some broken bones. It seems hardly pro¬
bable that their insane fanaticism can long be kept up, and affecting as
it does whole communities, or nearly whole communities, it is a sort of
anachronism in the beginning of the twentieth century. They are an
industrious and generally law-abiding people, but ignorant and obstinate
to the last degree, and the Canadian authorities doubtless wish they
were off their hands.

I saw an allusion not long since in an English book to “ Christian
Science and other American Soothsayers,” and take the opportunity of
here making a disclaimer of the American origin of all these recent
aberrations except Edcjyism. That we shall have to acknowledge as
starting in this country; it is a sort of successor to the homoeopathic
cult, which is on the wane. The others, Dowieism, etc., are exotics
like the Doukhobor fanaticism. We are responsible for a good many
things that we do not boast of, but it is not fair to credit us with more
than our due.

In my letter last year I spoke of the removal of Dr. Ohlmacher from
the position of pathologist at the Ohio Epileptic Asylum. Within the
past few months he has been recalled, this time to take full charge of
the institution. While this adds executive duties to his work, it will
not, I think, prevent his carrying out the researches he was formerly
engaged in, and will give him still wider opportunities. The appoint¬
ment of Dr. Meyer as Director of the New York State Pathological
Institute is another good one. He does not, I think, need any intro¬
duction to your readers, and we may look for good work from the
Institute, which is hereafter to have a teaching function for hospital
assistants, as well as serve as a research laboratory. In both of these
directions he may be expected to make it a success.

The movement for extra asylum treatment of the acutely insane in
special wards of general hospitals is progressing, and in a number of
institutions such wards have been provided, or are being planned. It
has been strongly advocated by Dr. Peterson, State Commissioner in
Lunacy in New York, as well as by other well-known authorities, and it
seems probable that these psychopathic hospitals and wards will rapidly
multiply in the near future. They have their limitations, but within

Digitized by v^.ooQLe

i 54

EPITOME.

[Jan.,

these their usefulness cannot be questioned. It seems to the writer
that sometimes too much is expected; it is a very common claim in
this country that acute insanity can be better treated at home than in
asylums, and this error helps the common belief that general hospital
treatment also must necessarily be better for the insane. They will,
nevertheless, have a very useful function, and whatever ratio of insanity
they cure will be a relief to our already overcrowded institutions.

There have been fortunately but few deaths among the leading or
older alienists of the country during the past year. Dr. R. M. Bucke, of
London, Ontario, was a loss that is felt. He was a striking figure in
the profession, and a man of note in a literary as well as a medical
point of view. Dr. J. T. Eskridge, of Colorado, though not strictly a
practical alienist, was a close student of insanity as well as the leading
neurologist of his section, and in every sense a most valuable man.
Dr. Geo. A. Shurtlaff, the pioneer asylum superintendent of California,
is another notable man who has passed away during the present year.

FRANCE.

By Dr. Ren£ Semelaigne.

On the Self-accusing Insane.

At the “Congrfes des Mddecins Alidnistes et Neurologistes” Dr. Ernest
Duprd, of Paris, gave a lecture on the self-accusing insane, studied
from a medico-legal point of view. He made first an aetiological and
clinical study of the idea of self-accusation ; and second, a medico-legal
study of the conditions created by these patients, and the duties of
magistrates and of the physicians commissioned to report upon their
mental condition.

In psychiatry, one includes not only those who confess themselves
guilty of a peculiar crime, but also those who have general ideas of
incapacity, unworthiness, guiltiness, and remorse; but in medical
jurisprudence the self-accusing insane person is one who denounces
himself as guilty of an offence or a crime, relating all the particulars
of the case, such as place, time, and methods, and believes himself to
be liable to legal punishment.

Ideas of self-accusation may be observed in various morbid states
as follow:—Melancholic states; states of debility, want of balance,
obsession, paranoia, degeneracy; oneiric states in toxic psychoses, such
as alcoholism, pyrexias, etc.; delirious states of neuroses (epilepsy,
hysteria); demented states (general paralysis, senility, organic encepha-
lopathia).

i. Self accusation in Melancholic States .—At first the melancholic
merely express general ideas of incapacity, humility, and unworthiness.
Then the patient, being a prey to an inexplicable moral grief, looks for
a more precise interpretation of his culpability, and, as the conviction
of culpability is secondary to moral grief, the feeling of remorse
creates the notion of default. Many melancholiacs do not go beyond
this state of diffuse culpability; so they are more culprits than

Digitized by ^.ooQle

I 903«] PROGRESS OF PSYCHIATRY. I 55

self-accusing. They may confess any fault with which one should
happen to charge them. Such delusions of self-accusation are general,
indeterminate, and Platonic. But in that soil sometimes springs up
and grows an idea of peculiar culpability (a hyperbolic magnifying of
small peccadillos; a slanderous interpretation of an act of no import¬
ance ; an auto-suggestion of culpability concerning disasters or crimes
of the time).

2. Self-accusation in some States of Mental Degeneration .—A self-
accusing degenerate is more active in his delirium of culpability than a
self-accusing melancholiac, and he willingly denounces himself to the
magistrates. Dr. Dupr£ successively studies the ideas of self-accusation
of degenerates suffering from— (a) a mental debility and want of
balance; ( b) obsessions; ( c ) some varieties of paranoia, acute or
chronic, primary or secondary, which seem to be transitions from
genera] mental degeneration to chronic systematic insanity.

While a self-accusing melancholiac is sincere, anxious, and repentant,
a self-accusing debile is lucid, a liar, and indifferent or vainglorious.
Such a patient does not present true delusions of culpability, and the
lucid self-denouncement does not come from delusion but from moral
and intellectual perversions. There is a morbid appetite of vainglory,
an instinctive need of a scenic appearance. Whilst all self-accusing
melancholiacs seem to be alike, self-accusing degenerates are dissimilar
from each other.

One may observe two principal varieties of debilitated degenerates—
either intellectual with an infirm mind, or moral with a deficiency of
moral sense. The self-accusing intellectual debilitated patients are
impulsive or vain. Some patients suffering animal or shameful
obsessions may present ideas of self-accusation consecutive to a series
of criminal impulsive obsessions; these multiply, and the patient soon
questions if he did not really perpetrate the crime. At last he is
thoroughly convinced that he is the culprit.

Among the paranoic degenerates who manifest ideas of self-accusa¬
tion one may observe— (a) self-accusing persecutory melancholiacs; (b)
self-accusing persecutory alcoholics; (c) self-accusing primarily deluded
patients. The self-accusing persecutory melancholiac associates both
delusions of persecution and self-accusation, and such association
might be co-existent, subsequent, or alternate. In the one case the
melancholic feeling, with its secondary delusions of culpability and
self-accusation, inaugurates the disease. By degrees the ideas of per¬
secution make their appearance, which finally prevail and eventually
constitute a secondary post-melancholic paranoia.

In another case ideas of persecution primarily appear, and ideas of
self-accusation are subsequent. Both delusions might co-exist, alter¬
nate, combine, or make their evolution side by side without penetrating
each other. Such are the self-accusing persecutory melancholiacs.

In a third case an idea of self-accusation is associated with ideas of
persecution. Such patients are not genuine melancholiacs or classical
cases of persecution, but hypochondriacal degenerates with obsessions.
Hypochondriacal and obsessional preoccupations generally influence
misanthropic, distrustful, and timorous minds, which are subject to all
varieties of obsession. The insanity of self-accusation is often only

Digitized by v^.ooQLe

156

EPITOME.

[Jan.,

a general hypochondriacal condition, but it sometimes becomes a
criminal obsession and is followed by self-denouncement. Among
such patients one may observe a persistent wish for surgical interference
for the purpose of modifying or repairing genital organs, a tendency
to self-mutilation, or attempts at suicide.

In a fourth case both delusions of persecution and self-accusation
happen to combine in a soil prepared by alcoholism. Such are the
self-accusing persecutory alcoholics.

3. Self-accusation in Toxic Psychoses. —All toxic and infectious states
create psychical disorders, such as hallucinatory delirium, oneirodynia,
mental confusion, etc. Most generally, the type of hallucination and
of all secondary disorder is painful, sad, or terrifying. Toxic psychoses
bring together all the pathogenic elements capable of creating and
increasing ideas of self-accusation. Lasegue used to say that when a
man pretends to be a murderer, one might assert, ninety-nine times in a
hundred, that he is alcoholic. So, in these cases, alcoholism must
always be looked for. Strong and healthy people survive long poison¬
ing, but acting on a degenerated soil, the least intoxication might awake
an idea of self-accusation. As a rule that kind of delirium is of a
transitory type. At first there are alternations of half-conscious lucidity;
then the phases of delirium lessen, and at length disappear.

Self-accusation of alcoholic origin is principally noticed in psychic
or delirious inebriation, and in subacute alcoholic delirium. But it
may also be observed in the various combinations of alcoholism and
mental degeneracy ; there is a kind of pathological mixture.

Next to alcoholic psychoses, the acute infectious psychoses cause the
most numerous cases of self-accusation from a toxic origin. Dr. Dupr^
reports five observations of self-accusation in typhoid fever.

4. Self-accusation in Dementia .—In dementia from a paralytic,
organic, or senile origin, ideas of self-accusation occasionally appear.
Such ideas are mobile, diffusive, incoherent, absurd, and contradictory;
but sometimes, and especially in the early stages of general paralysis,
they present a more systematic appearance.

5. Self accusation in Psycho-neuroses. —Self-accusation may be ob¬
served in psychopathic states of a hysterical or epileptic origin.
Hysterical patients generally are most suggestible, most prone to
hallucinations, amnesic, and vain. They may make false imaginary
accusations which are sincere or untrue, or sometimes both together.
Such accusations generally have reference to other people, but there
are also self-accusations, and that clinical type presents the appearance
of lucidity, abundance and precision of all particulars, likelihood of the
confessed fault, uniformity of the narration. Such a self-accusation
constitutes a special medico-legal type, being nearly always united with
a hetero-accusation ; it is a complicity a deux . Seif-accusation in epilepsy
is uncommon. Some patients try to explain the unconscious acts which
they have done during their fits.

The interesting work of Dr. Dupr£ includes a medico-legal study and
many observations of cases.

Digitized by

Google

PROGRESS OK PSYCHIATRY.

157

»903-]

On the Anxious States in Mental Diseases .

According to Dr. Lalanne, director of the private asylum of Castel
d’Andorte, in Bordeaux, the disorders which follow anxiety are physical,
affective, and intellectual. We may find disorders of general sensibility
and motility; also circulatory, respiratory, gastric, and secretory dis¬
orders ; anomalies of tendencies and feelings concerning the preserva¬
tion of the individuality and mankind; psychical and cerebral symptoms.

The principal disorders of general and special sensibility are anaes¬
thesias, hyperaesthesias, and paraesthesias. During violent fits of anxiety
some patients are capable of severely mutilating their body without
sustaining pain. Hyperaesthesia from an emotional origin brings forth
hypochondriasis, and a violent irritability of the nervous system.
There are perversions of sensibility (heat or cold, shivering), of special
senses (chiefly of hearing, sight, feeling). There are disorders of
motility, such as asthenia (muscular weakness, general lassitude),
contractures, tremor, absence of co-ordination of voluntary movements,
disorders of speech; disorders of circulation, such as spasm of the
muscles of the heart; respiratory disorders (difficulty in breathing,
dyspnoea); digestive disorders (constipation, gastro-intestinal atony,
stomach cramps, sometimes diarrhoea); secretory disorders (polyuria,
paralysis of bladder, sialorrhoea, absence of salivation, fits of perspira¬
tion) ; affective and intellectual disorders (anxious expectation, obses¬
sion).

Anxiety may be observed in many varieties of psychopathies, such
as degeneracy, mania, melancholia, folie a double forme , melancholia
with ideas of persecution, psychoses from intoxication, and even general
paralysis. But there are some anxious psychopathies of a special and
common type. It is not apparent at first; the patients suffer anxiety
during a very long time. That is the primary and predominant sign
in its various aspects. Such diseases are always springing up and
growing in a pre-existent soil of anxiety. The genuine type is
anxious melancholia. Chronic anxious melancholia, in its typical form,
presents the following phases:—1, The phase of primitive melancholia,
with ideas of unworthiness, guiltiness, ruin, self-accusation. 2. A period
of doubt. 3. A melancholic delirium, with ideas of negation, damna¬
tion, possession, which all represent an alteration of personality. 4.
The delirium ends in a phase of megalomania.

Professor Brissaud, of Paris, insists on the difference between
anguish and anxiety. Anguish has a bulbar, and anxiety a cerebral
origin; anguish is a physical disorder (sensation of constriction and
suffocation), anxiety is a psychical disorder (sensation of indefinite
insecurity).

GERMANY.

By Dr. J. Bresler.

At the annual meeting of the Association of German Alienists (held
at Munich on April 14th and 15 th, 1902), one of the first items of

Digitized by v^.ooQLe

EPITOME.

[Jan.,

i S 8

business was the appointment, at the instance of Professor Hoche, of
Friburg, in Baden, of a statistical committee to collect information on
all occurrences regarding the insane, especially suicides and crimes com¬
mitted by insane persons, judicial condemnations of the insane and the
weak-minded, the admission of sane persons to asylums; in short, all
the incidents which go to show the defects of the lunacy law and the
need for its reform. In this way it is hoped that they will be in a
position to give material help to the State in the framing of new lunacy
legislation.

At the same meeting attention was again drawn by Dr. Brosius to the
need for the extension of “ after-care ” societies.

Of general questions which have interested us in the course of the
year, I specially mention that of the suitable size of asylums , regarding
which two opposite views are held. Some maintain that the number of
patients should not be more than 600 if the director is to have personal
knowledge of all the patients. Others believe that the cost of an
asylum for 1000 patients and upwards is much less than that of two
asylums for 500 each, and that in large asylums greater independence is
secured to the medical superintendents.

The question of abstinence from alcohol in asylums has also been to
the fore. Adherents are constantly being gained to the view that
alcohol as a beverage should be excluded from asylums, and that it should
only be used as a therapeutic agent.

Similarly the problem, “ To isolate or not to isolate ? ” has led to much
interesting discussion. The general view is that an absolute prohibition
of isolation is not practicable, but that it can be reduced to a minimum ;
there are asylums in which for many years isolation has been abolished.

In Gottingen a society of Jurists and Alienists (Vereinigung—
Juristisch-Psychiatrische) has been formed, having as its object a
mutual understanding on moot questions of forensic psychiatry. A
similar society has existed for several years past in Dresden under the
name of the Association of Forensic Psychiatry (Jorensich-psychiatrische
Versammluttg); the co-operation of jurists and alienists has had good
results here.

Should any of our English colleagues desire a succinct review of
lunacy matters in Germany, compiled critically from the official
year-books of recent years, I should recommend Dr. DeitePs work,
Stand des deutschen Irrenwesens , 1900-1901 (Halle, published by
C. Marhold).

ITALY.

By Dr. G. Cesare Ferrari.

The Italian scientific production in the domain of psychiatry has
been, in 1902, rich, important, and varied; and although our young
alienists spread themselves over the whole field, yet they neglect
somewhat the practical side—the application of the theoretical views
and conclusions to great questions, such as the hospital treatment of
the insane, the overcrowding of the asylums, family care, etc. These

Digitized by v^.ooQLe

PROGRESS OF PSYCHIATRY.

>903-]

1 59

have not yet been settled, but the younger section of alienists will
finally, by their enthusiasm, find a solution.

It is not their fault On one hand, they cannot do very much
because, in the committees of the asylums, the medical directors only
are heard. On the other hand, the work to be accomplished is so
great that many succumb in the struggle. It is necessary, notwith¬
standing, that they should prepare themselves (and some have already
begun) for the task of hospitalisation of the asylum, which humanity
and economy may call for to-morrow.

As the greater part of the articles in our journals are sooner or later
reviewed in the Journal of Mental Science , we shall give simply a
bibliographical sketch.

Beginning with Northern Italy, we find at Turin two journals of
psychiatry; the Archivio di Psichiatria , Scietize penali , ed Antropologia
criminate , edited by Lombroso (about 700 pages, 6 fasc., price i6*. per
annum), and the Annali di Freniatria , directed by Marro (400 pages,
6 fasc., price ioj-.).

The Archivio di Psichiatria is the real organ of the Italian criminal
anthropological school, and it always bears the vigorous imprint of
Lombroso. This publication has been in existence for twenty-three
years, the present year containing principally anthropological contribu¬
tions. There are to be noticed a study of Lombroso on the brigand
Musolino, an essay of Portigliotti on “ The Insane Man of Genius ”
(Savonarola), the reports of Parnisetti, Audenino, and Frigerio on the
subjects already discussed at the last Congress of Amsterdam, of
Roncoroni and Sanna Salaris on nervous diseases with alterations of
sensibility, etc. etc.

The Annali di Freniatria has been in existence for twelve years, and
is publishing more especially work on psychiatry and neuropathology,
containing contributions by Pellizzi, Tirelli, Martinotti, Arullani, Burzio,
and Filippello. Special mention should be made of the remarkable
study of the physiologist Dr. Grandis on the physiology of the magnetic
field.

Other neurological studies find frequently “lieu et place” in the
Gazzetta della R. Accademia di Medicina di Torino , but as a rule this
journal only publishes abstracts.

From Turin we pass to Reggio Emilia, where we find the Rivista
sperimentale di Freniatria , of which Tamburini is the editor (1000
pages a year, quarterly, 1 6 s. per annum). This journal has existed for
twenty-eight years, and for nearly ten years it has been the official
organ of the Society of Italian Alienists. It is on this account that the
first number of the present year contains the proceedings of the last
Congress of the Society. We must point out that amongst the very
fine reports published there will be found the one of Dr. de Sanctis on
the subject of the classification of the psychopathies. This report is
particularly interesting on account of the important remarks made by the
author on the basis which must rule every classification. Respecting
the classification detailed and adopted by the Congress, it has all the
faults of productions made collectively, but as it is official (at least for
some time), and will be used for the Italian statistics, I mention it
below.^) Among other reports of interest are those of de Sanctis and

Digitized by v^.ooQLe

i6o

EPITOME.

[Jan.,

Colucci on the possible re-education of the weak-minded and of
dements, which gave rise to a discussion full of interest, and the
report of Prof. Tamburini on the crowding of the asylums.

In the other numbers published this year is an important paper by
Dr. Ceni, chief of the studies at the Institute of Psychiatry at Reggio
Emilia, on the aetiology of pellagra. He has found as pathogenetic
agents of that disease the Aspergillus fumigatus and the A. flavescens.
Dr. Ceni has also tried serum-therapy with encouraging results.(*)
The lack of space prevents us from mentioning other articles of
Tamburini, Badaloni, Brugia, Pizzoli, Patrizi, Cavani, etc. The last
number contains only works on neurology of Biancone, Panegrossi,
Panichi (of Rome), Pighini (of Parma), Bombicci (of Padua), etc.

At Ferrara, not far from Reggio, was published this year a new
journal, Giomale di Psichiatria clinica e di teenica manicomiale , directed
by Tambroni (400 pages quarterly, 6 s. 6 d. per annum). This journal
is nearly exclusively written by Cappelletti, d’Ormea, Lambranzi,
Muggia, Vedrani, Ferrarini, etc., and the doctors of the asylum of
Ferrara; in it we find very remarkable original studies, among which
is the historical and critical study of Cappelletti on the two principal
systems of the family care, the Belgian and the Scotch. The author
concludes in favour of the latter.

Coming to Florence, we find the interesting Rivista di patologia
nervosa e mentale (600 pages a year, in twelve parts, 15J.), edited by
Tanzi. This journal corresponds to the German Centralbldtter , and is
just as useful. We must mention, as being of particular importance
this year, the studies of Tanzi on the secondary atrophies, and of Bel-
mondo on yellow fever as predisposing to progressive paralysis. Also
works of Lugaro, Obici, Pellizzi, Catola, Camia, Gabbi, Pagano, etc.

In Rome there is only one journal, Annali delP Istituto Psichiatrieo
di Roma , of which Sciamanna is the director. This journal, which a
year ago took the place of Rivista di neuropatologia e di psichiatria, , is
not published periodically. The first volume, of 175 pages with plates,
contains many original memoirs by Pardo, Guidi, Cerletti, Pittaluga,
all pupils of Professor Sciamanna, director of the Institute of Psy¬
chiatry. The psychiatrists and neuropathologists of the asylum of
Rome, director Prof. Bonfigli, do not possess a journal of their own,
but they are using the Rivista di Reggio Emilia and of Florence, and
also the Monatsschrift fur Psychiatrie of Ziehen, etc.

Going further down still, we find two journals of psychiatry in Naples,
—Annali di neurologia , directed by L. Bianchi, now having reached its
twentieth volume; and the Rivista mensile di psichiatria forense ed
antropologia criminate , directed by Penta, which for five years has
appeared every month.

The journal of Bianchi always contains important contributions on
microscopical anatomy, on psychopathology, and on psychiatry, written
by the students of the clinic, and by the doctors of the asylum of
Naples, Colucci, Fragnito, dAmato, Crispolti, Sciuti. This year there
is also an interesting article by Prof. dAbundo on the experimental
atrophies. The bibliographical part is very large.

The Rivista of Penta has published this year many interesting
contributions. I refer to that by Saporito (dAversa) on “ Criminality

Digitized by v^.ooQLe

PROGRESS OF PSYCHIATRY.

161

1903.]

amongst Soldiers” and one by Angiolella (from Nocera), on “The
Phrenosies and the Ethnic Element of Character,” full of interesting
points.

Still further south than Naples, at Nocera Inferiore, there has been
published for eighteen years from the interprovincial asylum itself a
journal, H Manicomio (450 pages per annum, in 3 parts, per
annum), of which Ventra is the director, assisted by the doctors of the
asylum. Del Greco and Angiolella are the principal contributors to
this publication, but it contains also some articles from other doctors
of Southern Italy.

Finally, in Sicily we find II Pisani (from the name of the celebrated
alienist), edited by Salemi Pace and Dotto, director and vice-director
respectively of the asylum of Palermo. It appears three times a year,
and publishes almost exclusively original works.

Besides these ten journals, which represent a mass of work, many of
the asylums publish their own Bulletin , and a great number of psychia¬
trical and neuropathological works are found in journals of general
medicine. In the Rivista di filosofia e seienze affini (Zamorani and
Marchesini of Bologna) Prof. Morselli, who is the director of the
psychiatrical clinic of Genova, publishes every month an account of
contemporary philosophy. In the same journal Dr. Del Greco con¬
tributed this year an interesting article on “ The Elements of Know¬
ledge in the Insane,” in which he shows that the alterations of the
mind are intimately united with the alterations of personality. Angiolella
also contributes “ Biological Sciences and Education.”

Another article, “ An Objective Definition of the Psychical Pheno¬
mena,” profound and full of originality, by Lugaro of Florence, is
found in Arehivio per P antropologia e P etnografia (Prof. Mantegazza),
organ of the Anthropological Society of Florence.

This enormous production, of which any nation could justly be
proud, makes us regret that a little of this energy is not employed in
a more direct way in the amelioration of the condition of the insane.
In Italy the number of the insane, which in 1874 was 12,210, has
risen in 1893 to 36,931, of whom 28,364 are kept in forty-three
pylums. From recent statistics it appears that in these asylums there
is an excess of 5000 patients. At the last Congress of the Society of
the Italian Alienists, Prof. Tamburini, the President, brought forward
these figures, and pleaded for immediate steps to be taken to alleviate
this sad state of affairs. He laid stress on the benefits of family colo¬
nisation, which he has himself established at Reggio around his asylum,
and which has had every success. Dr. Cristiani followed his lead at
Lucca, with encouraging results. Alienists must initiate individual
systems of family care, and they will be rewarded by their asylums
becoming less overcrowded. The population of Italy is varied on
account of the many different races that have from time to time
invaded it. This is an important point, and renders impossible any
general scheme of “ family care ” which would apply to the whole
country.

The Italian Government is much exercised at the increase of lunacy,
especially from the financial side, the cost of maintenance reaching

Digitized by v^.ooQLe

EPITOME.

162

[Jan.,

11 *65 per cent, of the total budgets of the various departments, many
of which will be no longer able to support this expense.

Thanks to the good offices of the Government, we have at last in
Italy a “ Law for the prevention and treatment of pellagra.” The sale of
damaged maize is forbidden, and the doctors are obliged to declare
any case of pellagra. Every person infected with pellagra will be fed
in special sheds ( pellagrosarti) at the charge of the department and
of the communes, the State furnishing every year a subsidy of 200,000
lire. All families in which cases of pellagra may occur will be able to
receive the necessary aid. Of course this law will not solve the
questions concerning pellagra, but it is without any doubt a great
benefit to a large part of our rural population. To correctly estimate
this, one has only to remember that, according to the latest statistics,
the total number of pellagrous cases was 60,000, and that they are
more or less a burden on the national finances.

The Italian psychiatric world has been much stirred this year because
of the medico-legal reports which some of our most conspicuous men
of science have made on the subject of the last classical brigand of
Calabria, Giuseppe Musolino. All experts have admitted that he was
an epileptic, but concerning the responsibility of his acts opinions
were divided. In fact, the experts called by the defence have denied
it; on the other hand, those called by the Tribunal admitted it One
must admit that the Italian Penal Code presents an exceptional place
for the mental conditions which delimitate responsibility, and it is
because they thought it more just to comply with the Code than with
principles of psychiatry that the experts of the prosecution maintained
their opinion; at all events, it is perhaps to the great fuss created by
this trial that we shall owe the establishing of a special “ School for
the Medico-legal Experts.” The value of the diplomas granted by this
school has not yet been determined.

The new regulations for criminal asylums, when they come into force,
will prove of great benefit. Up till now these establishments were
under prison administration, and the doctor who had charge 6f the
patients played rather a subordinate part. At every Congress of the
Society of Alienists this condition of affairs has been deplored, and
at last our complaints have been heard, and before long these asylums will
become like those for ordinary insane, only they will be surrounded by
a wall and be under the special supervision of the Minister of Justice.

We should congratulate ourselves upon another advance, though it
does not concern strictly the domains of psychiatry. Following in the
footsteps of the 11 National League for the Protection of Mentally
Deficient Children,” of which Dr. Ireland has recently written in this
Journal, Dr. Pizzoli has established at Crevalcore, near Bologna, a
course of lectures approved of by the State, demonstrating the principles
of experimental pedagogy to teachers (both sexes) of the primary schools,
so as to enable them to recognise the psycho-physiological possibility of
the children under their care, and the necessity which may arise for
medical or psychiatrical assistance.

We cannot describe here the organisation of this institution, which
may in the future exercise a great and benevolent influence over the
schools. We have been pleased simply to remember the existence of

Digitized by ^.ooQle

I9°3-] PROGRESS OF PSYCHIATRY. 163

such an institution and its affinity with our field of studies, and also to
prove that in Italy the most generous ideas can be pushed forward and
receive a practical sanction.

( l ) Simple acute psychoses: states of mania and melancholia, amentia, etc.
Chronic primary and secondary psychoses: paranoia and periodical psychoses
(hallucinatory psychoses). Senile psychoses: dementia—primary, juvenile, and
secondary. Paralytic psychoses: classic paralytic dementia, syphilitic, neuras¬
thenic, choreic, etc. Toxic psychoses: alcohol, morphine, cocaine, etc. Pellagrous
psychoses. Infection psychoses: post-influenzal, febrile, syphilitic, etc. Acute
delirium.—(*) Sero-therapy in pellagra has been assayed by Drs. Antonini
(Voghera) and Mariani (Bergamo), who injected with good results the serum of
the blood of cured pellagrous cases into persons affected with this disease. They
have published only a brief note on their observations.

RUSSIA.

By Professor P. T. Kovalevsky.

The following is a brief notice of the Russian Literature of Nervous
and Mental Diseases:

Affections of Bones in Cases of Syringomyelia . By Prof. Anfimof, 1902.
—The author investigated a case of fracture of the thigh bone in a woman
act. 32, suffering from syringomyelia. There was also fracture of the
left radius. Both fractures were spontaneous. The author suggests
that the affection is dependent on a “ gliotic ” disease of the spinal
marrow.

Syphilis in the Central Nervous System . By Prof. Bechtereff,
1902.—This monograph contains a description of the pathological
anatomy of the nervous system in cases of syphilitic disease. The
author bases his opinions partly on personal researches and the investi¬
gations of his pupils and partly on the literature of the subject.

Acute Hysterical Psychoses . By Dr. Mouratoff, in the Messenger
of Neurology , 1902.—The author differentiates real hysterical psychoses
from psychical diseases complicated by hysteria. In distinguishing
these two groups of psychical conditions one is to be guided by the
following clinical phenomena:

1. Immediate dependence of the psychosis on an hysterical attack.

2. The occurrence of hysterical symptoms in the clinical course of
the psychosis.

3. When there is no apparent connection between the two groups.
Emotional outbursts and maniacal excitement should not be considered
as independent forms of psychoses; they form a detail of the picture of
the psychical disease, and may enter into the phenomena of hysterical
attacks.

Auto-intoxication as a Cause of Mental Disease . Prof. A. Popoff
( Russian Medical Messenger , 1902).—This is a very detailed work which
advocates that the strongest aetiological factor in psychoses is auto¬
intoxication. Auto-intoxication is to be divided into— (a) General
(organic); (b) Sectional (nervous); and (c) LocaL A healthy man can
deal effectually with his normal toxines. When from some cause or

Digitized by v^.ooQLe

EPITOME.

164

[Jan.,

other he can no longer do so the organism is poisoned and mental
disease is a result.

Effect of Gonorrhoea on the Nervous System . Prof. U. F. Fellenbff
(Journal of Venereal Skin Diseases , 1902).—Noting that gonococci are
to be found in the central nervous system, the author studies the toxic
effects of these germs, which in certain cases produce actual changes in
the central and peripheral nervous systems.

The Intra-cranial Circulation in Acute Mechanical Asphyxia. Prof.
Orleansky. —The author details his own investigations, and observes
that when animals are suffocated by compression of the windpipe the
pulse-rate drops, but the amplitude of the pulse-wave increases, pro¬
bably from stimulation of the centre in the medulla, and there is lower¬
ing of the blood-pressure. The intra-cranial pressure rises and the total
quantity of blood in the skull cavity increases by the active dilatation of
the blood-vessels of the brain.

The Pathology of the Nerve-cells in Cases of Pellagra. Dr. Kofovski
(Russian Physician , 1902).—On examining the brain in those dying
from pellagra the author has found that in the protoplasm of the nerve-
cells and processes are to be observed fine granular yellow deposits of
pigment, which do not stain or enter into combination with reagents.
The pigmentation of the processes differs from pathological processes
in the other parts of the cell. The pigmentation is different in normal
and diseased cells.

Bulbar Paralysis of Vascular Origin . Prof. M. Popoff (Neuro¬
logical Messenger , 1902).—The author describes a case of bulbar
paralysis of vascular origin in a man forty-one years old, who had
had syphilis. The illness began suddenly with a fit, and the patient
quickly recovered. The author considers the cause of the illness to
have been thrombosis of the basilar artery and its branches. He gave
a prognosis of probable recurrence and possible death. Two months
later the patient came into the Policlinik, where another fit took
place and death resulted.

Treatment of Spinal Atrophy . Prof. Darkshewitch (Russian
Physician , 1902).—The author holds that syphilitic cases are curable
in the early stage. In early cases mercurial treatment arrests the pro¬
gress of the disease, and even causes recovery, but advanced cases are
hopeless. One must remember that the symptoms may disappear for
a time and afterwards recur.

Obsessions and Fixed Ideas. Drs. Ganonckine and Souchanoff
(Neurological Journal\ 1902).—They find that obsessions affect men
four times as frequently as women. Nearly all the patients had a
neurotic heredity and betrayed indecision, suspicions, impressionable¬
ness, irritability, argumentativeness, egoism, cruelty, and a dread of
mental disease.

Definition of Progressive Paralysis . Prof. Chich (Journal of Neuro¬
logy and Psychiatry , 1902).—The author gives the following definition :
—Progressive paralysis is a parasyphilitic disease of the oiganism in
general which depends on a particular variety of syphilitic poison that
pervades the tissues. The pathological and clinical definition of
progressive paralysis is the same. It causes proportional and equal
destruction of all the tissues, no one organ being attacked by preference

Digitized by v^.ooQLe

PROGRESS OF PSYCHIATRY.

1903.]

165

nor one spared; not one function is spared, not one destroyed by
preference.

Headaches and their Frequency in Tomsk. Prof. M. Popoff (Russian
Medical Messenger, 1902).—The author, after spending several years in
Tomsk as Professor of the University, was struck by the prevalence of
headaches in Siberia, especially during the winter. The headaches
made their appearance with the cold weather and became worse as the
severity of the frost increased; they gradually became less frequent
and disappeared as the weather grew warmer. He attributes these
headaches to anaemia of the brain and altered intra-cranial blood*
pressure. The pains were relieved by the constant electrical current;
but residence in a warmer climate was the only means of ensuring
recovery.

Gout and Neuroses . Prof. P. J. Kovalevsky (Russian Medical Mes¬
senger , 1902).—The author describes four diseases connected with gout:
angina pectoris, Anxietas prcecordialis , epilepsy, and hemicrania.
According to his investigations, all these diseases often manifest
themselves in gouty subjects; gout, however, must not be looked upon
as of ^etiological moment in their production^ but only as stimulating
them to activity. The appearance of such neuroses in gouty affections
must be preceded by predisposition, either through morbid inheritance
or the habits of the patient. All conditions which favour gout increase
the neuroses also; and all measures, therapeutic and hygienic, directed
against gout weaken the neuroses. Treatment directed against the
neurosis alone will not be effective, it must be directed against the
gouty state also.

Digestion in Mental Diseases . By Dr. Touchenko (Russian Phy¬
sician , 1902).—The author records the results of numerous researches
on digestion made in twenty-five patients at different hours after meals,
and on an empty stomach. His investigations are not limited to
abdominal digestion. In one group of cases Dr. Touchenko gives a
physiological explanation of clinical facts, based on the latest works of
Prof. Pawloff and his pupils on digestion, which proves the existence of
two periods in normal digestion, /. e. psychical (appetite) and reflex
(chemical). He describes two types of derangement, asthenic and
torpid. Investigations of the gastric juice in three melancholiacs showed
the same derangement of digestion in its first period. No gastric juice
or only a small quantity was secreted in the early stage, but later secretion
was more profuse, and digestion progressed in a more normal manner.

In an excited maniacal woman a sudden loss of appetite was noted,
but in another, on the contrary, an asthenic type of digestion was
present The same thing appears in cases of neurasthenia. In all
progressive paralyses at different stages of the disease the digestion had
the same type, viz. loss of appetite and a quite insignificant derange¬
ment of the gastric secretion. In paralytics who chew anything indis¬
criminately the mastication does not provoke the secretion of gastric
juice, but the latter appears as soon as food enters the stomach. In a
case of hysterical psychosis the patient did not eat owing to complete
absence of appetite. The psychical phase of digestion was thus entirely
absent. The same thing was noted in the case of two katatonics during
the period of apathy.

XLIX* 11

Digitized by v^.ooQLe

EPITOME.

[Jan.,

166

On the contrary, during the period of excitement the appetite was
healthy and gastric juice was secreted normally. Out of nine paranoiacs
five refused food during marked mental excitement; there was no par¬
ticular deviation in the digestive processes. One patient with perverted
feelings satisfied her appetite by preparing food; she refused with dis¬
gust to eat it, and had to be forcibly fed with a stomach-tube. The
action of the gastric juice was very weak.

In the case of paranoiacs who have for long refused food the following
takes place. Gastric juice is secreted in the morning at the time of
artificial feeding. The juice, if collected from an empty stomach, often
has an acidity 0*4 per cent, HCL Considering the fact that the col¬
lected fluid consists of gastric juice mixed with saliva and mucus,
Dr. Touchenko concludes that the pure gastric juice of a man contains,
not *2 per cent, of HC1, but as much as *5 per cent , 9 the same propor¬
tion that Prof. Pawloff found in dogs. The researches of Dr. Touchenko
are of great value. They show the difference between artificial feeding
by means of a stomach-tube and when food is taken normally. They
also show the value of milk as being the least excitant of the nervous
system; and, finally, they give us rational grounds on which to base
the treatment of disturbed digestion in mental diseases.

SPAIN,

By Dr. W. Carolen.

The State Secretary for the Department of Instruction has to some
extent been an agent in the progress of mental science by rendering
compulsory for students of forensic medicine a course of lunacy in an
asylum extending over two months. By an unfortunate imitation of
the Italian system, which in a single chain unites subjects of so diverse
a character as toxicology, legal medicine, and mental diseases, the best
method of freniatric teaching is not obtained. In Spain, a physician
at the end of his career knows nothing at all of mental infirmities and
affections. The action of the State Secretary is the more surprising
when one remembers his order founding and establishing separate and
compulsory chairs, both clinical and theoretical, of dermatology, oto¬
logy, and ophthalmology. Alienists in Spain are disappointed, and
regret that so incomplete a step should have been taken in so
important a matter, for physicians at present look either dumb or
foolish at court when cases of criminal responsibility, civil incapacity,
etc., are being tried.

Psychiatric literature has been scarce, owing to the non-existence of
special reviews. All the branches of medical learning are represented
journalistically in Spain except mental science. The Medicine and
Surgery Practical Review in Madrid has published an article of Dr.
Otsy Esquerdo relating to “Early Dementia” (7th June), and
another by Dr. Bonafonte on “Surgical Interventions in Mental
Diseases ” (28th July). In the same review of 14th September is to
be found “Hysterical Insanity,” by Dr. Ots. The latter’s pen has

Digitized by

Google

NEUROLOGY.

*9°3J

167

also been responsible for “Convulsive Hysterics,” in the Medical
Correspondence of Madrid (24th February), “ Infectious Insanities ”
(8th May), “Lucid Insanity” (24th October), “Hedonal in certain
Forms of Mental Diseases,” in North Medical Gazette (January), and
11 Fatal Hemicrania ” (May).

New asylums have been constructed at Reus (Catalonia) and
Pamplona (Nowarra). In Barcelona the Holy Cross Hospital, the
most ancient beneficial institution, founded in the year 1400, has now
its lunatic asylum at St. Andrew, one of the suburbs of the great
capital. It has been provided with some of the most modem
improvements, such as dormitories for the bed treatment of the
agitated and maniacal cases, and rooms for the photo-therapeutic treat¬
ment in certain forms of insanity. Dr. Sivilla, head physician, neglects
nothing that can conduce to the well-being and health of his patients.
He has advocated with great zeal and strength the open-door system,
and is gallantly fighting against an administration which desires no
improvement on the old system, which dates from 1850.

The Clinical Hospital of Barcelona, now being completed, will be
the seat of a psychiatrical clinic. Dr. Gin£, of Partagas, a most
venerable figure of the speciality and doyen of the faculty, is appointed
professor. If this proves a success, it will be the first serious attempt
to teach psychiatry in Spain.

Epitome of Current Literature.

1. Neurology.

The Plantar Reflexes [Riflesso plantare: fenomeno di Bakinski e riflesso
antagonistico di Schaefer ]. (Ann. di nevr. } fasc. 1, 1902.)

Capriati , V\

In this paper the author discusses at some length the nature and
relationships of the various reflexes which have been described in the
foot. There are at present very marked differences of opinion among
the various authorities as to the value and pathological significance of
these reflexes.

The author considers that the normal plantar reflex can be repre¬
sented by different movements in different subjects, and that the
opinion of those who would limit this reflex to the movement of flexion
in the toes is sometimes in contrast with the facts.

The method indicated by Schaefer does not produce anything charac¬
teristic ; normally it does not give rise to a reflex. In morbid con¬
ditions, acting as a painful stimulus, it may sometimes produce Babinski’s
phenomenon, which is a plantar reflex, and which should not be
considered as anything different, J. R. Gjlmour,

Digitized by v^.ooQLe

i68

EPITOME.

[Jan.,

Clinical and Histological Facts in Relation to the Softenings surrounding
Cerebral Tumours [Fatti clinici ed istologici in rapporto ai ram-
mollimenti che ciscondario certi tumori cerebrals]. (Riv. di Pat
nerv. e ment.,January, 1902.) Pellizzi, G. B.

The author describes a case and the pathological appearances found
after death, and bases upon it some considerations regarding cerebral
tumours. The patient for years had suffered from a monoplegia
affecting the one arm, and was also subject to attacks of epilepsy.
There was no headache, no vomiting, no disturbance of vision, and no
weakening of the intellect. Twenty-five years after the beginning of
these symptoms dementia supervened. At the autopsy, a tumour about
the size of a small hen’s egg was found in the middle of the right
Rolandic region in correspondence with the posterior third of the
frontal lobe. The tumour was an endothelioma, rich in cells pro¬
bably of a sarcomatous nature, and without any nervous elements.
The author points out the complete absence for twenty-five years of
any mental symptoms is in complete accord with the theory of Bianchi,
the unilateral nature of the lesion and the extraordinary slowness of its
development giving time for compensation. An examination of the
contents of the softening showed that the vessels remained normal;
the nerve-fibres were very markedly altered, and the nerve-cells were
reduced in number. The permanence of any cortical nerve elements
was due to the slowly progressive interruption from the gradual com¬
pression and to the absence of any inflammatory process. The soften¬
ing that surrounds tumours has been attributed by some to the com¬
pression of the small vessels, or to a superadded obliterative arteritis
caused by syphilis or tubercle, the degeneration of the nervous elements
following this. The author regards the extension of the softening to
have been caused, not by the pressure of the tumour itself, but rather
by pressure of fluid surrounding it. This produces in some cases an
increase of tension, to which the white matter cannot offer sufficient
resistive power, and hence the degeneration. J. R. Gilmour.

a. Physiological Psychology.

Theory of Obsession [Sur la thiorie de Pobsession], (Arch, de Neur. t
No. 76, April ’ 1902.) Amaud.

In the discussion of obsession the point at issue has been especially
the relative importance of the intellectual and the emotional element.
Recent experiments apparently establish that organic modifications
(muscular or vaso-motor) are anterior to the affective state, and there¬
fore to the idea, and not consecutive.

Arnaud is satisfied with neither the intellectual nor the physiological
(peripheral) theory of emotion. It is strongly in favour of the former
that an idea becomes obsessive only when there is some mental altera¬
tion present; but, on the other hand, there is no fixed relation between
the importance of the obsessive idea (as regards possible consequences)
and the intensity of the anguish present, and the evolution of the

Digitized by v^.ooQLe

PHYSIOLOGICAL PSYCHOLOGY.

169

1903.]

obsession in crises with intervals of comparative calm is scarcely com¬
patible with the intellectual theory, /. e, the hypothesis that the idea
plays a preponderating part. The emotional or physiological theory, he
considers, proves a useful reaction against the exclusively intellectual
doctrine; but when it subordinates everything to neuro-vascular modifi¬
cations it encounters serious objections. The extreme importance
attached to emotional expression and peripheral modifications, as a
consequence of this (latter) theory, is not justified by observation; the
expression is often, for example, not adequate to the emotion. In the
absence of emotion, or with a minimum of such, the most vehement
expression may be noticed. On the other hand, in states of very lively
emotion the expression may not be perceptible.

The general conclusion of the author, after analysing the various
factors brought into play in the evolution of dominant ideas of obses¬
sion, is that their cause varies. In some it must be sought in the
organic phenomena of emotion, in others in ideas. In either case,
however, the emotion or the idea is but the determining cause of the
obsession. The real deep cause resides in some lesion of the will.
Motor disorders (voluntary) are generally present in cases of obsession;
hesitation, uncertainty, are strongly evident In cases of “ folie du
doute,” the type of intellectual obsessions, these motor disorders are
especially observed; but they are also present in other obsessions, in
the “ fear of contact.” Abulia is the fundamental condition of obsession,
and the emotional and intellectual elements play but a secondary
although important part in its pathogeny. H. J. Macbvoy.

Contribution to the Psychology of the Genesis of Psycho-motor Hallucina¬
tions [ Contribution d la psychologic de la genlsc dcs hallucinations
psycho-motrices\ (Arch, de Neur., No. i 8 9 fune, 1902.) Vaschide
and Vurpas.

The object of this paper is to show the important part played by
introspection in the mechanism of certain delusions, and especially in
the genesis of psycho-motor hallucinations. The complete notes of a
case carefully observed in this connection are given—that of a woman
aged forty-three years. Tormented by the thought of wrong-doing, by
ideas of doubt and fear, the patient was especially anxious to analyse
and explain her mental condition. She at first is satisfied that her
ideas take birth within her mind, then believes that she is self-
hypnotised ; a stage further she suspects the domination of some indefi¬
nite power which directs her thoughts, experiments upon her, hypno¬
tises her, and speaks within her. If she thinks evil of certain persons
she hears them “ inside ” herself replying, insulting her. At times she
moves her lips when speaking her own ideas, and is conscious of a
conversation, an asking and a replying, going on in her head. Ideas
of guilt are generally associated with these phenomena, and she asks
forgiveness for these ideas, which spring up without the intervention of
her will. The explanation which satisfies her best is that she is hypno¬
tised and made to think, and the measure of her guilt is the consent
which she gives to certain of these ideas—this consent being withheld
in the case of others. The thesis which the authors endeavour to

Digitized by v^.ooQLe

170

EPITOME.

[Jan.,

prove is that the interior language is the principal source of a consider¬
able number, if not of most, psycho-motor hallucinations. They urge
the importance of a careful study of the mental life of patients, and the
fallacy of restricting observations to somatic examination alone.

H. J. Macevoy.

3. iCtiolo gy of Insanity.

Five Observations of Conjugal General Paralysis \Cinq observations
de paralysie gentrale conjugate ]. {Arch, de Neur ., No. 78, fune,
1902.) Kkraval and Raviart .

These five cases are interesting on account of the important question
of the aetiology of general paralysis.

(1) Male, aet. 40, with good family history, contracted syphilis while
in the army. Married in 1881 ; no children. He was a good worker up
to 1893, when he had dyspeptic troubles which caused him to lose his
work and run through his savings. This caused depression. Ad¬
mitted to Armentiferes Asylum, September, 1896, with physical and
mental symptoms of general paralysis; the disease rapidly proved fatal.

His wife, aet. 40, of good family history, presented signs of tabes and
depression. After the death of her husband her melancholia became
aggravated, and she was admitted to the asylum with ideas of grandeur
and lightning pains. She became demented, developed tremors, etc.,
and died in December, 1899, of paralytic cachexia.

(2) Male, aet. 50, with a good family history. No alcoholism nor
syphilis. Married in 1878 ; he had two healthy children. Nineteen
months before the present illness suffered from gastric symptoms;
giddiness. Now exhibits typical signs of general paralysis, attributed
to worry through his wife leaving him in 1886 to lead a life of debauch.

Wife, aet. 40, returned in ill-health to her husband a few months ago
after fifteen years' absence spent in debauch and prostitution. Now
suffering from advanced general paralysis. No clear history obtained
of syphilis. Alcoholic and venereal excess for fifteen years.

(3) Male, aet. 48, employed in a brewery. Had one uncle a general
paralytic. Married and had four healthy children. Drank to excess
at times. On admission in August, 1895, was suffering from melan¬
cholia, delusion of persecution. In January, 1896, mental confusion,
weak-minded, physical signs of general paralysis. Died in March,
1897. His wife, aet. 49 years (good family history, a drinker), a year
after the admission of her husband develops progressive mental
weakness. In December, 1896, she develops physical signs of
general paralysis, and dies in May, 1897.

(4) Male, aet 38 years, blacksmith. No syphilis, no alcoholism.
Family history good. Married in 1877; one daughter. In March,
1889, was wounded in the head while at his work, and shortly after
developed hallucinations of vision. Later he developed typical general
paralysis (loss of memory, affection of speech, epileptiform attacks, etc.).
He died in March, 1897.

His wife, aet. 33 years (good family history, no alcoholism), after her

Digitized by v^.ooQLe

I903-]

/ETIOLOGY OF INSANITY.

1 7 1

husband’s illness was left poor. In 1894, without any other reason
apparently than grief and poverty, developed mental symptoms—ideas
of grandeur, incoherence, etc She became more and more demented,
showed physical signs of general paralysis, and died of the usual
marasmus in November, 1898.

(5) Male, aet. 45 years. One twin brother died of general paralysis
at the age of thirty-nine. Married twenty years, has had five children.
No history of alcoholism or syphilis. Five months before admission
developed 44 cerebral congestion; ” then became melancholic, with
delusions of negation. Physical signs of general paralysis appeared
later; he became demented, and died two and a half years after
admission into the asylum.

His wife, aet. 40 years, without any apparent cause but grief, became
demented two years after her husband’s illness. She presented the
mental and physical signs of general paralysis, and died of marasmus
six months later.

In spite of the difficulty of obtaining full data in the history of such
patients, the observation of these cases does not favour the view that
syphilis is the one constant factor in the aetiology of general paralysis,
or that there is any one constant factor. In the first case, syphilis was
almost undoubtedly the cause, in the second, probably; but in the
third, the only factor seems to have been alcoholism. In the fourth,
traumatism in the husband and grief in the wife; and in the fifth
heredity in the husband and grief in the wife are the only apparent
causes. In none of these observations does the occurrence of general
paralysis in a married couple appear to have been a mere coincidence.

H. J. Macevoy.

On the Investigation of Heredity and the Degeneration of the Spanish
Hapsburgs [ Ueber die Untersuchung von Vererbungsfragen und die
Degeneration der spanischen Habsburger\ (Arch, f Psychiat .,
Band xxxv, Heft 3.) Von Stradonitz.

Dr. Stradonitz, in a long paper, recommends historical research in
connection with hereditary disease, and prescribes some methods of
inquiry which are sufficiently obvious. Every one has two parents and
four grandparents, and in this ratio his ancestors might go on doubling
at each generation, till three hundred years back the ascendant roll
might have 1024 persons. Actually this never takes place through the
marriage of cousins in the first, second, and farther degrees.

The author is a doctor of law and philosophy, not of medicine,
which may explain some of his oversights. Dr. Stradonitz passes
over the fact that the first application of history to illustrate the laws of
hereditary insanity was made by me twenty-two years ago in the paper
44 0 n the Hereditary Neuroses of the Royal Family of Spain,” published
in the Journal of Mental Science , and reprinted in “The Blot upon the
Brain.” He cites the genealogical table of the Spanish royal family
framed by D£j£rine in his 44 L’h£r6dit£ dans les maladies du systeme
nerveux” (Paris, 1886), which was compiled from my paper, as the
French professor, of course, acknowledged. Dr. Stradonitz makes no
reference to historians using the English language like Robertson,

Digitized by CjOOQle

172 EPITOME. [Jan.,

Prescott, Stirling, and Bergeroth, who have added so much to the
history of the Spanish kings. He adopts the ingenious (“ geistreich ”)
hypothesis of Lorenz that the origin of the neurosis of the Spanish
dynasty came from John of Gaunt through his daughters, the half-
sisters Philippa and Catherine, who, he says, were drunkards. This is
perplexing, for neither John of Gaunt nor his father, Edward III, was
insane. John took for his second wife Constance, the daughter of
Pedro the Cruel, of Castile, through whom the neurosis may probably
be traced back to Pedro II, of Portugal (1357—1367). Catherine, the
daughter of Constance, was married to the Prince of the Asturias,
afterwards Henry III, king of Castile. John of Gaunt was thrice
married, yet none of his descendants by his English wives seem to
have been insane, though Henry IV, his eldest son, became epileptic
towards the end of his life. The derangement of Henry VI of
England was probably derived from his French mother.

Dr. Stradonitz gives us some additional information concerning the
mental weakness of the Spanish kings Philip III and Philip IV, and
their brothers and sisters. He neglects to take into consideration
their illegitimate descendants, of which kings generally have plenty.
These, not being the offspring of consanguine unions, are more healthy
than the legitimate children, and often escape the ancestral taint.
There is a strain of insanity and nervous disease in every royal family
in Europe, and the only way to regenerate them is to prohibit close
marriages, and to make the members marry into healthy stocks.

William W. Ireland.

4. Clinical Neurology and Psychiatry.

Potential Criminality and Homicidal Obsessions [Lacriminalitapotenziale
e le ossessioni omicide ]. (ArcA* di Psichiat. % vol. xxiii, fasc . 4, 5,
1902.) Mariani.

This is the report of a case of homicidal obsession developing as a
result of nervous exhaustion in an individual of the so-called criminal

type- ...

The patient, an unmarried woman aet. 27, with slight hereditary
nervous taint, after a series of emotional shocks and a prolonged attack
of uterine haemorrhage became subject to intense homicidal obsessions
with praecordial anxiety. She suffered also from periodical migraine,
from occasional attacks of vertigo, and from recurrent fits of depression.
Under tonic treatment with hypnotism the obsessions were removed.

The anthropometric examination of the patient showed the existence
of a considerable number of the characters assigned by the Italian
school to the homicidal type—relative over-development of the arms,
prominent supra-ciliary ridges, large orbital fossae, square voluminous
maxilla, virile physiognomy, sensory and motor sinistral predominance,
etc.

In the author’s opinion, the development of homicidal rather than of
suicidal obsession under the influence of nervous exhaustion is to be

Digitized by v^.ooQLe

I903-] CLINICAL NEUROLOGY AND PSYCHIATRY. If3

attributed to the latent criminal disposition of the patient, this disposi¬
tion being shown by the somatic and functional stigmata, and by the
existence of symptoms of probably epileptoid character.

W. C. Sullivan.

On the Se-ealUd Polyneuritic Psychosis [Sulla cosidetta psichosi poll -
nevritied). (II Afanicotnio, anno xviii, No. 2, 1902.) Esposito .

In this paper, the author reports two personal observations which
presented a combination of mental disturbance with symptoms of peri¬
pheral paralysis, and in connection therewith enters at some length into
a critical examination of Korsakow’s disease.

In the first case, the patient was a man 41 years of age. The mental
symptoms consisted in a short prodromal phase of insomnia and malaise,
followed by vague, unstable illusions and hallucinations with profound
disorder of attention and memory, the memory defect taking the form
of immediate amnesia for recent events with good recollection of past
events. On recovery, the amnesia for the period of the attack persisted.
The accompanying somatic phenomena included a moderate degree of
paresis and anaesthesia in the lower limbs, more marked distally, with
some exaltation of the patellar reflexes. No electrical examination was
made. These symptoms, in the author’s view, justify a diagnosis of
multiple neuritis. The only aetiological factor was alcoholism.

In the second case the patient, aet. 35, presented somewhat similar
symptoms of confusional insanity—mobile hallucinations with vague
delirium of persecution and motor agitation—ending in recovery within
two months. The memory defect consisted in very rapid amnesia for
recent impressions with less marked loss of recollection for past events.
On recovery the salient incidents in the period of the attack could be
evoked. The chief somatic symptom was a paralysis of the right
internal rectus, apparently from a nuclear lesion. The onset of the
attack was marked by vertigo and titubation. In addition to alcoholism,
syphilis and malaria were noted in the patient’s history.

Discussing the recent literature of the polyneuritic psychosis the
author notes a tendency to apply the term indiscriminately to all cases
where confusional insanity is associated with any sort of peripheral
paralytic symptoms. He would maintain, on the contrary, that to
justify the retention of Korsakow’s disease as a nosological entity it
should be shown that the two orders of symptoms are in some essential
connection, and that the mental condition has in it something dis¬
tinctive. He holds that neither of these propositions is true: multiple
neuritis frequently occurs without mental symptoms; the mental
symptoms described by Korsakow are often seen without any evidence
of neuritis; and the special disorder of memory, which has sometimes
been regarded as pathognomonic, is met with not uncommonly in all
toxi-infectious psychoses, and may be absent in cases of insanity with
multiple neuritis.

The author publishes his cases as examples of the fortuitous co¬
existence of the mental and somatic phenomena.

W. C. Sullivan.

Digitized by v^.ooQLe

174

EPITOME.

[Jan.,

The Nature and Pathology'of Myoclonus Epilepsy . (Amer. Joum. of

Insanity , voL lix , Afa. 2, 1902.) Picrce-Clark, Z., am/ Prout t T. P.

After an introduction and historical sketch of this rare and interesting
disease, the authors give a detailed analysis of the recorded fifty-seven
cases as to aetiology, symptomatology, prognosis, diagnosis, and treat¬
ment. The aetiology rests largely upon a family predisposition of
degeneration, plus a transient and slight excitant of the character of a
toxic or autotoxic agent In the development of the disease epilepsy
appears first a few weeks to several years in one half the cases; in rare
cases the epilepsy ceases in later life. The epileptic attacks are usually
grand tnal in character, preceded by myoclonic spasms. For a greater
or longer period of time after the fits the patient is free from his
myoclonus. The myoclonus is often atypical in degree and character.
There is usually much mental impairment attending the development
and end of the disease. The prognosis is poor, yet life is often pro¬
longed for years, the patient dying finally of inanition, pulmonary con¬
gestion, and premature senility. The children begotten of myoclonic
epileptics usually die early of an intercurrent affection, yet they in turn
may live to develop the disease. The disease has been found in many
cases indirectly as well as directly transmissible. The disease is largely
one of the family type of neurosis. The authors place emphasis upon
the fact that faulty diagnosis is the result of laying too much stress on
single symptoms of the disease. The treatment, while largely palliative,
must be undertaken with great care in the proper use of large doses of
sedatives. Bromides rank in first place. The hypochlorisation adjuvant
principle is highly recommended. Cases not benefited by bromides
are decidedly in the minority. Chloral in connection with bromides is
recommended in stubborn cases. Care of the diet, general hygiene,
and a non-stimulative country existence are found to give best results.
The authors present three new cases, which, in addition to one previously
reported by Clark, constitute the only cases of the association diseaseat
present in the English language. A study of the cortex in one case
under ideal conditions of methods was made, and lesions found were in
the second and third layer of cells, those of sensory and motor type.
The changes in the second or sensory type are those which the authors
have previously urged as the characteristic lesion of epilepsy, while those
in the third or large pyramid cell are charged to the myoclonus. The
lesions as demonstrated by camera lucida drawings were a destruction
of the intra-nuclear network and its replacement by a granular substance.
As a consequence of this change in the cell, body abstraction of the
nucleolus occurred easily and frequently in making the sections. The
exhaustive lesion of chromatolysis was shown over the entire cortex.
The pathogenesis of the association disease appears to be an intoxica¬
tion or auto-intoxication of motor and sensory cortical cells, probably
brought about by a faulty chemotaxis of such because of their inherent
cellular anomaly.

Digitized by v^.ooQLe

*903-] CLINICAL NEUROLOGY AND PSYCHIATRY. 1 75

Imbecility and Asexualism [Imbecillith ed asessua/ismo], (II Manicomio,
Anno xviti, No, 2, 1902.) Angio/ella.

This is a report with full anthropometric details, and illustrated by
two photographs, of a somewhat uncommon case of sexual abnormality
with arrest of mental development.

The patient, a youth 18 years of age, presents the general physical
characters of infantilism ; no trace of the testes can be made out; the
scrotum is represented by a slight cutaneous prominence with a median
raphe, above which is a rudimentary penis—an appendage 1 cm. long
and about § cm. in diameter, traversed by the urethra, but showing no
differentiation of a glans and no trace of a corpus cavemosum. There
is slight gyraecomastia, and general absence of secondary sexual differ¬
ences. Mentally, the patients level is that of a rather dull child.
There is a total absence of sexual feelings and instincts, whether in
normal or abnormal directions. The patients parents are both weak-
minded, and there is an indefinite history of some operative inter¬
ference on the occasion of patient’s birth.

In a lengthy and acute discussion of the case the author argues that
the psychic neutrality of the patient justifies an inference that the
condition is one of total absence or most rudimentary development of
the testes, and not of cryptorchidism; and the psychic state, he holds,
is to be regarded as the result and expression of the physical anomaly.
Moreover the non-development of the related areas of the nervous
system reacts on that system as a whole, and is the cause of the arrest
of mental growth. The case may accordingly be described as one of
asexual imbecility, and classed as a special variety of cerebroplegic
(Freud-Konig-Tanzi) or cerebropathic (de Sanctis) idiocy. Its mechan¬
ism may be supposed to be in part through the absence of the internal
secretion of the sexual glands, in part through the anatomical and
physiological effects of the non-development of considerable nerve
tracts, and in part also through the lack of the instincts and feelings
which are at the root of the social personality. W. C. Sullivan.

Suicidal Tendency and Suicide in the Insatie [La tendenza at suicidio ed i
suiddii negli alienatt], (II Manicomio , Anno xviii, No, 2, 1902.)
Gucci,

The aim of this paper is to investigate the frequency of suicidal
tendency in the insane, and the forms of mental disease in which such
tendency is more common, and further to determine how often and
under what conditions asylum patients find means to commit suicide.

The author takes his evidence on these points from his experience in
the Florence asylum. In the section for men in that institution, there
were, on the day selected for inquiry, 405 patients, of whom 124 were
noted as suicidal before reception, and 8 others were subsequently
found to be so. Of these 132 (32*59 per cent, of the total number of
inmates) the suicidal tendency had persisted in 87 (21*48 per cent,),
and was regarded as particularly dangerous in 14 (3*4 per cetit,).

The forms of insanity with most suicidal proclivity were found to be
dementia praecox, melancholia, and epilepsy. In the asylum, the suicidal

Digitized by v^.ooQLe

EPITOME.

176

[Jan.,

tendency usually persists, though the attempts gradually become less
frequent The usual method is strangulation.

In the Florence asylum, the number of actual suicides from 1844 to
1901 was 22, being 0*91 per thousand admissions. Relative to the
numbers of the inmates, the frequency of suicide has been very much
less in the latter years of the period.

The author illustrates his remarks by numerous detailed clinical
notes. W. C. Sullivan.

Traumatic Astasia-abasia in an Epileptic Child [Astasia-abasia trau¬
matica in bambina epilettica]. (. Riv . di pat. nerv. e ment .,
February , 1902.) Gobbi, V.

The patient was a child of 7 years, of good family history, both
direct and collateral. No other members of the family suffered from
epilepsy, and there was no evidence of syphilis. Somewhat slow in
development, she began to walk and speak in her fourth year. About
this time she would fall down with loss of consciousness lasting from
five to six minutes. Bromide diminished these attacks, but afterwards
marked convulsions developed, without aura or cry, with frothing at the
mouth, incontinence of urine, marked prostration, and headache.
Further symptoms supervened. On examination the patient was found
to be well developed and nourished. Each three or four months she
suffers from the convulsive attacks previously described. Percussion of
the head causes the following phenomena:—A light blow on the scalp
or face without warning to the child causes either an immediate fall or
sudden and very marked trembling, and movements in the upper limbs
are noticed. These bear no relation to the strength of the blow, and
any hurt to the body produces no effect. Methodical percussion over
the motor areas does not produce any isolated contraction. There is
no difference on the two sides of the cranium. Excitement increases the
effects. Anaesthesia of a skin area by chloride of ethyl produces no
alteration. Electrical stimulation does not influence the condition. After
the fall the child arose crying and agitated, the walk was uncertain and
hesitating, the arms being used to balance, and she walked zigzag, as if
the power of directing herself were lost—almost like a cerebellar gait.

The author discusses at some length the condition. Astasia, which
is in this case the principal symptom, has been variously described and
classified, and has been generally held to be of an hysterical nature.
Charcot considers that for the execution of the movements in the
erect posture and walking we have two centres, the one cortical and the
other spinal; and that in astasia-abasia this mechanism is faulty—a form
of spinal amnesia. Friedlander considers the centres affected probably
cortical. Ballet considers that the symptoms may be produced not by
amnesia, but by a fixed idea from subconscious fear of want of power to
remain erect

The child being epileptic, the motor areas are probably a locus minoris
rcsistentia , and so may be centres for the provocation of morbid phe¬
nomena. As the manifestations of epilepsy are spontaneous astasia and
convulsive seizures, so hysteria may reproduce an astasia, a rudimentary

Digitized by v^.ooQLe

*903-] CLINICAL NEUROLOGY AND PSYCHIATRY. 1/7

form of convulsive attack, the reproduction though incomplete being
true. The case is of interest in being traumatic. J. R. Gilmour.

The Light Reflex studied in the same Patients during the Three Stages of
General Paralysis \Du r'eflexe lumineux etudie chm les mimes
malades aux trois pModes de la paralysie ginirale ]. (Gaz. des
Hip., No. 30, March i$th , 1902.) Marandon de Montyel.

The author observed 104 general paralytics, but only 30 of these
passed through the three stages, the others dying either in the first or
second stage; 750 successful observations were made altogether, from
which the following important conclusions among others are made by
the author. The light reflex is more often abnormal than normal, and
the alteration is almost invariably in the sense of diminution. Diminu¬
tion and abolition were about equally frequent, and mostly the same in
the two eyes. Abnormality was found in about one fourth of the
admissions. Certain differences in the frequency of abnormalities were
found according to the form of general paralysis, and according to the
apparent aetiology. In the first two stages of the disease the light reflex
was more altered in cases exhibiting motor affection. No clear relation
seems to have been observed between alterations of the light reflex and
sensory affections, except that diminution of tactile sensation was asso¬
ciated generally with some abnormality of the light reflex or its abolition.
While examination of the light reflex, by revealing frequent and early
alterations, is useful in the diagnosis of doubtful cases of general
paralysis, it is of no assistance in prognosis. H. J. Mackvoy.

The Accommodation Reflex ( Pupillary) studied in the same Patients
during the Three Stages of General Paralysis [Le reflexe accom -
modateur itudii chez les mimes malades aux trois piriodes de la
parafysie ginirale], (Rev. de PsychiatNo. 6, fuin, 1902.)
Marandon de Montyel.

Dr. de Montyel gives the results of his investigations on the sixth of
the reflexes which he undertook to study in general paralysis. The discre¬
pancies noticed in the conclusions of many other observers are attributed
to their studying patients in various stages; in all researches of this
nature it is indispensable to follow the only method susceptible of
furnishing data which may be compared with one another,—that is,
following up and examining the same patients from the onset to the
termination of the disease. Out of 104 cases of general paralysis this
method was satisfactorily carried out in the case of thirty only, the
others having succumbed either in the first or second stage; 680
satisfactory observations were made, and the results of these are
carefully tabulated. The following are some of the author’s general
conclusions:—Accommodation is more often abnormal than normal in
general paralysis; exaggeration of the reflex is rare; diminution is
twenty-four times more frequent—abolition being slightly more common
than simple diminution. The reaction is nearly always equal on the
two sides; in a few rare cases one finds normal accommodation on one
side and abolition on the other. In the early stage only does one find

Digitized by v^.ooQLe

178

EPITOME.

[Jan.,

normal accommodation more frequent than abnormal; but in the second,
and more so in the third stage, abnormality is the rule. Abolition is
commoner in the late stage. In more than a third of the remissions
there was abnormality. Certain differences in the accommodation
reflex are found in the various forms of the disease; it is more often
and more profoundly altered with conditions of excitement As regards
the aetiology the reflex was always found abnormal in traumatic general
paralysis ; next in frequency (i. e. after abnormality of reflex) comes the
alcoholic form. Alteration of the reflex is common with cases at the
extreme ages of incidence of the disease (after fifty and below thirty).
Accommodation was more often and more profoundly affected in the
first two stages of general paralysis in proportion to the impairment of
motor power. The investigation of the accommodation reflex on
account of its frequent and early alterations may be helpful in the
diagnosis of doubtful cases, but it affords no indication as to the slow or
rapid evolution of the disease. H. J. Macevoy.

Observations on General Paralysis at the Clinique of the University of
Moscow [La paralysie gbUrale cPapris les donnkes de la clinique
psychiatrtque de P University de Moscou\ (Arch, de Neurol.,
No. 81, Sept., 1902.) Soukhanoff and Gannouchkine.

Out of a total of 3916 cases of insanity (2493 male and 1423
female) observed at the Moscow Clinique for Mental Diseases between
November, 1887, and January, 1901, there were 682 of general paralysis
—590 men and 92 women ; so that nearly 25 per cent, of the male and
6*57 per cent, of the female cases were general paralytics. The propor¬
tion is larger in recent years than in the earlier years of the foundation
of the clinique. The greater number of cases in men were between
thirty-six and forty years of age; in the case of women the commonest
age is thirty-one to thirty-five years. The authors give notes of three
cases of juvenile general paralysis. Various tables of classification
dealing with occupation, nervous heredity, alcoholic inheritance,
presence of syphilis, etc., are given, and the following are some of the
authors’ general conclusions :—General paralysis is uncommon or even
rare in the case of farm labourers. The importance of heredity is
great in the case of general paralysis, as in other psychoses or mental
diseases. Syphilis was present in more than 75 per cent, of the cases,
and in 90 per cent, of these there was an interval of from six to
twenty years between the date of infection and the appearance of
morbid symptoms. Alcoholism is of importance in the aetiology of
general paralysis in men; in over 60 per cent, there is a marked history
of abuse. The demented form of general paralysis was observed in
half the male cases, the maniacal form being next in frequency. In
women two thirds of the cases were of the demented type, and a
quarter of the maniacal. The demented type was decidedly commoner
in recent years. Concerning certain symptoms especially noted in
general paralysis, the authors found that among men exaggeration of
the knee-jerks was present in about half the cases, absence in one fifth;
among women exaggeration was found in about 60 per cent., and
absence in 15 per cent.

Digitized by v^.ooQLe

1903*] CLINICAL NEUROLOGY AND PSYCHIATRY.

179

As regards the state of the pupils, about one third of the total
number of general paralytics presented equality of the pupils, and two
thirds inequality; but in nearly four fifths the pupils were either
inactive or presented a feeble reaction to light. Apoplectiform attacks
were common, and epileptiform attacks rare. H. J. Macevoy.

Biography of a Fixed Idea [Biographic dune idee fixe\ Observation of
Casper . {Arch, de Neurol ., No. 76, Aprils 1902.) Casper .

This is the interesting account of a case, mostly the autobiography of
the patient, relating the development of an idea of morbid blushing in
a boy, which persisted for years, and finally apparently led to suicide,
after the victim had at one time seriously contemplated blinding him¬
self on account of his ereuthophobia. H. J. Macevoy.

Notes of a Case of Hystero-Epilepsy with Distinct Crises , Spontatieous
Ecchymoses , and Attacks of Hysterical Fever [Note sur un Cas
d*Hystero-JSpilepsie d Crises distinctes avec Ecchymoses sponian/es
et Accls de Fibre hystlrique]. (Arch, de Neurol 1, No. 77, May,
1902.) Multever.

The case is that of a girl set. 18 years, who was admitted into the
Mulhouse Hospital on January nth, 1899. She was illegitimate, and
her family history was unknown. From the age of eight she had
frequent convulsive attacks, occasionally preceded by an aura (visual),
during which there was loss of consciousness, frequent biting of the
tongue and lips, and injury to the head, and occasional involuntary
micturition (no doubt epileptic ). At the onset of menstruation she had
some nervous disturbance. After admission two small bluish spots
were noticed on the right knee; similar ones had apparently been
present before, and others were observed on several occasions during
her stay in hospital They were painless, and usually disappeared in a
few days. During her stay in the hospital she had several apparently
typical epileptic attacks. She was treated with bromide of potassium.

On December 23rd, 1900, she was admitted for the second time.
While out of hospital, with the exception of an interval of six months’
freedom from fits, she had been about the same. On January 5 th and
the 13th she, however, developed two attacks, differing from the others
in the character of the convulsive movements, and in the second she
did not lose consciousness; it was followed by a febrile attack without
apparent cause. On the 23rd a second attack of fever. During the
next fortnight small, almost painless nodules, with redness of the skin
over them, appeared on the arm, on the thigh, and on the calf (left
side). On February 8th she had another typical epileptic attack, and
three weeks later, after other hysterical symptoms, she had an hysterical
fit with convulsions.

The interest of the case is especially in the association of true
epilepsy with hysterical attacks—hystero-epileptic attacks appearing in

Digitized by

Google

i8o

EPITOME.

[Jan.,

a girl the subject of epilepsy since infancy. The occurrence of the
spontaneous ecchymoses and attacks of fever (the latter observed five
times during her stay in hospital) without any obvious cause, and not
apparently immediately related to the convulsive attacks, leaves no
room for doubt that they were in reality hysterical manifestations.

H. J. Macbvoy.

General Paralysis in Twins [Observation de paralysie gin/rale gimel-
lairt homomorphe ; dHiredes nkgations\ ( Arch . de Neurol ., No. 77,
May, 1902.) Keraval and Ravi art.

A. D. Q— was admitted into Armentieres Asylum, September 14th,
1888, at the age of 39. His early symptoms began apparently after the
death of his wife about four months before; he was depressed, said he
couldn’t eat, that he was dead, left off working, and stayed in bed. On
admission he presented all the signs of general paralysis of the melan¬
cholic type, with delusions of negation. The disease progressed rapidly,
and he died in January, 1889.

J. V. Q—, his twin brother, was admitted on November 3rd, 1896,
at the age of 47. Five months before he had “ cerebral congestion,”
and became queer in his head; six weeks before admission he
presented very definite symptoms of insanity; refused food, thought
he was dead, and kept to his bed. On admission he was depressed,
scarcely answered questions, often cried, and had marked delusions of
negation (“all is lost,” “it is no use eating,” “he is dead,” “has no
legs,” etc.). The physical signs of general paralysis soon appeared; he
became more and more demented, and died in a condition of paralytic
marasmus in May, 1899. (His wife died of general paralysis in
January of the same year.) The most interesting part of this observa¬
tion is the appearance of the same type of general paralysis in twins,
without any definite cause, such as nervous heredity, alcoholism,
syphilis. It was not folie k deux; the two brothers were married, and
lived apart from each other, and the affection appeared in one eight
years after the other. Of course, one must not lose sight of the fact
that J. V. Q—’s wife died of the same disease, so that, perhaps, syphilis
could not be excluded for certain. H. J. Macevoy.

On Agrammatism following Inflammation of the Brain [Ueber Agram -
matismus als Folge von JTerderhrankung], ( Zeits . f Heilkunde ,

Heft 2, 1902.) Pick .

In a reprint from this journal Professor Pick describes the case of a
woman cet. 41 years, who after confinement showed symptoms of mental
derangement. She was much excited and tore her clothes; speech was
much disordered. When admitted to the clinique at Prague she was
found to speak indistinctly, slurring over some consonants. The same
deficiency was found in her writing, which scarcely recalled the words
she was supposed to signify. She could understand reading, and what
was said to her, though her intelligence was notably impaired. After a

Digitized by v^.ooQLe

PATHOLOGY OF INSANITY.

181

«903.]

short stay in the hospital she was discharged, but was brought back
eight months after in a much worse condition. In her writing, both to
dictation and spontaneously, she only reproduced a few letters, though
she copied correctly. There was paresis of the right side. The mental
power went on diminishing, and the speech getting more unintelligible,
till she died of pneumonia ten months after admission.

On examination, there was found a distinct diminution in the lower
portion of the second and third frontal gyri. This extended to the top
of the left temporal lobe. There was also atrophy of the same parts
on the right side, but less marked. The left hemisphere weighed 408,
the right 430 grammes.

Microscopic examination showed degeneration of Broca’s convolution
and the whole temporal lobe on the left side. This was thought to be
the sequel of acute encephalitis.

Dr. Pick observes that one cannot say whether the morbid process,
which in the end involved the whole speech zone, affected the whole
tract at once, or began with the temporal lobe, thence spreading to the
frontal gyri. In the first case the paraphasia might be regarded as the
first stage of the complete aphasia; in the second case it would be
consonant with the view previously illustrated by Dr. Pick that
agrammatism is the result of lesion of the temporal lobe. Ddjdrine
and his school hold that agrammatism may be simply a stage in a
degenerative affection of Broca’s convolution. This view has been
recently supported by Bernheim in his treatise De FAphasie motrice
1901. On the other hand, Pick assures us that he has studied the
whole literature on the subject, and has constantly found that this
affection of speech is associated with lesions of the temporal lobe.
This holds good even with the cases cited by Bernheim. In no clinical
cases is the possibility of the implication of the temporal lobe excluded,
and in all the cases which came to examination after death the temporal
lobe was found to be involved. Pick remarks that the independence of
thought from words is now admitted even by some philologists, and he
quotes the recent treatise on The Psychology of Thinkings by Ben no
Erdmann, that the real conception which is intertwined with words in
formulated thought is not produced, but only indicated through speech.

William W. Ireland.

5. Pathology of Insanity.

The Pathology and Pathogenesis of the Acute Confusional Psychoses
[S/udi sulF Anatomia Patologica e la Patogenesi delle Psicosi Acute
Confusional\ (. Riv . di Pat . Nerv. e Ment., fuly, 1902.) Camia , M.

This number is wholly occupied by a paper on this condition.
The author has already in previous numbers described seven cases,
and he now records fourteen others, in addition to which he has
collected from various sources over fifty cases.

Dr. Camia tabulates the various alterations in the nerve-cells in the
nerve-fibres both in the brain and cord, and also the chief alterations
noted in the organs throughout the body. Certain of the cases without
complications presented a picture with slight alterations of the chromatic
XLIX. 12

Digitized by v^.ooQLe

182

EPITOME.

[Jan.,

substance of the cells in the various parts of the nervous system;
slight fatty degeneration of the epithelial cells in the liver and kidney,
and with a certain amount of increase in the nuclei of the vessel walls.
These changes may be taken as the basis of the condition, being
common to all. In cases of delirium tremens these do not differ in
any marked characteristic from cases with the common symptoms of
marked mental confusion. From the anatomical point of view there is
a difference in certain cases with motor signs or with hallucinations of
sight, of alterations in the cells of origin of the pyramidal tract from
“ reaction at a distance.”

As regards the origin of the toxic substances, pathological anatomy is
not yet sufficiently advanced. There must be a lessening of resistance
of the nervous system of those affected, probably of a hereditary
character. In alcoholics, for example, some such difference may
determine whether their symptoms shall consist of delirium tremens, or
one of the psychoses, or some other disease. Similar considerations
probably act in all cases of chronic intoxication. Even in the cases
developing in convalescence from acute infective conditions, altered
processes of “ assimilation ” may be advanced.

A third group consists of true febrile delirium, either manifested
during the course of a septicaemia or the so-called cases of absorption
in which the septicaemia had passed off.

In the last group of cases, no evident etiological factor is present
Bianchi and Peccenino have stated the existence of a specific bacillus.
Philippers considers cases of shock as cases of intoxication,
caused by alterations in the metabolism produced by the influence of
the nervous action. In some of these forms of psychosis a similar
origin may exist; it may be by a psychic or nervous injury causing
sudden alterations in the metabolism. We are able to draw the con¬
clusion that pathological anatomy does not clear up the pathogenesis
of many cases; the acute confusional psychoses have a common
symptomatology and anatomical lesions, probably all caused by
chemical alterations which may depend upon very varied causes.

J. R. Gilmour.

On the State of the Cercbro-spinal Fluids in Getieral Paralysis [ Ueber
das Verhalten der Cerebrospinal Flussigkeit bei Dementia
Paralytica , etc.]. ( Allgem . Zeits. fur Psychiat., Bd.lix , H. i.)

The author recalls that since Quinke, in 1891, directed the attention
of the Wiesbaden Congress to the use of lumbar puncture, numerous
publications have appeared on the subject. He observes that the high
expectations of the therapeutic value of this operation have not been
realised, any improvement following being seldom lasting. It has been
used with most effect in acute, serous, and sero-purulent meningitis, and
less so in simple hydrocephalus, brain tumour, and tubercular meningitis.
Lumbar puncture has, however, been an important addition to our
means of diagnosis. Through it we are able to ascertain whether there
is abnormal increase in the spinal fluid. This gives an important
indication in cases of brain tumours and of serous meningitis with
obscure symptoms. In doubtful cases of tubercular meningitis the

Digitized by v^.ooQLe

PATHOLOGY OF INSANITY.

1903 ]

183

detection of tubercle bacilli in the spinal fluid determines the diagnosis
of the disease.

Quinke gives the pressure of the spinal fluid taken lying on the side
as 40—70 mm.; Riecken, 40—60 mm.; Bergmann, 40—130 mm.;
Gumprecht, 40—100 mm. The height notably increased on sitting up.
Any pressure above 150 may be put down as pathological. In acute
serous meningitis and in tumours of the brain a pressure up to 700 has
been noted. With due aseptic precautions the operation of puncture
is quite safe.

Dr. Schaefer made fifty-three punctures in twenty-five cases of general
paralysis, and found an average pressure of 182 mm.; in two thirds of
the cases the pressure was between 250 and 280. In the fourteen
general paralytics in which spinal puncture was practised by Turner,
the pressure lay between 70 and 320 mm., while in fourteen cases of
paralytic women in the supine posture the mean pressure was found by
Nawratski and Arndt to be 113 mm.

Dr. Schaefer considers that the increased amount of fluid in the
brain and spinal cord of general paralytics is owing both to the wasting
of the nervous tissues and to the fluid exuded from the inflamed
membranes. Dr. Schaefer found the rate of pressure to remain high
after repeated punctures. He never allowed fluid to pass to reduce the
height below 40 mm. The pressure in tabes dorsalis was as high as in
general paralysis.

Dr. Schaefer had a bad case of chronic epilepsy. There was stupor
with clonic spasms in some muscles. Assuming that there was pressure
of fluid in the occipital region of the cranium, he tried to relieve it by a
puncture in the spinal region, when the clonic spasms promptly ceased
and the stupor diminished. He found that the pressure in epileptic
dementia was about 180 mm. This was higher than what was observed
by Nawratski and Arndt, who give their mean as between 100 and
150 mm. Schaefer observes that his were cases of long-standing
dementia, in which there was atrophy of the brain and hydrocephalus
tx vacuo; he found that the pressure of the spinal fluid was much
increased by impeded or suppressed respiration. He found that
in fifteen idiots the fluid pressure varied from 130 to 500 mm.
The mean was 220 mm. In twenty imbeciles the pressure ranged
from 65 to 290, the mean being 170 mm. This he considers to be
owing to the transudation of fluid in place of defective development of
the brain, or sometimes owing to the deposit of meningitis. The
quantity of albumen in the spinal fluid of healthy persons is very small.

Nawratski found that in general paralysis the albumen in the spinal
fluid was always increased, the quantity ranging from 0*468 in the
thousand to 1*696, the mean being 0*891 per mille.

Schaefer himself found an increase of albumen in all the cases of
general paralysis ranging between 0*75 and 3*5 per thousand, the mean
being 1*23.

He gives the amount of albumen in the spinal fluid in patients
suffering from various affections, as ascertained by Riecken, to be in—
Meningitis serosa chron. and hydrocephalus . 0*95 per mil.

Meningitis serosa acuta . . . 1 *84 „

Meningitis tuberculosa .... 200*0 „

Tumor cerebri.2*17 „

Digitized by v^.ooQLe

184

EPITOME.

[Jan.,

Schaefer himself found that the mean amount of albumen in the
spinal fluid was—

1. In dementia after apoplexy . . 0*25—0*3 per mil.

2. In secondary dementia . . . 0*3 —0*5 „

3. In congenital weak-mindedness . 0*33—0*5 „

4. In epileptic dementia . . .0*3 —0*5 „

In four cases of this form it was 075—-1*5 per mil.

Dr. Schaefer gives as the general result of his researches that in
general paralysis the pressure of the cerebro-spinal fluid is notably
increased, as also the proportion of albumen, and that in the other
forms of mental impairment the pressure of this fluid is almost always
higher than in the normal condition. William W. Ireland.

6 . Treatment of Insanity.

The Serum Therapeutics of Epilepsy [La sieroterapia dell' epilessia\
(Arch, di jpsichiat., vol. xxiii, fasc. 4, 5, 1902.) Roncororti.

The author criticises adversely the experiments and theories of Dr.
Ceni published in a paper analysed by Dr. Sainsbury in this Journal
(vide page 782), and records a series of observations which he has made
with a view to testing Ceni’s results.

In Ceni’s cases any favourable effects of the serum injections were
evident within the first fortnight of treatment. Roncoroni has there¬
fore assumed that a relatively short period of experiment is sufficient
for decision, and his observations have accordingly been made within
a period of three months.

Serum from one female and five male epileptics was injected at
regular intervals and in increasing doses into eight other patients—six
epileptics, one dement, and one imbecile. No effect whatever was
produced either on the body-weight or on the frequency of the fits.
In further experiments serum from two of the epileptics and from the
two non-epileptics in the above series, taken at the beginning of the
second month of treatment, was similarly injected in progressively
increasing doses into four other epileptics. Here also the results were
entirely negative. In none of the experiments were any toxic effects
noted.

These observations accordingly are in contradiction with Ceni’s
theory of a “ specific stimulating substance ” in the blood-serum in
epilepsy, and also with the hypothesis that the serum in epileptics con¬
tains any substance capable of determining the formation of epileptic
antitoxins. W. C. Sullivan.

Clinical Treatment of Inebriety. (Quarterly Journ. of Inebriety , vol.
xxiv % No. 2, April\ 1902.) Crothers .

In this paper the author has put together some general observations
suggested by his exceptional experience in the treatment of the
inebriate. It is noteworthy that, on the whole, his attitude is dis¬
tinctly optimistic. In the first place he pleads for more discrimination

Digitized by v^.ooQLe

TREATMENT OF INSANITY.

I8 5

*903.]

of cases. He distinguishes three classes of inebriates : (1) paroxysmal
cases, where there are often premonitory symptoms in change of cha¬
racter, morbid impulses, etc., treatment of which may abort the attack;
{2) delusional inebriates with mental exaltation, which may be pro¬
dromal to general paralysis; for such cases rest and change with
eliminative and subsequently tonic treatment are indicated; and (3)
senile and demented cases.

Crothers attaches a high value to treatment by suggestion, but holds
that, at least in its simple form, it is never sufficient alone to effect a
cure. He insists on the need of supplementing it by drugs and physical
methods, having as their end—first, the promotion of elimination by
skin, bowel, and kidneys; and secondly, the re-establishment of nervous
tone. For the latter purpose strychnine is the most useful agent
amongst drugs.

Regarding the home treatment of cases of delirium tremens, the
author advocates the use of massage and hot baths with mild purgation
in the early stages, and is strongly opposed to the exhibition of
narcotics. He adds a word of warning,* by no means superfluous,
against the dangers of over-feeding in the early stages of the attack; at
this time the risk of exhaustion is usually small compared with that of
further poisoning the patient with products of intestinal fermentation.

W. C. Sullivan.

The Suppression of Salts of Chlorine from the Diet in the Treatment
of Epilepsy by Bromides [La dilte hypochlorinie dans le traitement
bromique de Fepilepsie\ {Rev. de Psychiat. y No. 4, April\ 1902.)
Cappelletti and D'Ormea.

The authors give the results of their treatment of epileptics by the
method suggested by Richet and Toulouse, according to whom dimi¬
nution of the excess of chlorides present in the organism favours the
curative action of bromide salts in epilepsy without disturbing appreci¬
ably the normal physiological metabolism. They experimented on
twenty patients, eleven men and nine women, who were taking from
45 to 120 grains of bromide per diem. Chlorine was suppressed from
the diet. They noted the number of crises during the six months
preceding this special treatment, during the forty days of treatment,
and during the two months following. A brief history of each case is
given. No objection to the treatment occurred on the part of the
patients. Their general conclusions may be thus summarised :

(1) The diet suggested by Richet and Toulouse has a marked effect,
and is undoubtedly efficacious, with regard to the number, severity, and
duration of the convulsive seizures; (2) this diet produces no appre¬
ciable harm; (3) the psychical condition is often improved under this
method of treatment; (4) the general nutrition improves in the
majority of cases; (5) the suppression of the treatment by diet does
not do away, at all events for some time, with the improvement
observed, and causes no exacerbation of the convulsive attacks, even
when suddenly effected; (6) the return to a diet including chlorides
does not improve the condition of the general nutrition. The authors
give tables showing the number of attacks during treatment, body-
weights, etc. H. J. Macevoy.

Digitized by v^.ooQLe

186 epitome. [Jan.,

The Bed Treatment of Chronic Insane Patients [Ueber die Bettbe-
kandlung bei chroniscken Psychosen]. {Allgem. Zeits. fur Psychiaf . 9
Band lix , Heft i.) Wurth, A.

The author observes that the treatment of acute cases of insanity by
confinement to bed has made good progress, in spite of criticism,
during the last ten years.

Dr. Wurth determined to try this method upon chronic excited
patients. At the end of the first quarter he had a hundred patients
under treatment. He considers the result encouraging. He found
that out of sixty-three patients so treated, thirty lost weight, twenty-
eight gained, and five remained as they were. He found that excited
patients became quieter under this treatment, and that acts of violence
or the desire to tear and destroy were much lessened, so that restraint,
isolation, or narcotics were not so much called for.

William W. Ireland.

7. Sociology.

Criminal Sociology [La Sociologic criminelle ]. (Bev. de VHyp., May
and June, 1902.) Niceforo .

In this lecture, delivered before the University of Lausanne, the
author defines the issues between the old classic school of penology
and the modern scientific spirit.

It is the eternal opposition of the metaphysical and the positivist
methods. 44 The classic school has created the modern penal codes ; it
has restricted itself to building abstract theories of crime. The
positivist school has created criminal sociology ; it has sought to study
the criminal, the criminal environment, the prison, and, above all, it
has sought for practical methods of prevention.” The classic school,
founded on the doctrine of free will, had taken form before the
positivist method had revolutionised the natural sciences, and in its
subsequent evolution it had remained voluntarily ignorant of the new
conception of crime which has necessarily followed from the progress
of experimental psychology and psychiatry. The modern school, on
the contrary, takes its origin from these sciences; it brings to the
study of the criminal the experimental method ; it sees in crime, as in
every other human act, not the expression of free will, but the resultant
of the organic constitution of the individual and of his social and
physical environment; and, studying that organic constitution, it finds
in the criminal the characters of degeneracy. So envisaged, the scope
of criminal sociology may be outlined as follows :

1. Causes of crime.

Physical causes.—Sociogeography: relations of the criminal to
climate, latitude, altitude, soil, etc.

Individual causes.— (a) Criminal anthropology: study of the cranial,
skeletal, visceral, etc., characters of criminals ; (b) criminal psychology •.
study of the emotions and intelligence in criminals ; the physiological
psychology of the criminal.

Digitized by v^.ooQLe

1903.] SOCIOLOGY. 187

Social causes.—Criminal statistics: study by the statistical method
of the relations between the social milieu and the criminal.

2. Criterion and means of repression.

(a) Criterion and means of repression : study of responsibility, of
the idea of crime, and of penal action.

(b) Means of repression : study of the different systems (elimination
and correction) applied by the law to criminals.

3. Criminal polity.

(a) Preventive : the prophylaxis of crime.

(ib) Repressive: study of the treatment of the criminal in the institu¬
tions to which the repressive law consigns him. W. C. Sullivan.

Criminal Suggestion in a Paretic Alcoholic [Suggestione criminate in
alcoolista paresico\ {Arch, di Psichiat '., vol. xxiii\ fasc. 4, 5, 1902.)
Lombroso.

This is the report of a case of great medico-legal interest.

The body of a murdered man was discovered in a well adjoining a
cabin belonging to two brothers Fissore, and by a complete chain of
circumstantial evidence the crime was brought home beyond doubt to
the elder of the brothers, and a reasonable probability of the other’s
complicity was established. At the trial the elder Fissore, who up to
this had denied the charge, confessed that he was guilty, but asserted
that his brother was innocent, and named as his real accomplices in
the murder two other individuals, alleging further that the crime was
undertaken at the instigation of a prostitute. These persons were
accordingly arrested; the woman and one of the men accused, who had
hitherto had an excellent character, denied absolutely any knowledge of
the affair, but the third prisoner, an individual named Martinengo,
after for a time protesting his innocence, at the fourth examination, after
a month’s detention in prison, admitted that he was guilty, corroborated
Fissore’s evidence, and added details to it. On fuller investigation,
however, it turned out that Fissore’s story was a tissue of lies. A con¬
clusive alibi was proved in regard to the three individuals whom he
accused, and in Martinengo’s case it was further shown that at the time
of the crime of which he acknowledged himself guilty he was actually
laid up with neuritis and an injury to the foot. Eventually any remain¬
ing doubt was cleared up by the confession of the younger Fissore.
The self-accusation of Martinengo was, therefore, clearly the result of
suggestion; the reiterated assertions of Fissore, the questions of the
juge d 1 instruction and of the police, operating on his feeble brain, created
the belief in his own guilt, and this idea he elaborated with that tendency
to pathological lying which is usual in the weak-minded. Martinengo
was, in fact, a chronic alcoholic with symptoms—pupillary inequality,
slow and tremulous speech, modified reflexes, etc.—of organic brain
changes. He was very demented, with a tendency to optimism. His
evidence, though apparently accepted for a time by the judicial autho¬
rities, gave ample proof, in its variations and inconsistencies, of his
morbid mental state.

This curious incident of false testimony as a result of suggestion is
the chief interest of the case; but some other points are also worthy of

Digitized by v^.ooQLe

EPITOME.

I 88

[Jan.,

note. The existence, for instance, of insanity, crime, suicide, and
alcoholism in the family history of the assassins, and the physical and
mental stigmata of degeneracy which these individuals bore, afford a
good example of the pathological basis and affinities of the criminal
character. These points are well brought out in Lombroso’s interesting
analysis of the case. W. C. Sullivan.

The Relation of Alcoholism to Tuberculosis . (Quarterly Journal of

Inebriety , vol. xxiv, No, 2, April , 1902.) Kelynack .

The author shortly reviews the opinions which have been held
regarding the relationship of alcoholism to tubercular disease. There
are three possible views, and each has had its advocates : (1) that
alcoholism is antagonistic to tuberculosis; (2) that alcoholism has no
special relationship to tuberculosis ; (3) that alcoholism definitely pre¬
disposes to tuberculosis. The last view is that which at present tends
to prevail, and the most reliable sort of evidence—that afforded by the
pathological study of a large mass of cases—is strongly in its favour.
For instance, in ten fatal cases of alcoholic polyneuritis the author
found pulmonary tuberculosis in eight. And examination of the records
of the Manchester Royal Infirmary showed evidence of tubercular
disease in 23 per cent, of the fatal cases of common hepatic cirrhosis.

In the authors experience the tubercular processes, as met with in
alcoholics, do not present any special or exceptional features.

The peculiar liability of alcoholics to tubercle is in part to be
ascribed to their impaired vitality, but is even more importantly related
to the unhygienic conditions of public-houses, which in these countries
must be amongst the most dangerous agents for the spread of infection.
A practical corollary to be drawn from these facts is that outdoor
labour and special precautions against tubercular infection are essential
in institutions for the care of the inebriate. W. C. Sullivan.

Superfluous Autopsies \Ueber uberfliissige Sectionen ]. (Arch, fur

Kriminalanthrofologie , Bd, viii.) Kornfeld.

This paper has, at least, the quality of the unusual. It is a protest
from a criminologist of repute against the holding of post-mortem
examinations in cases where the cause of death can be inferred
with reasonable probability from other evidence. The author is
particularly opposed to the provision of the Prussian law which requires
autopsies for legal purposes to be performed by two doctors in the
presence of a magistrate. The grounds of objection appear to be
partly sentimental and partly economical. If such a thing were con¬
ceivable about a German professor, one might suspect a ponderous jeu
ifesprit . W. C. Sullivan.

Digitized by v^.ooQLe

‘ 903 -]

NOTES AND NEWS.

189

Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

The General Meeting was held at the Rooms of the Association, n,Chandos
Street, Cavendish Square, W., on November 20th, 1902, under the presidency of
Dr. J. Wiglesworth.

Present.— A. J. Alliott, W. Lloyd Andriezen, Henry T. S. Aveline, Horatio
Barnett, Fletcher Beach, H. A. Benham, George F. Blandford, Charles H. Bond,
David Bower, A. N. Boycott, A. H. Boys, G. Braine-Hartnell, J. F. Briscoe,
P. E. Campbell, Herbert N. Cappe, James Chambers, J. W. S. Christie, Robert H.
Cole, John B. Cook, Sydney Coupland, Maurice Craig, William Douglas, Charles
C. Easterbrook, F. W. Edridge-Green, Charles Edwards, Francis H. Edwards,
G. Stanley Elliott, James W. Evans, Wm. J. Farquharson, David Ferrier, David
Fleck, Edwin Goodall, Horace E. Haynes, J. Carlyle Johnstone, Robert Jones
(Sec.), Walter S. Kay, Harold A. Kidd, Percival Langdon-Down, Reginald
Langdon-Down, Henry C. MacBryan, P. W. Macdonald, T. W. Macdowell,
S. R. Macphail, H. J. Manning, Charles A. Mercier, William J. Mickle, Alfred
Miller, W. B. Morton, F. W. Mott, James Neil, A. S. Newington, H. Hayes
Newington (Treasurer), Edwin S. Pasmore, Robert N. Paton, Bedford Pierce,
Henry Rayner, J. Peeke Richards, William Roots, Edward H. O. Sankey, W. J.
Seward, James Scott, G. E. Shuttleworth, R. Percy Smith, J. Beveridge Spence,
R. C. Stewart, R. J. Stilwell, F. J. Stuart, D. G. Thomson, Alex. R. Urquhart,
George A. Watson, Lionel A. Weatherly, Ernest W. White, James R. Whitwell,
Joseph Wiglesworth (President), Henry F. Winslow, T. Outterson Wood, David
Yellowlees.

Apologies for non-attendance were received from Drs. James M. Moody, Adam
R. Turnbull, and E. B. Whitcombe.

The following visitors were present: — P. Beecher, Sir William H. Broadbent,
Bart., Thomas Buzzard, Sir William S. Church, Bart., Sir William R. Gowers,
C. Juler, M. Squire, James M. Swainson, Richard D. Sweeting, Jas. Taylor, Sir
John Batty Tuke, M.P., R. J. Wicksteed (Canada).

The following candidates were elected ordinary members:—Collie, Robert John,
M.D., Assistant Medical Officer, School Board for London, 25, Porchester Terrace,
Hyde Park, W. (proposed by S. Rutherford Macphail, R. N. Paton, and Robert
Jones) ; Green, Philip Anthony Mark, M.R.C.S., L.R.C.P., Assistant Medical
Officer, Claybury Asylum, Woodford Bridge, Essex (proposed by F. W. Mott,
J. S. Bolton, and Robert Jones) ; Greene, George Waters, B.A.Cantab., M.R.C.S.,
L.R.C.P., Assistant Medical Officer, Claybury Asylum, Woodford Bridge, Essex
(proposed by F. W. Mott, T. E. Ewart, and Robert Jones).

Sanity and Insanity—Lunacy and Law.

An address on this subject was delivered by Sir William Gowers. This address
is printed in full in the British Medical Journal and the Lancet of November 22nd,
1902. An abstract of it is appended :—

Sir William Gowers, after some introductory remarks, said that the special
subject which he desired to bring before them was the harmful influence of the
present Law of Lunacy in so far as concerned patients taken in private for
treatment. The ostensible object of the law was the personal safety of the subject.
To ensure this it is decreed that all persons of unsound mind shall be treated
alike, certified as insane, deprived of liberty, and placed under the control of the
Commissioners in Lunacy. No distinction is made as to the nature of the case,
the needlessness or harmfulness of the proceeding. Thereby injustice and injury
are done far exceeding that which the law can prevent. One criterion only is
adopted—the technical evidence of mental unsoundness; one condition only deter-

Digitized by v^.ooQLe

190

NOTES AND NEWS.

[Jan.,

mines its application—whether the care of the patient was paid for. The conditions
are the same for the most harmless patient and the most dangerous. Yet any
person, however violent, may remain uncertified in his own house, or under the
care of those on whom he is dependent; but no other person, even a relative, may
take a patient for payment without certification. Besides the many cases of
mental unsoundness for whom the process of certification is needless and some¬
times harmful, there is the large class of border-line cases, patients on the verge
of insanity, some just over it. Many of them may recover, but they may be
actually rendered insane by the process of being declared so, which certification
constitutes. Such cases are very numerous. Three examples were mentioned.
In one, a harmless delusion was the residue of a graver state, but made the
patient technically unsound in mind. The law was broken by a doctor who
received him into his house. In a fortnight the patient was quite well, and he has
continued so now for six months. Had the law been complied with, the distress
would certainly have greatly retarded the improvement, and perhaps would have
prevented it altogether. In another case a harmless delusion prevented a patient
obtaining a much needed change. An aunt who desired to take her could only
do so on payment; she had been a nurse, and knew the law, and dared not run
the risk. In a third case mentioned great strain in private life had recently
brought a single woman to the verge of unsoundness, perhaps over it. She had
an intense dread of going out of her mind. Under the care of a lady, who ran
the risk of prosecution t>y taking her, she steadily improved. To have had her
certified according to the law would probably have made her definitely insane.

It was well to consider what the process of certification is to the patient. The
nearest relation must undergo the pain of signing a request that the patient shall
be “detained and taken care of as a lunatic, idiot, or person of unsound mind.”
The last term is generally chosen, but it is well known to be synonymous with the
first. Then follows an examination by two doctors, separately, who have, with
such tact as they possess, to probe the inner secrets of the mind and find out any
delusion and the degree and character of any depression. Each has to make a
declaration to the effect just mentioned. These documents are presented to a
justice of the peace, who has power personally to examine the patient, happily
not often exerted. Then follows removal to someone’s care, a virtual imprison¬
ment under the Commissioners until they release. The nature of the process
cannot be concealed from many patients, and is most clear to those to whom it
is most harmful. Too many on the brink of insanity are always haunted by the
question “Shall I go mad ? ” To them it sounds the knell of hope, for it gives
the answer “You are mad.” If the present law were strictly carried out, it
wouLd cause a large increase in the number of the insane by destroying the chance
of recovery which is often secured by breaking it.

It is a monstrous thing that the interest of the patient should be absolutely
without influence in deciding whether certification should take place. That it is
needless matters not; that it is harmful matters not. According to the law it
depends solely upon technical evidence of mental unsoundness, upon what is
essentially a legal point.

Why was this regulation made? The great fear was that the sane should
be treated as insane, but this cannot be prevented by compelling all insane persons
to be treated alike. It doubtless arose from a desire to guard against ill-treatment
by placing all insane persons under the supervision of the Commissioners, but
the danger of ill-treatment of those for whom there is payment is small. The
cases of ill-treatment have been chiefly by those on whom the patients were
dependent, and for these the law makes no regulation. Instances of ill-treatment
of the weak-minded by those who received them for payment have been very rare,
and of other forms of insanity almost unknown. A patient can leave or be taken
away at any time. The present law actually does more harm than it prevents,
and if strictly enforced it would do vastly more harm. That which constitutes
the hardship is that it compels the compulsory certification of every case, however
needless it may be, as a condition for the skilled care which can only be obtained
for payment.

All the security the present law can give, and more, would be ensured, and all its
harmful effects would be avoided by a system of notification. Let the law remain as
it is for cases in which certification is necessary in the real interest of the patient;

Digitized by v^.ooQLe

NOTES AND NEWS.

1903 ]

191

but for all cases in which this process seems unnecessary, and especially in early
cases, in which there is so often a prospect of recovery, and all border-line cases,
substitute the following system. Let every one who receives such a case inform
the Commissioners within a certain time. Let them, or some one deputed by
them, visit the patient, and enjoin certification, if necessary in the patient’s
interest. The visit could be repeated, and information should be given when the
patient passed from care. But let the well-being of the patient, and the safety of
others, be the only criteria. For justice’ sake, for right’s sake, abolish once and
for all the artificial standard of technical mental unsoundness as determining
the proceeding. It might involve an increase in the number of the Commissioners,
but this is needed for other reasons. To give a large number of cases their best
chance of recovery, the law must be constantly broken, with grave risk of prosecu¬
tion to those who take charge of such. They feel that a sword is ever above
them, hanging by what seems a thread.

The injustice of the present law is shown conspicuously by some of the prosecu¬
tions for its infraction, for the •' illegal charge of cases ” which the Commissioners
are obliged to undertake. Several examples of these were given from the reports
of the Commissioners. In one, an old lady was bedridden from paralysis of all
her limbs, due to brain disease, which had also caused delusions. She was well
cared for in the house of a doctor. Information was received by the Commissioners,
perhaps from some discharged nurse, and the doctor was prosecuted, convicted,
and fined. The unhappy lady, at the instigation of the Commissioners, was
certified as a lunatic, removed, and placed under other care. Again, a lady in a
nursing home at York had to be certified and moved to an asylum. She had been
in the home for three months in the hope that the treatment there might do good.
In consequence, the lady manager of the home, and the nurse also (though there
was no allegation of ill-treatment), were prosecuted, convicted, and fined. A patient
was received by a lady in an East coast town who, in a few days, wrote to the friends
that the case was too serious for her, but, because a month elapsed before the
patient could be transferred under certificates to an asylum, the lady was prose¬
cuted. The Justices seem to have had no choice but to convict, although their
common sense prevailed, and they only told the lady to come up for judgment
when called on. In other cases of prosecution there was no pretence of need,
so far as the patient was concerned, but a professional opinion of technical mental
unsoundness ensured conviction.

In Scotland the law is far more reasonable and humane ; any patient, either on
the verge of insanity or definitely insane, can be taken uncertified for six months,
“ with a view to recovery,” on a simple medical recommendation. The system
answers well, and prosecutions seem unknown.

How vast is the work of the medical Commissioners the Reports show. They
have their own responsibility for all the insane under their supervision. They are
three, the same in number as when they were first ordained in 1845. The
number of the insane under them is not known before 1859; it was then 36,700.
Now it is 110,700; so it is not likely in 1845 to have exceeded 27,000. There
would be then one medical Commissioner to 9000 cases, and now there is one to
36,000. If the original proportion was right (and more supervision is exacted now
than then), there should, at the present time, be twelve medical Commissioners
instead of three. In Scotland there are now two for 15,800 insane, and the
same proportion would involve fourteen for England and Wales. Doubtless the
work of the three legal Commissioners has correspondingly increased, but it is
less in evidence. Besides the six Commissioners there are five other legal
members of the Board which presides over this vast department of disease.
Surely these are grounds for a thorough examination of the work and organisa¬
tion. Other subjects also press for consideration. The need for hospitals to
receive border-line cases has often been urged, and is unquestionably great. The
time has certainly come when a Royal Commission should investigate both the
work and constitution of the Board of Lunacy, the working of the Lunacy Act,
some remedy for its unjust and harmful effects, and the need for other provisions
than those it affords. The time—twelve years—which has elapsed since that Act
was passed has furnished ample experience of its effect and deficiency. But a
thorough investigation must of necessity take time. Meanwhile should this hard¬
ship be unrelieved ? It is earnestly to be desired that as a temporary measure

Digitized by v^,ooQLe

192

NOTES AND NEWS.

[Jan.,

either the Scottish system should be made legal, or, what would perhaps be’simpler,
the following brief enactment should be passed—so obviously right and just
that it could scarcely meet with opposition,—an enactment that “ the provisions
of the Lunacy Act relating to private patients taken for payment should apply
only to such cases as, in the judgment of the Commissioners, need to be certified
and detained in their own interest or for the safety of others.”

The head of the Board of Lunacy is the first lawyer of the kingdom, and at the
present time he is such not only by position but in reality, and is one who has
also a sense of what is right and just so keen that an adequate appeal to him
cannot be in vain. Vast and multifarious as is his work, so great is the trust in
the Lord Chancellor that the Lunacy Act was passed through both Houses of
Parliament in 1890 without discussion, as Hansard shows. But even the Lord
Chancellor is beneath the law, and grave indeed is the responsibility of the
Legislature. If its members having eyes saw not what was outside their range
of vision, they were free from blame; but if, having ears they now hear not
what is testified by those who see, is not their condemnation written P

Finally, Sir W. Gowers said that he had taken the opportunity of bringing
the subject forward under a compulsory sense of duty. He might fail, and
indeed could succeed only by arousing the efforts of others, but failure could not
be for long; no grave injustice, once perceived, remains long unredressed.

The President. —I am sure that we owe a very special debt of gratitude to Sir
William Gowers for his exceedingly able, exceedingly interesting, and extremely
important address. 1 think it is greatly to our advantage, and I hope I may say
our mutual advantage, that hospital physicians should at times come amongst us
and give us the benefit of their experience on subjects with which we are specially
concerned. The tendency of our speciality is to be too narrow, and anything
which will lift us out of that and give us an interchange of ideas with general
physicians is greatly to be desired. There is no question about the social import¬
ance of this subject, and I hope that the discussion we shall have this afternoon
will not be altogether nugatory, but will lead to some action being taken. 1 must
at once express my personal agreement with a great deal of what Sir William
Gowers has said. I think that there are many cases, not merely border-line cases—
to which I think he did not confine himself—but cases of really definite insanity
which are capable of being certified, and are habitually certified, but in which it is
quite unnecessary to certify, and which might be treated without certification to
the advantage of the individual. Asylum men do not see many of those cases. I
have myself had personal experience of some of them, and I have known persons
definitely certifiable who have been under care without certification, whose sur¬
roundings under private care without being certified were everything that could
be desired ; and yet, the patients being certifiable, it was illegal to detain them
under those surroundings. I will not, however, take up your time by quoting my
own experiences. We are honoured this afternoon by the presence of some very
distinguished physicians, and I am sure we shall be very glad to have the opinions
of those gentlemen upon this question, as hospital physicians see more of these
cases than asylum men do. We shall be very pleased to hear Sir William Church
if he will give us the benefit of his experience on this subject.

Sir William Church. —Mr. President and Gentlemen,—Until I came into this
room I had no idea that I should be called upon by you to speak first on the matter
which we are now going to discuss. It is one of very great importance, but one with
which I cannot claim to have much personal acquaintance. In fact, I came here to
learn rather than to express any opinion of my own. Sir William Gowers, to whom
we are indebted for the very interesting and forcible manner in which he has brought
the subject before us to-day, was kind enough to send me beforehand a copy of most
of that which he has delivered this evening, and since I received it I have endeavoured
to make myself better acquainted with the subject than I was before. I think all of
us who have been in general practice, or who have been in consulting practice as
physicians, have recognised from time to time the great hesitation and difficulty
with which we act in what Sir William Gowers so well calls border-line cases. I
myself have always had a most wholesome dread of being in any way mixed up
with them, and have wished to keep myself as clear as possible of such cases.
But in the course of one’s life one has met with many, and I must say that Sir

Digitized by v^.ooQLe

1903]

NOTES AND NEWS.

193

William Gowers has seemed to me to make a very strong case for our trying to
get some alteration in the existing laws with regard to certification. 1 think the
strongest argument that he brought forward is that in the neighbouring country of
Scotland the law seems to be much more reasonable, and he tells us that the result
is good. That seems to me a very strong argument for our requesting some change
in the certification of lunacy in this country. If the profession in this country
finds that there are, as undoubtedly I take it all who have any knowledge of these
cases admit, great defects in the certification of what are called people of unsound
mind and those on the borderland, and we hear from our professional brethren over
the border, where a six months' grace is given, their difficulties are less, a very
good case for reform is established. By this six months rule—I speak under cor¬
rection—most of those cases which make a good and complete recovery have
recovered before there is compulsory certification ; that is to say, a person who has
not recovered his mental balance in six months is apt, as far as my own ignorance
of the matter goes, not to recover for a long time. Therefore, when we are told
by our professional brethren over the border that these six months of grace act well,
we have very strong grounds for requesting that we shall have the same period of
grace, or that some other means of effecting the same purpose is given us. For it
must be most inadvisable, not to use a stronger term, for us wilfully to infringe the
law. Our profession is one which touches so closely upon the life of the nation that
we ought to be most particular never to go beyond the letter of the law, so that those
who wish to detract from us can never lay a finger upon any spot, however small,
and say, “ There, you are not doing what is right; you have broken the law." And,
therefore, although we cannot but regard—I was going to say with admiration—
those who are willing to run the risk of making themselves martyrs, it is not a
right thing to do; and, although Sir William Gowers and many in this room
probably have done so, I am clearly of opinion that it is wrong for any of our
profession to infringe the law in any way whatever. That seems to me another
very strong argument for asking that the law with regard to certification shall be
modified and amended. Very likely I may be going to tell you what many know
much more about than myself, but since this matter has been brought to my atten-
tion, and since I have felt it my duty to interest myself more or less in the matter,
I have been making some inquiries, and I find that at the present moment the Lord
Chancellor has got a Bill for amending the Lunacy Act in his pocket, and that it is
not owing to any fault or laxity or want of interest in the subject on his part that the
Bill has not become law. (Hear, hear.) He has, I think, twice passed it in the
House of Lords, and the Government have never found time for it to be brought
forward in the Commons. It seems to me, therefore, that now is a most favourable
and advantageous time for the profession to approach him. I daresay some in the
room may know what the contents of his amending Bill to the Lunacy Act of 1890
may be. I do not know that myself, and have not had the opportunity of finding
out, but it does seem to me that now is a very favourable time to approach the Lord
Chancellor and find out whether there is anything in the amending Act pointing in
the direction of Sir William Gowers’ proposal, and if there is not, to bring it to
his notice. And I cannot help thinking, from the very slight knowledge I have of
him, that anything which would appeal, as I think this would, to his common sense,
would be favourably received, and I think he would be willing to introduce it into
the Bill.

Dr. Gborgb Savage. —Mr. President and Gentlemen,—I rather hoped that the
outsiders—if I may use the term—would have spoken before one so intimately
connected with the subject as myself, for I rather hoped that I might have been
placed somewhat in the position of one who was summing up. But as I am called
upon to speak now I would first of all say that this subject has my most sincere
sympathy. I have felt for very many years that some kind of notification is
absolutely necessary, and many of you who are here present will remember that
in a former deputation, which waited upon the Lord Chancellor some five or six
years ago, I was at all events one of the spokesmen ; and I was then impressed by
the fact that the Lord Chancellor was almost converted to the belief that something
in the way of notification, apart from certification, was necessary. Since then, on
one or two occasions it has been my duty to give evidence on behalf of some of those
who have been prosecuted by the Commissioners. On the occasion of the prosecution
of Dr. Broadhurst, who afterwards committed suicide, I maintained that there were

Digitized by v^.ooQLe

*94

NOTES AND NEWS.

[Jan.,

two distinct clauses; that you might certify that a patient was of unsound mind, but
that this did not mean necessarily that he was a right and proper person to be detained.
The legal people on the other side said, “ No; the reading of this certificate is
that every person of unsound mind is a person who ought to be detained as a
lunatic.” It is this chiefly which we wish first to have removed in England, for it is
absurd to suppose that every person who is of unsound mind is necessarily a
person who ought to be detained; because, after all, insanity is a negation; it is a
statement that the person is not sane, and the degrees of that negation vary
immensely. I do feel most certainly that Sir William Gowers’ suggestion would
be for the good of the patient in every way. First I accept the statement that
every patient who is seen by a medical man and recognised by him to be of
unsound mind, and who cannot be properly treated at home, should be notified
as a person so suffering; there would be practically no greater difficulty than
there is in notifying smallpox or measles. It is perfectly certain that if such persons
were notified and information was given as to the places they were going to be sent
to, such places and such people should be visited by some one in authority. That
would be essential; and I believe that, instead of it preventing people being sent to
asylums who were most fit and proper persons for asylums, it would increase the
number of proper asylum patients. What occurs ? Every week of my life a
patient being on the border-line of insanity is sent into a layman’s or a doctor’s house,
and in a week, or a fortnight, or a month, or three months, the patient gets worse.
The doctor or the layman says, “ This patient must now be sent away; I
cannot keep him any longer. But for goodness’ sake don’t have him certified
from my house.” They know that if the patient is certified from the house
there will be an inquiry, which may lead to a prosecution. And yet the
patient when admitted into that house was not a certifiably insane patient,
and the person who is responsible has done the right thing in notifying the
friends that the patient must be removed. But they will do anything rather
than run the risk of prosecution. The friends say, “ No, we are not going to run
the risk. If the patient has to be certified we will see if something else cannot be
done ”—which means that many of these patients are hidden away. Therefore
what is now advocated would be a very great gain. Another thing which is
constantly occurring is this. The patient is sent to a private house. Those of us
who are in consulting practice’and have most to do with insane and nervous people
know that one of the first things the friends say is, “ You understand my relation
is not going to be certified.” You say, “Very well, I quite agree with you at
present, but you must adopt some definite course of treatment.” If Sir William
Gowers’ plan is followed the patient is sent into a nursing home or a medical
man’s home, and if an official goes and says, “This patient must be certified,”
the friends would accept this official statement very much more readily than
they would accept the statement from the general practitioner. In fact,
general practitioners have a very healthy dread of recommending patients to
be certified. Over and over again we hear the same tale, “ I recommended
at your suggestion that Mrs. So-and-So should be certified, and I have never
seen any member of the family since.” If there were an official notifier I believe
that source of trouble would be removed. I do feel that the Commissioners
are doing their very best. (Hear, hear.) I,think one has in the Commis¬
sioners friends, but one feels that they are overweighted ; and one knows that they
even recognise our small peccadillos. When one of the legal Commissioners
asked me if I was breaking the law as frequently as usual, I said “ Yes.” He said
at once, “ We recognise that you consultants do what you believe is best for your
patients, and have to disregard the law.” And so, rather in opposition to Sir
William Church, I would say there are cases where we feel we have to be above
the law. But already I have expressed my feelings very, very strongly. It has
been said that a larger consumption of whisky is justifiable in Scotland than in
England. It does not follow necessarily that everything across the border is the
best for everywhere. But I think the fact that a particular enactment has worked
there successfully should enable us to press forward for an inquiry. I agree with Sir
William Church that it would be just as well to see what the Lord Chancellor has
in his pocket before we urge too much of a campaign. But my feelings, I say, are
that the time has come for some step to be taken in which notification should
replace certification; and I believe that it would be found to answer admirably.

Digitized by v^.ooQLe

1 9°3-]

NOTES AND NEWS.

195

Sir William Broadbent. —Mr. President and Gentlemen,—I am happy
to say that my experience in such matters is extremely small, but that has not
prevented me from forming a judgment upon the very important question which
has been brought before the Society by Sir William Gowers; and I think
he has rendered a very important service to the public in general and to the
medical profession, not only by bringing the subject forward, but by doing so in
such a clear and emphatic manner. He has, I think, struck the true key-note of
what should be the guiding principle of legislation for the insane—that no man
should be certified unless it be either for his own advantage, or in the interests
of the public, or for the safety of the public. When we remember what it is to
be certified—that it is practically a sentence of imprisonment much more severe
than our worst criminals are exposed to—(No, no);—in the mental suffering
involved, which is a very important point—(No, no);—I say in the mental
suffering involved, for those who are unsound in mind are sufficiently appreciative
of the conditions to which they are exposed when they are mixed with lunatics in
general;—I believe it will be seen that their punishment and their sufferings are
worse than those of the habitual criminal when he is sent to prison—(Hear, hear,
and No, no);—not of course from anything which is inflicted upon them in the
asylum, but from the subjective point of view. And when we remember that the
fact of any member of a family being sent to an asylum brings a stigma upon the
individual, and that even if he gets well his self-respect is wounded for ever,
that he can never lift up his head again in society, and that the family is injured
in perpetuity, you will see the force of what I say. This question should be
tested from the view of the public, and you may depend upon it I am stating what
does not go beyond the truth. (Hear, hear). I think we cannot have safeguards
too great against the possibility of anyone being pronounced a fit subject for
detention and sent to an asylum, unless it is necessary in his own interest or for
the safety of the public. For my own part, I had no idea that the law was as
strict as it turns out to be; and unconsciously, in the few cases which have come
before me, I have no doubt been guilty of an infraction of that law; and, in spite
of the authority of the President of the College, I should rather break the law as
far as that lay in me than send a patient to an asylum and say that he needed
detention, unless the conditions of his own advantage or the public safety required
it. Again, I had absolutely no idea that there could go on in England such
prosecutions as seem to be imposed by the Lunacy Commissioners. I had no idea
that they could enter upon a prosecution and not make public the original source
of knowledge. One cannot but be astonished that two systems should have sur¬
vived side by side as that which prevails in Scotland and that which operates in
England, because that in Scotland is very much superior to the law here. One
cannot understand how they could have subsisted side by side. Of course the
question is very greatly complicated, because many of these mild cases of insanity
which do not require to be shut up, many of these border-line cases, many of
these weak-minded cases, do require protection in their own interests, and some
system of notification, or whatever it may be called, which brings them into the
purview of a responsible public authority, which shall prevent them from falling
into the hands of unscrupulous men, who prey upon these weak-minded people
very often; an authority which shall prevent such injury as has happened several
times within my own knowledge—cases of men getting married in the first stage
of general paralysis of the insane;—which would prevent men ruining their
families in the initial extravagance of that and other diseases. The question is an
extremely complicated one, and I think it is most desirable, before any amending
Act is passed, that at any rate the Lord Chancellor and the other responsible
authorities shall in some way have the fullest possible information on all the
complicated questions.which are connected with this subject of dealing with those
who are unsound in mind, and those who are on the border-line of that condition.

Dr. Hayes Newington. — 1 think, Mr. President, I speak the truth when I say
that as regards most of what Sir William Gowers has said he has been preaching
to very willing ears on the subject of an alteration in lunacy law in the direction
he has suggested. And I may say that not only shall we flatter him by following
bis advice, but we have done him the great flattery of to some extent anticipating
it. The Lunacy Bill which the Lord Chancellor had in his pocket contained a
provision that if a medical practitioner certifies that a person is suffering from

Digitized by v^.ooQLe

196

NOTES AND NEWS.

[Jan.,

mental disease—that is not the ordinary terrible certification entailing ** imprison¬
ment/’ but a document a little more advanced than mere notification—and that
the disease is not confirmed, and that it is expedient, with a view to his recovery,
that he be placed under the care of a person whose name and address are stated
on the certificate for the period therein stated (not exceeding six months), then
during that period the provisions of section 315 of the principal Acts shall not
apply. The effect of that is that the specific penalties incurred under the
statute for unlawful reception are removed, as regards such cases, and the common-
law rights mentioned by Sir William Gowers, to receive them, are restored.
But that only covers part of the ground, that referring to incipient and curable
cases only. I may say that that provision was inserted in this Bill, and
accepted by the Lord Chancellor on the representation of a joint committee of this
Association and the Parliamentary Committee of the British Medical Association.
And we are encouraged so far by the elasticity of the legal mind to hope that we
may some time go further. In fact, quite recently—that is, within the last two
years—we have addressed the Lord Chancellor on the point, and this is the text
of our last communication to him :—“ It is also suggested that section 315 of the
principal Act shall be amended so that penalties should only apply to a person
who regularly receives and detains a patient. It occurs sometimes that a person,
being of unsound mind, is not sufficiently deranged to justify giving a medical
certificate,which requires on the part of the certifier a definite opinion that deten¬
tion under care and treatment is necessary. Such a person may have neither a
home nor immediate relatives to receive him, and anyone receiving him to board
and lodge would be exposed to prosecution (unless no charge were made), however
willing the patient might be to reside.” That is our recommendation. Whether
we shall get it accepted or not is a matter of uncertainty; but it goes as far and
possibly further than what Sir William Gowers desires. The Act imposes
penalties on every person who receives or detains. We propose that the “or”
shall be made into 11 and; ” and the only question which would forbid reception
would be necessity for detention. I think common sense, and certainly our
experience, would say this: that if a person is so ill as to be detained against his
will, then the law should step in with a considerable amount of formality. Of
course it would be idle to suppose that the law would allow anybody to receive a
person, even if he did not require detention, unless there was some provision for giving
information to the authorities and for visitation, both of which are recommended
by Sir William Gowers. He goes for notification alone; but I do not think it
would be possible to stop there. To begin with, mere notification that So-and-So
has come to live with the person would be of no avail to the Commissioners.
They would probably say, “ What has this to do w ith us ?” It would be necessary
that the notification should contain some facts, and then the notification would
contain at least the germ of a certificate. There is another very strong reason
why one would say we must have a definite certification. It would be all very well
if the matter were in the hands of gentlemen in the eminent position of Sir William
Gowers and others, but it would not be right to place such a power in the hands
of everybody, so that they could take patients and board them without some little
supervision. (Hear, hear.) And it would further be right to have a certificate,
because we must remember that persons needing such treatment are frequently
unstable; they may change their opinions as to wishing to reside, and may turn
round at any moment on their former hosts, and allege all sorts of things against
them. The person who receives on the request of the medical man ought for his
protection to have the certificate to the effect not only that that patient was suffer¬
ing to some extent under mental disease, but that the person should not be
detained. That is most important, and I think notification, or whatever you call
it, should express an opinion against the necessity for detention. It has been said by
Sir William Gowers, and I think by others also—and to ’some extent rightly—
that this might increase the work of the Commissioners indefinitely. I am now
speaking entirely on my own responsibility, and I do not think that that follows.
The Act of 1890 produced, or started, a large machinery in regard to private cases
in the shape of justices specially appointed for the purposes of the Act, who might
be made use of for this purpose also. The most important part of the lunacy law
is now administered on an order of a Justice of the Peace, who has to take a very
serious responsibility. But in the question of the visitation of these borderland

Digitized by v^.ooQLe

I903-]

NOTES AND NEWS.

197

cases, if the real test was simply one of detention, no such responsibility would rest
upon him; he would have to judge of one simple matter, on lines perfectly
familiar to him when sitting on the bench. He would merely have to satisfy
himself that the person was not detained against his will; and I should take it
that visitation by a Justice who, as a rule, is not very easily convinced, would be
an ample safeguard under such circumstances, because, if he felt the least doubt,
he would report to the Commissioners. I do not altogether like to hear the
law called harsh or unjust, and in regard to this lunacy law 1 do not think
it is quite proper. We must remember that the lunacy law, as it at present
exists, was designed originally to overcome a very serious evil. One hundred
years ago there was no lunacy law to speak of; one hundred years ago
there was a terrible state of affairs, arising not merely from the brutality and greed
of individuals, but from entire absence of healthy public opinion in regard to
lunacy. I think I may say that at that time the highest in the land, when they
became insane, were treated in a way that would certainly entail prosecution now*
a-days, and that was then considered the right way to treat insanity. Then public
opinion became aroused, and the law has been altered in obedience to public
opinion up to the Act of 1890. And perhaps you will allow me to offer a little
correction of what Sir William Gowers said. The Act of 1890 was a mere Consoli¬
dating Act, and required very little attention at the hands of Parliament. But the
Act which was passed the year before, and which was at once repealed by the Con¬
solidating Act, was passed after much debate for five or six years'. This I am certain
of from personal watching during these years. It was debated up hill and down hill:
This Act having now been in operation several years, I think we can go to
the law and say, “You have done your work well; so well that you have
abolished malpraxis.” And we can almost go as far as saying, “You have not
only done that, but you have satisfied public opinion that there is not much wrong.”
Cases arise new and again, chiefly outside asylums, which arouse public attention,
but these, if pi oved, depend more on personal infraction of the law rather than on
failure of the L«w; and we may say that, outside the jealousy with which everybody
must look to the treatment of insanity—a very right jealousy which must always
exist—the public are to a great extent satisfied as to the sufficiency of the law.
I think further that we can say to the law, “You have succeeded; and now that
you have succeeded so well, you can well afford to relax your strictness.” In this
particular matter I think strictness might well be relaxed, and I should hope that
with our own action, backed up, as it is, by the help of such important members of
the medical world, we may succeed in persuading the Lord Chancellor to adopt our
views on the point.

Dr. YEi.LOWLr.fi >.—Mr. President and Gentlemen, I had no idea until I listened
to Sir William Gowers’ paper that matters were so bad in England in this
respect as they are; and I share the surprise expressed by Sir William Broad-
bent that this state of matters should have existed so long after the very different
system which obtains in that remote and unknown country called Scotland. I am
free to say that for the last fifteen or twenty years this whole matter has been
solved there in the most satisfactory way, and with great benefit alike to the
patients and to the profession. 1 think no one in Scotland believes that a person
of unsound mind necessarily requires treatment in an asylum ; there are two classes
of insane persons, those who require asylum care and treatment, and those who do
not. These are entirely different categories of patients, and our Legislature in
Scotland has dealt with them quite differently. Of the first class, those who require
asylum treatment, I need not speak, as they have not been the subject of to-day’s
paper. But as to the other class, the Legislature has distinctly recognised that
they also need care, and has recognised it in two ways. The first method is that
of the six months’ certificate, which Sir William Gowers has wisely declared to be
of the greatest benefit. That it is so I can personally and emphatically testify.
The certificate that is given is not only a certificate of illness, but it testifies that
the patient does not require asylum care and treatment. The mental illness is
treated as any bodily illness might be, by placing the patient, under his ordinary
physician, in the circumstances most favourable for recovery, and during six months
that course can be followed without let or hindrance from anyone. The certificate
is given simply for the protection of the person who receives the patient, so that it
might be produced in the event of anyone objecting to the patient residing there.
XLIX. 13

Digitized by v^.ooQLe

198

NOTES AND NEWS.

[Jan.,

But—and this has not been spoken of, though it is most important in view of what
the paper has touched upon—there is a further and most important provision for
another class of cases altogether. The six months’ certificate refers only to
incipient cases. But there is a large class of confirmed cases, who, while still
mentally unsound, do not require care and treatment in an asylum, and for that
class also we have ample and wise provision. We have many houses in Scotland
recognised and licensed by the Commissioners in Lunacy as suitable places in
which such patients can be boarded; the certificate given for such cases testifies
that the patient, although of unsound mind, is not dangerous to himself or others,
and does not require treatment in an asylum. On receiving such a certificate the
Lunacy Commissioners grant their sanction to the residence of the patient in the
particular house selected, and the patient may remain there for years and years,
subject only to a visit every three months from his own medical attendant or from
the local practitioner, who must report in a book kept in the house for this purpose
as to the condition and care of the patient and the suitableness of his surroundings;
and subject also to visitation and inspection at any time by the Commissioners or
by their deputies, to whom the visitation book must be submitted. This arrange¬
ment secures, I believe, perfectly sufficient and satisfactory care for such cases.
And there has never been, during all my experience, any difficulty in Scotland
either as regards the care of the incipient cases during the six months, or the care
of those harmless chronic cases boarded out in these private houses. It seems to
me that this, as I have described it, meets completely all the necessities of the
case, and the sooner you have it in England the better. I may add that it was at
the instigation and with the cordial approval of our Scottish Commissioners that
these provisions were made, and I do not understand why the English Commis¬
sioners do not themselves take an active part in introducing them here.

Sir John Batty Tukk. —Mr. President and Gentlemen, My friend Dr.
Yellowlees has so completely taken the wind out of my sails by the admirable
statement of our Scottish law which he has made that I feel I have very little to say.
He stated the case exactly. The patient under the six months’ certificate is never
certified to be insane; his name is never recorded in the books of the General
Board, and he is entirely under the care, as he ought to be, of his own family
medical attendant. The whole responsibility in the matter is thrown upon him.
The certificate only protects the householder who received the patient. Now, this
has worked with us admirably, and I think I am not very far from the mark when
I say that about one half of all patients coming from the monied classes—well-to-do
classes—are treated in that way. The consequence is, I believe, that we have only
a very small increase, if any, in the number of private cases in asylums, from the
simple fact that a large proportion of incipient and mild cases are cured by treat¬
ment at home and under the six months’ certificate, and, of course, never bear
after recovery anything like what is generally considered the stigma of lunacy.
But, sir, it must be recollected that we live under very different conditions in Scotland
to those under which you live here in England. Scotland is a small country, and
everybody knows everybody else, and we have—and I hope in saying so I shall not
be hurting the feelings of any person here—an efficient Board of Lunacy. The
public requires the assurance of an efficient Board of Lunacy to carry out such a
scheme as the one we are considering. For about io.ooo patients we have four
Commissioners in Lunacy,—that is to say, two Commissioners and two deputy
Commissioners. In England you have three medical Commissioners for something
over 100,000 patients. How can there be any elasticity in a system in which the
men who work out the law are obliged to work without anything like elasticity r
It is impossible. I think I express the feeling of the public in Scotland when I say
that there exists north of the Tweed a sense of perfect security and safety, and as
high a feeling amongst the public for lunatic hospitals as there is for medical
hospitals and infirmaries. (Hear, hear.) To bring about the same state of matters
in England you require that country to be broken up into six or eight districts,
with resident Commissioners in each. Such officers working in a limited area could,
like the Scottish Commissioners, be in close touch with all the neighbouring
hospitals for the insane, and, in fact, know each patient by headmark. Sir
William Church said he did not exactly understand why there should be a
difference of law in England and in Scotland. The main reason is that the English
law arose out of a series of what may be spoken of as regrettable incidents which

Digitized by v^,ooQLe

NOTES AND NEWS.

199

1903]

occurred a hundred years ago. Our Scottish law had a different origin. It arose
not from asylum scandals, but from the bad provision for a certain number of
pauper patients in pauper private asylums. We had been blessed for one hundred
years with those noble institutions the Royal Asylums of Scotland, which provided
for a large number of the insane. But it was discovered that a certain number of
pauper lunatics were very badly provided for, and a law was made with regard to
them, and district asylums were established. Thus the origin of the lunacy laws in
the two countries was entirely different. One was merely to improve the condition
of the insane, the other was conceived in a spirit of suspicion ; and I think if we
look upon the law under which you now work we shall find that that suspicion is not
dissipated. I fear that you in England will have some considerable difficulty in
getting a provision such as we have in Scotland until that suspicion is removed,
especially from the legal mind, and until you have convinced the law officers of
the Crown that they have to depend much more on the good faith and the honour
of those honourable and upright practitioners of medicine who administer the law
in asylums than on any provision that can be enacted by the law itself. I think,
sir, it would be opportune at the present moment to make a very strong representa¬
tion from this Association on the matter, backed up by the leaders of the profession
throughout England. And I can only say, if in my own small way I can be of any
service to you in promoting that object, I shall be only too happy to do so. (Loud
applause.)

Dr. David Ferrier. —Sir, I am very unwilling to take up the time of the
meeting unnecessarily, as I think we are all pretty much agreed on the main
points. But I should like to say, as a physician and neurologist, that I am in
thorough agreement with all that Sir William Gowers has said on this subject. I
am convinced that the law as it at present stands is exceedingly harsh and cruel ;
and, at the risk of incurring the censure of my president and of my official self, as
censor, I confess I feel justified, in the best interests of my patients, in frequently
transgressing the law, or aiding and abetting in the transgression of it. In the
class of cases which Sir William Gowers has alluded to it is exceedingly cruel to
stigmatise the patient by certifying him as insane, for though it ought not to be
so, it is unquestionably commonly regarded as a stigma, and we ought to prevent
that to the best of our ability. If we could get the English law assimilated to
that of Scotland, or even if the law could be modified by the insertion of the
clause Dr. Hayes Newington has alluded to, I think the main defects would be
removed. Therefore I hope this Society and all who are interested in this matter
will urge the Government to pass the new Act as soon as possible.

Dr. Blandford. —I have very little to add to what has been said already. I
agree with all Sir William Gowers has said on the subject. I only wish to remind
you and all the gentlemen who are here that this subject has been before our Asso¬
ciation for a considerable number of years. I have attended a great many meetings
on the subject, meetings of our own Parliamentary Committee and the Parliamentary
Committee of the British Medical Association. We have at those meetings
thrashed this subject out at very considerable length, and we went to the Lord
Chancellor and recommended to him that provision which they have in Scotland,
and we carried him and his opinion with us to the extent that the clause which we
drafted, based upon the Scottish law, he introduced into his Bill without any altera¬
tion whatsoever. (Hear, hear.) That Bill was brought in, I think, for the first
time in the year 1899, an ^ passed the House of Lords. It was brought in again in
the next year, and, I think, passed the House of Lords, but it went to the
Commons, and there it stopped. And that is our difficulty, gentlemen. You
know it is all very well to come here and talk about alterations in the law, but
you have to get those alterations made. The Lords have plenty of time, and they
go into the matter and send a Bill to the House of Commons; but the Commons
have got an Education Bill, or something of that kind on hand, and the Bill goes
down to the end of the Session, and then gets swamped. I have no doubt that
when we have this next Bill we shall have a somewhat similar clause inserted, and
what we really have to do is to get that Bill made an Act. We cannot pass Acts
-of Parliament ourselves, however desirable we may think them. To get an Act
of that kind passed through the House of Commons is an extremely difficult
matter. I daresay some of you may remember how that Bill which was passed
in 1889, and was eventually consolidated in 1890, took years to go through the

Digitized by t^.ooQLe

200

NOTES AND NEWS.

[Jan.,

House of Commons. It was referred to the Committee of Law, and I there heard
it discussed at very great length, and it did eventually become law; but, as I say,
it took years to accomplish it. All I can say in conclusion is that I beg of you to
do your utmost among the members of Parliament with whom you may be
acquainted to get such a clause as this passed in an Act of Parliament during the
next session.

Dr. Rayner. —Sir, I wish to thank Sir William Gowers for having brought for¬
ward this subject so admirably. It is a matter in which I have been interested for
some years, having read a paper on the same lines at Carlisle in 1896, when a
resolution was passed which led to the formation of a joint committee of the
British Medical and Medico-Psychological Associations, with the result that a
clause founded on the Scottish clause, but adding notification to the Commissioners,
was submitted to the Lord Chancellor, who adopted it in his Bill. The clause
which the Lord Chancellor has adopted veiy fairly meets the case; but we have
also to consider another side of the question, and that is, to try and get properly
qualified and experienced people to take charge of the patient. Considerable
dangers and difficulties may arise from unskilful treatment if large numbers of the
incipient insane are treated under this proposed clause. At present, however, we
might try to get this greater freedom of treatment. When we have obtained it we
can consider what regulations are required for getting the right kind of people to
take charge of these cases in suitable houses. At the present time one comes
across cases which have been placed under quite the wrong kind of person, and
with quite unsuitable house accommodation.

Dr. Mercier. —Sir, Sir William Broadbent and Dr. Yellowlees have expressed
surprise that the law of England could be so different, with respect to the detention
of persons of unsound mind, from the law of Scotland. This law cannot be properly
understood unless we have some regard to its history. The intense prejudice against
asylums, the stigma of insanity, as it is called, was due entirely to that obstructive
Scotchman Lord Eldon, that luminary of the law who for many years obstructed
every reform. The law, previous to the Act of 1889, was exceedingly satisfactory;
it worked from the year 1845 *° 1884 with perfect satisfaction to all concerned. (Dr.
Blandford: Hear, hear.) But in 1884 there occurred a cause ciUbre to which I will
direct your attention. A certain lady—a very attractive lady, a very clever lady,
and a somewhat eccentric lady (Mrs. Weldon)—was considered by her friends
to be a proper person to be detained under care and treatment; and they applied
to Dr. Winslow to aid them in this respect. He made the attempt, and the attempt
failed. It failed disastrously and ignominiously, and Mrs. Weldon remained
mistress of the situation. She brought actions in the Court of King's Bench
against Dr. Winslow, against Dr. Semple, against Sir Henry de Bathe, and she
was awarded ^500 damages against Dr. Winslow, jfiooo against Dr. Semple, and,
I think, another jfiooo against Sir Hemy de Bathe. Well, the public clamoured for
an alteration in the law. They said that the law was not strong enough ; that any¬
body might be seized and taken to an asylum under the law as it existed. They
seemed to imagine that asylums sent out pressgangs in order to knock people down
in the streets and carry them off to asylums. A more illogical outcry it would
be impossible to conceive. Mrs. Weldon was not detained for a single hour.
The attempt to place her under detention absolutely failed, and for that attempt
the persons who made the attempt were practically ruined. It was as if John Bull
had possessed a safe, in which he locked up that inestimable jewel or fetish of his,
“ the liberty of the subject,’’ and it was as if burglars had made an attempt to open
the safe, with the.consequence that the jewel or fetish remained perfectly secure,
but that the burglars had ^2500 taken out of their pockets and transferred to the
pockets of the custodian of the safe. Most people would have considered that an
instrument like that was worth preserving, that such an apparatus was good
enough. Not so John Bull; he was in a panic, and when he is in a panic it is no
use appealing to such reason as he possesses. And the clamour for an alteration
in the law was so loud and persistent that the Government of the day had to yield.
Well, the consequence of that was that we had the law as it at present exists.
It was as if John Bull said, “ This safe of mine is not good enough ; I must have
a new safe, with a gun attachment to it, so that if a burglar makes an attempt
upon it it will shoot him." And he went to the Legislature, and he got his new
safe made with its gun attachment. And John Bull has gone to sleep, and the

Digitized by v^.ooQLe

NOTES AND NEWS.

201

1903 .]

gun is going off and maiming and mutilating innocent passers-by. But John
Bull does not care about that. The picture would not be complete unless we
remember that this safe has no back to it, and that anybody can go round to
the back and take out that fetish and pound it up; and John Bull will look on
approvingly and shout, 44 Well done 1 ” Anybody who remembers the case of
Mrs. Cartwright, which was tried a few months ago before the House of Lords,
will understand what I mean. In regard to the existence of the evil, I should be
in agreement with Sir William Gowers and others who have spoken; but in
regard to the mode of remedying it I should not be in agreement with him. I
am no advocate for resorting to the Legislature for remedying grievances.
In my own opinion—in which I fear that, as usual, I am in a minority of one—
the proper function of the Legislature is to supervise and control the expenditure
of the country, and when it exceeds its proper function and embarks upon legisla¬
tion it usually does mischief. Every mechanic knows that if a defect exists in a
machine, and you attempt to remove that defect by some alteration ad hoc t you
usually, if you remedy that defect, introduce half a dozen others which you did
not expect. It is so with the Legislature. If it attempts to remedy grievances
by legislation ad hoc it generally, as in this case, introduces other evils which it
neither foresaw nor expected. I think in this case, as in other cases, we should
not appeal to the Legislature to help us until we have done what we can to help
ourselves. I do not see that it is necessary to have an Act of Parliament to
insert that word 44 not,” which Sir William Gowers speaks of, in the certificates. I
submit it is open to us all, when we give a certificate, to say that the patient is of
unsound mind and is not a proper person to be detained under care and treatment.
It is true that Sir William Gowers regards 44 the second part of that clause as
essentially connected with the first,” and it is true, moreover, that Dr. Savage
has told us that the legal authorities who advise the Commissioners have the same
opinion. I do not give my own opinion upon a legal point; that would be worthless,
but, in venturing to question the validity of these dicta, I am not without authority
for what I say. In one of the numerous trials of Weldon against Winslow, Mr.
Justice Manisty, sitting with Mr. Justice Watkin Williams, in a Divisional Court,
made remarks as follows :—He read the statutory documents which were produced,
and in the statement of particulars he read, “‘Whether dangerous;—doubtful.’
That,” he said, 44 is the whole question. Everything depended upon that. For,”
he said, 44 it is not every harmless eccentricity or delusion which renders it
necessary to place a person in confinement; it is not even every delusion
which incapacitates from making a will or contract. The statute required
a certificate not only that the party was unsound in his mind, but in a state
which required detention; ” and therefore the Court set aside the non-suit,
and ordered a new trial. And upon that the judgment in the Court below was
upset. It was taken to the Court of Appeal, and that judgment was confirmed by
the Court of Appeal, by three very strong judges, the then Master of the Rolls
and Lords Justices Bowen and Fry. And therefore I say there is considerable
authority for my view that those two clauses in that sentence are to be regarded
as separate; and that it is open to us to give a certificate that a person is of
unsound mind but is not a fit person to be detained under care and treatment.
And, armed with such a certificate as that, I maintain that the person who for
payment receives the patient need not fear prosecution, for already magistrates
and juries are by no means eager to convict. On the contrary, even where the
law has been flagrantly violated, H is not at all easy to obtain a conviction. And,
armed with such a document as that, I say no conviction could be secured, and no
prosecution would be undertaken. We should then be able to address the Legis¬
lature as Dr. Johnson addressed Lord Chesterfield; we could say, 44 1 hope it is no
very cynical asperity to confess to no obligation where no benefit has been
received, nor to be unwilling that the public should ascribe that to a patron which
Providence has enabled me to do for myself.” With regard to the peculiar
phrase which our Scottish friends are unable to understand, the phrase in the Act—
44 lunatic or alleged lunatic ”—perhaps I may relate a little incident which occurred
last night to show what a very peculiar condition this law is in. It happened
yesterday evening that I was in the H6tel M^tropole with my good friends Dr.
Urquhart and Dr. Carlyle Johnstone. And it happened, in some extraordinary and
unaccountable and unprecedented manner, that a difference of opinion arose

Digitized by v^.ooQLe

202

NOTES AND NEWS.

[Jan.,

between Dr. Carlyle Johnstone and myself. Well, Dr. Urquhart intervened in the
discussion. Evidently Dr. Urquhart saw that I was right; but we know Dr.
Urquhart’s tender heart, and his patriotism and loyalty, and that he is not the
man to see a fellow-countryman getting the worst of it without intervening on his
behalf. And Dr. Urquhart used a phrase which I have no doubt he has since
regretted, and the effect of which I have no doubt he did not appreciate at the
time. But the spoken word cannot be recalled. He spoke to me in these terms—
“Why, Mercier, you are getting demented.” Now, if the terms of the Act are
to be severely construed in their literal sense, Dr. Urquhart has rendered the
directors of the Gordon Hotels Company, Limited, and I do not know whether he
has not rendered the whole of the shareholders also, liable to prosecution, for
they were for payment receiving, to board and lodge, an “alleged lunatic.”

Dr. Ernest White. —Mr. President and Gentlemen, You have already heard
so much on the subject before us this afternoon that I will not detain you long.
But you know I am connected with an institution which receives now over one
hundred private patients annually, and of these no small number come from single
care. Dr. Rayner touched the chord which appealed to me, and that is, that
those having charge of these people must be suitable and skilled, and trained in
the care and treatment of the insane; otherwise the patients under single cqre go
there merely to be housed, and to drift into chronic insanity. We know all our
patients in rate-paid and private institutions are thoroughly well fed and clothed,
but it is the influence of skilled people which is to counteract moral obliquity
amongst the insane, even in the earliest stage of their disease. I refer to those bad
habits which are, unfortunately, very marked amongst the more civilised and
highly-educated classes of the community, far more than I ever found them in the
old days amongst agricultural labourers and the industrial classes. You must
bear carefully in mind that the nurses having charge of these people should be
thoroughly trained in mental work, and should be the proper people to take charge
of patients, not merely with regard to their care, but having in view their recovery
also. The medical men who are in attendance on these patients must be thoroughly
trained in the treatment of mental disease. Otherwise your patient is merely put
under care, and the very object you have in view—recovery—is lost. The chief
advantages of single care, I presume, are to preserve secrecy and to give greater
domesticity to your patient. I know of no other advantages. There are many
disadvantages, for there is the monotony of the life, the being under the charge of a
lady who knows nothing of the care of the insane. There is the want of the com¬
plete school discipline, as I would call that discipline which brings your patient
into line with natural life, where the day is apportioned out—so much for pleasure
and recreation, so much for work or occupation, and so much for meals—so that
the patient is taken out of himself or herself. And all that is most important in
single care, as in institution life. It is the very essence of our success in many
cases. There must be the school discipline to correct the moral obliquity and bad
habits which are so common. Self-abuse amongst the educated classes of the
insane community is very common, far more so than amongst the lower classes.
I have been very much struck during the last ten years with the enormous differ¬
ence in the proportion of immoral habits among private insane patients compared
with the pauper or rate-paid patients, with whose habits I have for many years past
been so thoroughly conversant.

Dr. Urquhart. —May I say a word upon this question ? I would merely
declare that, as far as this Association is concerned, our withers are unwrung. We
have listened to Sir William Gowers with due attention, but he must remember
that we have for long called upon the general physicians of the country to come
and aid us in this matter. (Hear, hear.) As you have been reminded, in this
Association and in the British Medical Association we have been no laggards in
trying to induce the Legislature to give facilities for the adequate treatment of
incipient insanity in private care. And I would emphasise what Dr. White has
said, that if we indicate private care we mean medical treatment, active treatment
by a medical man in a medical spirit. It is absolutely useless to us to have our
patients stowed away in back parlours and left there to rot mentally. (Applause.)
For myself, I represent an institution which, fortunately, has at command every
kind of house suitable for the medical care of the insane, and therefore I am in a
position to place patients either in separate care or in institutional care, according

Digitized by ^.ooQle

1903]

NOTES AND NEWS.

203

to the state of mind in which they are. I am not restricted by licence. If I find
that a patient is better placed in a separate house, if I am assured that the morbid
introspection which private care so often engenders will not be encouraged, I may
so place him with one or two skilled nurses. But, remember, that is an expensive
affair. It is only comparatively few persons, in Scotland at any rate, who can
afford eight or ten guineas a week to be so treated adequately, and command that
attention and nursing and medical skill that is essential for one who is on the verge
of declared insanity. I lately treated a patient in one of our detached houses. She
declared, “ I shall never be well until you take me into the asylum.” She went from
bad to worse until she had to be brought into the asylum, where she rapidly re¬
covered. This was done at the expense of the “ stigma ” of the lunatic asylum.
We hear a great deal too much about stigmata, and one becomes rather impatient
of the iteration. Another case : We received from a doctor’s house in the West
End of London a young gentleman, who had been condemned to a back parlour
existence for months, with the result that he, too, veiy soon recovered. Being
brought face to face with the facts of life, and being told that he was insane, and
that he must be properly treated, in his own interests, we have had the satisfaction of
knowing that he in due time passed well into Sandhurst, and that he has been
serving his country ever since. These are facts, illustrating the other side of the
case, which might easily be multiplied by every one here, and which we cannot
forget. We should deal with these cases in hospitals for the insane, discriminating
between the patients suitable for asylum or for private treatment in the first
instance, but always from the point of view of the physician, doing what is best for
the person in the particular circumstances in which he is found. That is our test,
and if we have, in the past, given our authority and our influence to enlarge the
sphere of private care in England, it is with the proviso that private care shall only
be employed when it is the right and adequate course for the patient. It is the
individual patient we have to do with ; every other question is subsidiary to that.

Dr. Robert Jones. —I rise to say a few words of thanks, and to express, as an
official of this Society, how much indebted I am personally to Sir William Gowers
for his paper. Anything Sir William Gowers says exacts attention. He is the
possessor of a style which we all admire, and he has attacked this question with
great point and frankness. He has refused to bend the knee to a law which is
unjust, and I feel sure that the Lunacy Commissioners will help us if necessary to
have this pressing question fully considered.

The President. —Before asking for a reply, I should like to congratulate the
Association upon the exceedingly important discussion which has taken place,
and it would be a great pity if it were allowed to remain without action being
taken. (Hear, hear.) We are not in a position to pass any definite resolution;
there is nothing to that effect on the agenda, and therefore we cannot pass a
resolution making a definite recommendation. But I propose that the matter be
referred to the Parliamentary Committee, for them to consider it and take any
action which may be thought fit. (Applause.) If that meets with your approval
we will take that course.—Agreed.

Sir William Gowrrs. — I have only to express my keen sense of the manner
in which my effort has been received. There is little in what has been said which
calls even for a semblance of a reply. I think I might make a trifling correction
of Dr. Hayes Newington by saying that he may search the pages of Hansard ,
not only in 1890, but in 1889 also, without finding anything like a semblance of
real discussion; for I have been through every volume of Hansard for 1889.
There was a little discussion in 1888, but not in 1889. With regard to the
remarks of Dr. Mercier, it is rather curious that I struck out of my address the
I'emark that I should very much like to know what would be the effect of sending
a certificate with the word “ not ” inserted, to the Commissioners, but that I
apprehended the result might be a visit of a superintendent of police. I am sorry
if I have not done justice in this address to previous efforts of the Society. I
knew a good deal about them, but I thought that more effect might be produced
by a somewhat fresh impetus, and if I am successful in exciting the efforts of
others, and I hope I may be, I shall feel amply rewarded.

The remainder of the agenda was, by consent, postponed.

The members afterwards dined together at the Cafe Royal, Regent Street, W.

Digitized by

Google

204

NOTES AND NEWS.

[Jan.,

Council Meeting.

The Council met on the same day, and the following members were present:—
Dr. Wiglesworth (President), Drs. Yellowlees, A. R. Urquhart, H. Hayes Newing¬
ton, A. Miller, P. W. MacDonald, R. L. Rutherford, Maurice Craig, A. N.
Boycott, G. Braine-Hartnell, J. B. Spence, H. A. Kidd, R. C. Stewart, C. H.
Bond, L. A. Weatherly, H. Rayner, and Robert Jones.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting was held at the Cleveland Asylum, Middlesbrough, on
October 8th.

Members present:—Drs. H. G. D. Brockman, J. T. Callcott, J. Tregelles
Hingston, C. K. Hitchcock, H. W. Kershaw, S. W. Me Do wall, Alfred Miller,
James Middlemass, Bedford Pierce, G. Stevens Pope, J. B. Tighe, E. A. Trevelyan,
H. J. Mackenzie. Visitors:—Drs. J. Hedley, J.P., Francis Townsend, and
Samuel Walker, J.P.

Dr. G. Stevens Pope having been voted to the chair, the minutes of the
previous meeting were read and adopted. The amended rules were considered,
especially those more immediately concerning the divisions of the Association;
the following alterations were unanimously adopted, and the Hon. Secretary was
requested to forward a copy of these to the General Secretary to lay before the
Revision Committee; he was also requested to forward a copy to the various
divisional secretaries.

Rule 28.—In place of second paragraph, “ Each division shall nominate annually
to the Council, after taking a vote of the division, a member to act as secretary to
the division, also one member as their representative on the Council. Such
nomination to be received by the Council and presented to the Annual Meeting.”

Rule 34.—To strike out “ and two Auditors.”

Rule 35.—To add after the word “Committee,” “and the Divisional Secre¬
taries.”

Rule 4 6 .—To replace “ by the Auditors,” by “ by two Auditors elected by the
Council from their number.”

Rule 51.—To add as fresh paragraphs between present paragraphs “ c ” and
“ d,” “ the names of the Secretary and of the Member of the Division nomi¬
nated for the Council.”

An invitation from Dr. Menzies to hold the next meeting at Cheddleton was
unanimously accepted.

Dr. Bedford Pierce read a paper entitled “The Arrangements for Nursing in
Institutions for the Insane, and the Training of the Staff” (see page 37).

Dr. Pope showed plans of the asylum new buildings.

The members were entertained at luncheon and dinner by Dr. Pope. A hearty
vote of thanks was accorded him for his hospitality and for his conduct in the
chair.

SOUTH-WESTERN DIVISION.

The Autumn Meeting was held at the Devon County Asylum, on October 2Sth,
under the chairmanship of Dr. Davis. There were also present Drs. Rutherford,
Miller, Benham, Aveline, MacBryan, Bullen, Stevens, Stewart, Turner, Eager,
Baskin, Rorie, Laval, and the Hon. Sec., Dr. P. W. Macdonald.

The three following candidates were elected ordinary members:—Frederick
Day Welch, M.R.C.S., L.R.C.P.Lond., A.M.O. Burghill Asylum, Hereford; A.
Alwyne Hingston, B.A.Cambs., M.B., C.M.Aberd., A.M.O. Cotford Asylum,
Taunton; and Evariste Laval, M.B., C.M.Edin., A.M.O. Brislington House, Bristol.

On the proposition of Dr. Turner, seconded by Dr. Stewart, Dr. Benham’s
invitation to hold the Spring Meeting at the City Asylum, Bristol, was accepted
unanimously.

Digitized by v^.ooQLe

NOTES AND NEWS.

205

1903 .]

Dr. Bbxham said he would be very pleased to receive the Division next April.
He wished to say how much he appreciated the vote they were kind enough to
pass at the last meeting when he was laid aside through illness. He was glad to
say that after a long rest he had been able to return to his duties, and, he hoped,
for some considerable time to come. He was also greatly indebted for the great
amount of sympathy he received, not only from the members of that Division, but
from the whole of his brother medical men in other Divisions of the Association.
He would never forget the kindness that was displayed towards him through his
illness, and he only hoped that he would be spared for some considerable time to
attend the various meetings of the Division.

In accordance with the resolution passed at the Annual Meeting, the rules were
next considered, and, after a very full discussion, several important amendments
were unanimously agreed to, and the Hon. Sec. was instructed to forward the
same to the Rules Committee.

Dr. Baskin then read a most instructive paper on “ Some Aspects of Phthisis
in the Insane; with Notes on the Urea Treatment of Phthisis” (see page 52).
Owing to the late hour it was not possible for any discussion to take place.

The members dined afterwards at Pople’s new London Hotel.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held by the courtesy of
Dr. Seymour Tuke and Mr. C. M. Tuke at Chiswick House, Chiswick. W., on
Wednesday, October 29th, 1902.

Among those present were Drs. Bond, Bower, Benson Cooke, Chambers, P. Camp¬
bell, F. G. Crookshank, R. H. Cole, P. Langdon-Down, F. H. Edwards, C.
Edwards, G. S. Elliott, Lieut.-Col. J. W. Evans, Drs. Fee, Gostwyck, J. R. Hill,
Hyslop, Haslett, Haynes, Higginson, Kidd, Wolseley Lewis, Miller, Moore,
Macevoy, A. S. Newington, J. P. Richards, Steen, Shuttleworth, R. J. Stilwell,
T. Seymour Tuke, Thomson, H. F. Winslow, Ernest White, Worth, and Boycott
(Hon. Sec.). Visitors: Messrs. F. W. Tuke, W. F. Chevers, F. H. Lloyd, and
Ogilvie.

. After luncheon a meeting of the Divisional Committee was held, and the house
and grounds were inspected.

The General Meeting of the Division was held in the afternoon, Dr. Seymour
Tuke being voted to the chair.

The minutes of the last meeting, having already appeared in the Journal, were
taken as read and confirmed.

An invitation from Dr. Harding to hold the Spring Meeting of the Division at
Berrywood, Northampton, in April, 1903, was unanimously accepted with much
pleasure.

The following gentlemen were by ballot elected ordinary members of the Asso¬
ciation :—Laurence Otway Fuller, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Darenth Asylum (proposed by Drs. Taylor, Robinson, and Boycott);
Saville Waldron Hanbury, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, London County Asylum, Banstead (proposed by Drs. Wolseley Lewis,

i ohnston Jones, and Murphy); Patrick Gabriel Kennedy, L.R.C.P.&S.Edin.,
..F.P.S.Glasg., Assistant Medical Officer, London County Asylum, Banstead
(proposed by Drs. Wolseley Lewis, Johnston Jones, ana Murphy); Charles
Seymour Parker, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer, Darenth
Asylum (proposed by Drs. Taylor, Robinson, and Boycott); Ernest Frederick
Sail, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer, West Sussex
County Asylum, Chichester (proposed by Drs. Kidd, Steen, and Boycott).

The amended and revised Rules of the Association, as submitted to the Annual
Meeting at Liverpool and by resolutions referred to the Divisions, were considered.
With reference to Rule 28, the following resolutions were carried :

(1) Proposed by Dr. Douglas, seconded by Dr. Bower:—“ That each Division
shall appoint annually a member to act as Honorary Secretary to the Division.”
(2) Proposed by Dr. Bower, seconded by Dr. Richards:—“ That in the opinion

Digitized by v^.ooQLe

206

NOTES AND NEWS.

[Jan.,

of this Division the Rules should provide for proportionate representation of the
Divisions on the Council.”

(3) Proposed by Dr. White, seconded by Dr. Lewis:—“ That it is the opinion
of this Division that each Division should nominate a representative or repre¬
sentatives upon the Council. Such name or names to be submitted to the
Annual Meeting for election.” An amendment proposed by Dr. Bower:—“That
the present practice of suggesting names should be continued,” was not carried.

Concerning the remainder of the Rules the following resolutions were passed :—

(4) Rule 35.—After the word 11 Committee,” add the words “ and the Divisional
Secretaries.”

(5) Rule 51.—Add a paragraph as follows :—“ ( e ) The names of the Members
nominated as Honorary Secretary and Representatives of the Division on the
Council.”

(6) Rule 67.—Add after the word “year” the following words:—“Unless he
can satisfy the Council that his absence was unavoidable.”

(7) Appendix, Form D :—Omit the word “ President ” underlined in black.

A letter was read from Dr. Bond, the Honorary Secretary to the Committee
for revising the Statistical Tables, asking the Division to communicate to him any
suggestions on the subject which they might think desirable. It was decided to
consider this matter at the Spring Meeting.

A paper was read by Dr. Seymour Tuke and Mr. C. M. Tuke on “Work
at the Manor House and Chiswick House.” Photographs and engravings of
Chiswick House and grounds in the old times were passed round for inspection.

The Hon. Secretary reported that Drs. Corner and Pugh were unavoidably pre¬
vented from attending the meeting, and their papers were postponed.

A hearty vote of thanks was accorded to Dr. Seymour Tuke and Mr. C. M.
Tuke for entertaining the Division at Chiswick House, as was also a vote of
thanks to Dr. Tuke for presiding in the chair.

The members afterwards dined together at the Cafd Monico, Regent Street.
Drs. Alliott, Savage, and T. O. Wood, who were unable to be at the meeting,
were present at the dinner.

IRISH DIVISION.

A meeting was held at the Royal College of Physicians, Dublin, on November
25th, 1902.

Dr. Conolly Norman occupied the chair, and there were also present Drs. M. J.
Nolan, A. Finegan, Revington, Oakshott, T. A. Greene, M. Curran, H. M. Eustace,
and W. R. Dawson (Hon. Sec.).

The minutes of the previous meeting were read, confirmed, and signed.

Date of Next Meeting.

It was decided that the next meeting of the Division should be held in Dublin
about tTie middle or end of January, 1903, the exact date to be fixed later.

Election of Ordinary Members.

The following were unanimously elected :—M. J. Forde, M.D., M.Ch., R.U.I.,
Assistant Medical Officer, Richmond Asylum, Dublin (proposed by Drs. Conolly
Norman, J. M. Redington, and W. R. Dawson); and W. Cooke, L.R.C.P.I.,
L.R.C.S.I., Assistant Medical Officer, St. Patrick’s Hospital, James Street, Dublin
(proposed by Drs. R. R. Leeper, C. Norman, and W. R. Dawson).

Revision of Rules.

The General Secretary’s communication with reference to the revision of the
rules having been read, a prolonged discussion of various suggested amendments
took place, in which all the members present joined. Ultimately the following
resolutions were adopted:

(1) Rule 28.—For second paragraph read:—“Each Division shall nominate

Digitized by LjOOQle

NOTES AND NEWS.

207

I 903 ]

annually to the Council a member to act as Secretary, and also one member as
their representative on the Council, absent members being entitled to vote for the
latter.”

(2) Rule 34.—Omit the words 11 and two Auditors.” Rule 46.—Replace words
“ by the Auditors ” by the words “ by two Auditors elected by the Council, but not
from their number.”

(3) Rule 35.—After the word “ Committee ” add “ and the Divisional Secretaries.”

(4) Rule 51.—To stand as it is.

(5) Rule 67.—Insert between the words “year” and “and,” “unless he can
satisfy the Council that his absence has been unavoidable.”

(6) Rule 77.—After the second word “vacancy” insert the words “except in
the case of a Divisional Representative.”

(7) Rule 101.—To stand as underlined.

(8) That “ Articles of Association ” should be separated from “ Bye-laws,” and
that the Association should obtain in the former power to alter and amend the
“ Bye -laws” consistently with the Articles of Association. The Articles of Asso¬
ciation should be printed separately from the Bye-laws.

(9) That, with the exceptions above indicated, the draft rules as forwarded to the
members are approved.

The Secretary was directed to ascertain whether or not copies of the Journal
were sent to the Corresponding Members, and to express the opinion of the meeting
that, if not, this should be done.

Hour of Meeting.

The Secretary was instructed to ascertain the views of the members of the
Division with reference to holding the Divisional Meetings at a later hour than
has been customary.

Communication.

Dr. M. J. Nolan read a paper entitled “ Clinical and Pathological Notes,” which
was illustrated with photographs and microscopic preparations.

A number of the members dined together at the Dolphin Hotel, Dublin.

COMPLIMENTARY.

Dinner and Presentation to Dr. Yellowlees in Glasgow and Unveiling
of Medallion Portrait at Gartnavkl.

Dr. Yellowlees* retirement from the position of Physician Superintendent of the
Glasgow Royal Asylum has not been allowed to pass unnoticed by his friends, but
has been commemorated in a most appropriate and well-deserved manner.

It was resolved to entertain Doctor and Mrs. Yellowlees at dinner, to present
them with a service of plate, and to place in Gartnavel a permanent memorial of
him in the form of a medallion portrait in metal.

The response to the invitations to assist in so honouring him was most cordial and
gratifying, and on the 31st day of January, 1902, Doctor and Mrs. Yellowlees were
the guests of over eighty of their friends in the Central Station Hotel, Glasgow.
Sir James Marwick was in the chair, and among the alienist physicians present were
Sir John Sibbald, Sir J. Batty Tuke, Drs. Clouston, Rutherford, Urquhart, Havelock,
Robertson, Keay, Carlyle Johnstone, Turnbull, Oswald, and Parker. The medical
profession of Glasgow was represented by Sir Hector Cameron, Professor McCall
Anderson, Dr. Finlayson, Dr. Renton, Professor Glaister, Dr. McVail, and many
others. The University and City of Glasgow were also well represented.

Apologies for absence, accompanied in many cases by expressions of keen regret,
were intimated from many English asylum physicians, and from among others the
Commissioners in Lunacy for Scotland, Sir Arthur Mitchell, the Very Reverend
Principal Story, Sir Charles Cameron, and Professor McKendrick.

Sir W. T. Gairdner wrote as follows:—“ There are few men living to whom I
should more earnestly have desired to show honour and respect, but the opinion

Digitized by ^.ooQle

208

NOTES AND NEWS.

[Jan.,

of my medical advisers is altogether opposed to my undertaking any kind of
evening social engagement even here in Edinburgh for some time to come. I
believe I have the distinction of being about the oldest of Dr. Yellowlees’ friends
in the West of Scotland, and also of having been very intimate with him from the
time of his studentship, when I believe I was more or less the means of his having
his attention directed to the special branch of medicine in which he has gained so
great a reputation. I can most thankfully and heartily bear witness that during
all that long time not a single cloud has ever passed over our friendship, nor have
I ever entertained a misgiving as to the wisdom of the choice originally made by
him in selecting lunacy practice as the work of his life. It is needless to add that
as the medical superintendent of Gartnavel he has more than fulfilled the expec¬
tations of his earlier friends, and has presented to all the world the example of a
strong, sane, and yet human-hearted physician in contact with infirm and dis¬
tempered minds, with constant sympathy and healing influence as regards the
latter. But above all the impression of Dr. Yellowlees that I would like to give
effect to in this letter is that his character as a public man is exactly what we, his
intimate friends, know in private—a man of unswerving honour, absolute fidelity
and truthfulness, warm in his affections, and constant to his friends, yet full of
courage and resolution, justum et tenacem prepositi virutn.”

Sir James Marwick, in proposing the toast of “Our Guests,” sketched briefly
Dr. Yellowlees’ early professional career, his work in England and Wales, and
the events that led to his appointment to Gartnavel. He dwelt on his own long
personal friendship with Dr. Yellowlees as one to whom 44 as the shadows lengthen
along the furrows ” he clung with ever deepening affection and regard. He bore
eloquent witness to the administrative and financial success of the asylum under
Dr. Yellowlees’ superintendentship, and to the deep interest taken by him in many
philanthropic schemes. 44 His all-round sympathetic work,” he said, ** has gained for
him an amount of respect and affection of which the gathering here to-night is but an
indication. It is pleasant to think that we, his Glasgow friends, are not to lose him,
that the city in those varied interests with which Dr. Yellowlees has hitherto
associated himself will probably receive even more of his active sympathy than
his engagements hitherto have enabled him to give, and that his long and varied
experience will still be available to those who may need to consult him profes¬
sionally. In any case, the duties and activities of life, the pleasures of home and
family, and the associations and enjoyments of friends, are available to him. That
in these, and in the solacements of wife and children ministering to his happiness
and calling forth his deepest sympathies, he may spend the many years of a yet
long and useful life we all most earnestly hope and pray.”

Sir James then, in the name of friends in Glasgow, Edinburgh, and throughout
the country, presented to Dr. and Mrs. Yellowlees a silver tea and coffee service,
a gift that had been specially chosen so that they might be joint recipients of the
expression of their friends’ feelings towards them.

Sir John Sibbald said he felt it a great honour to be allowed to say a few words
indicative of the respect and affection with which he regarded Dr. Yellowlees.
44 It is now,” he said, 44 nearly half a century since I was first made acquainted
with Dr. Yellowlees. We were young then, and we looked into the unknown land
of the future not knowing the roads we might have to travel; but of one thing I
felt always certain, that David Yellowlees, in whatever direction he might be led,
would command the respect and confidence of his associates, and would do
honour to the vigorous race from which he sprang. I am sure, however, that not
in his wildest dreams did Dr. Yellowlees contemplate that towards the end of his
career there would be a meeting such as this, where ladies and gentlemen repre¬
sentative of the culture of Glasgow, and other friends from different parts of
Scotland, would be joined in such numbers and so heartily in the desire to do him
honour.”

Having referred to Dr. Yellowlees’ early professional career in Edinburgh, to
his work in Wales and Glasgow, to the honours conferred on him by the Univer¬
sity of Glasgow and by his professional brethren, Sir John said he saw in those
present the concrete fulfilment of the anticipation with which all who knew Dr.
Yellowlees regarded his appointment to Gartnavel, and he congratulated him and
the charming lady who shared his honours and his joys on the happy event of the
evening.

Digitized by v^.ooQLe

1903-]

NOTES AND NEWS.

209

Lord Dean of Guild Gourlay, as representing the Directors of the Glasgow
Royal Asylum, expressed the regret with which the Board of Directors had re¬
ceived Dr. Yellowlees’ resignation. He desired warmly to acknowledge the debt
Gartnavel owed to their guest, and to join heartily in what had been said regarding
his high attainments. He, Dr. Gourlay, had been associated with Dr. Yellowlees
for many years, and he expressed his own great pleasure and that of his fellow-
directors at the intention to place in Gartnavel a medallion portrait of one who
had served the institution so long and so faithfully.

Dr. Yellowlees, in replying, said : Sir James Marwick, Ladies and Gentle¬
men,—my kind and valued friends,—It is said that out of the abundance of the
heart the mouth speaketh. My experience is just the contrary. I find that the
heart may be so full that utterance becomes very difficult.

Since sitting down at this table I have-been trying, and it has not been easy, to
realise that this great gathering and this magnificent gift have anything to do
with me; and while listening to the far too kind and flattering words spoken by
yourself, sir, by Dr. Gourlay, and by my old friend and colleague, Sir John Sibbald,

I almost began to doubt my own identity. I was forcibly reminded of an old
Glasgow citizen, who, amid similar laudation, had to fall back on the Shorter
Catechism, and tell his friends that “No mere man since the fall has been able
perfectly to keep the commandments of God, but doth daily break them in thought,
word, and deed.” This amazing and utterly undreamt of demonstration makes
me very humble as well as very proud—very proud because of your exceeding
kindness and appreciation, and very humble because I feel so little worthy of it.
I cannot feel that I have done anything to deserve such a tribute. God gave me
one of His best blessings in giving me as my life’s work, work that was entirely
congenial. My daily duty, notwithstanding all its worries and responsibilities,
was my daily joy, and so I did it with all my heart and all my energy, and never,
never dreamt of any such recognition as this. I wish I could go back again and
try to do it all better.

Your speech, sir, brought back the long-ago days when I came to Glasgow, and
it is quite true that, humanly speaking, but for you and good Sir James Watson,
I would never have been at Gartnavel. I knew only four persons when I came to
Glasgow as a candidate, and when I compare that small beginning with this large
assembly, I feel that I have indeed been given in abundant measure what the
aged king sighed for in vain—“ love, honour, and troops of friends.”

The inducements which led me to come from South Wales to Glasgow were the
wider sphere of work which it offered, the prospect of teaching in its university,
and the more congenial associations and surroundings of my Homeland. In all
these respects I have reason to be most thankful that the “ Divinity which shapes
our ends ” led me to Glasgow. My life and work here have been happy and suc¬
cessful far beyond my deserts, and you are crowning them to-night by kindness
which overwhelms me.

Dr. Gourlay’s most kind words were in accord with all my experience of the
Gartnavel directors. I may confess that my chief anxiety in coming to Gartnavel
was as to the kind of men with whom I was to work, but I need not tell you that
this anxiety soon vanished when I found on the Board such men as George
Thomson, John Roxburgh, and John Brown, jun. Their successors are like them.
From first to last it has been a true pleasure and satisfaction to work under such
directors. They believed in my earnest devotion to the work, and they helped
me in it by their confidence, support, and kindness in every possible way. They
have done me further honour by appointing me honorary consulting physician to
the asylum, and by desiring that I should become a director of the institution.

It is peculiarly touching and gratifying to me that your munificent kindness
includes a medallion on the walls of Gartnavel, and that the directors, through Dr.
Gourlay, have so cordially welcomed its erection. Nothing could be more
pleasing to my own feelings than some memorial of my work at Gartnavel. I
should not like to be speedily forgotten where I lived so long, and where so much
of my work was done, and I am glad to think that many of my friends both among
the patients and the staff will see the visage of their old doctor on the walls, and
will like to see it.

The too kind words of my friend Sir John Sibbald awakened echoes of yet
earlier memories, for we were assistants together in Morningside more than forty

Digitized by

Google

210

NOTES AND NEWS.

[Jan.,

years ago, and have been friends ever since. Assuredly, as he said, such an
honour as this had no place among my wildest youthful aspirations, and his own
well-deserved title was as little thought of then. He has anticipated me in
saying, what I feel strongly, that our whole specialty is being honoured to-night.
It is a very great pleasure to see here so many superintendents from the other
asylums of Scotland. They have come not from the west only, but from
Dumfries and Melrose in the south, from Inverness and Perth in the north, from
the kingdom of Fife in the east, from Edinburgh, and from Larbert, feeling, I am
sure, as I do, that in honouring so highly one of their number you do signal
honour to that branch of the medical profession to which they and I belong.

I greatly regret that the state of his health has not permitted Sir William
Gairdner, my old teacher and lifelong friend, to be with us to-night. The letter
you have read from him has moved me deeply, and I wish I were more worthy of
such words from such a man.

Were this a fitting occasion, I could say much about the changes I have seen in
the care and treatment of the insane during the forty-one years I have spent
among them. Perhaps the change is most marked among the insane poor. Forty
years ago, although the cruelties of earlier days had ceased, their rooms were still
bare and comfortless, their airing grounds were like prison yards, and their diet
poor and meagre. Their bread was butterless, and I well remember a patient who,
during service, audibly supplemented the fourth petition by “And butter, and
butter.” Now the condition of the insane poor is a triumph of practical
Christianity. They are housed, fed, and surrounded with comforts and elegances
as they never could have been but for their insanity. The feeling of the public
towards insanity has also changed greatly. It is no longer regarded as a doom and
a horror, but as a disease involving no more reproach or blame than other diseases.
A good illustration of this change is found in the Gartnavel gate. When the
asylum was built the entrance gate was deliberately placed in a back lane for
the sake of privacy, and because no one would wish to be seen going to such a
place. Now public opinion is wiser, and the gateway is the most handsome
entrance on the principal avenue to the second city of the Empire. Now that I
have got to the gate I fear to enter on any retrospect of my work, lest I know not
where to stop. There have been 5083 patients under my care at Gartnavel during
the last twenty-seven years. Of these 1^36 recovered completely and 1349 others
recovered sufficiently to return to home and friends.

In 1874 there were 167 private patients and 422 parish patients. At the close of
1902 there were 431 private patients and practically no paupers. In 1874 the
lowest rate at which private patients were admitted was ^57 a year. Now over
200 of the private patients pay only ^40 a year, and some of them much less.
This immense boon to the community directly fulfils the benevolent object for
which the asylum was founded, and I have always felt it a great privilege to be the
instrument in administering such a charity. This charity is of necessity limited
by the available funds, and money could not be better bestowed than in aiding this
most beneficent work. The asylum needs no aid for itself, it is a self-supporting
charity, although it has no income except the board paid by patients, and the in¬
terest on invested funds. I do not know why ordinary infirmaries should not
receive paying guests as well as brain infirmaries. The patients would of course
be attended by their own doctors, but with the advantage of consultation and
nursing by the infirmary staff.

As to finance, Gartnavel, I am glad to say, has been prosperous. A debt of
£ 11,000 which rested on the buildings in 1874 has been paid off, a reserve fund of
^34,000 has been accumulated, and the institution owns the site on which it stands,
which is worth at least ^100,000.

I resigned the work I loved so well with great regret, and solely because my eye¬
sight had become unequal to it. Such work requires the full activity of all the
faculties of both mind and body, and my dimmed vision made my duty clear.

A novel and welcome feature of the dinner to-night to which I cannot but
allude is the presence of ladies, who add so greatly to the brightness and pleasure
of the evening. I have been bantered on the subject, and told that a dinner to me
would not be complete without ladies. I met the banter by cordially accepting it.
It has been my privilege and happiness to have many true and dear women friends,
and I know of no influence more refining, elevating, and delightful than the

Digitized by v^.ooQLe

1903-]

NOTES AND NEWS.

21 I

friendship of a good woman. The presence of ladies this evening is a special
pleasure to me.

For this magnificent gift before me, I desire to thank you most sincerely in my
wife’s name as well as my own. You have included her in it, and she well deserves
the recognition. She has ever been my earnest helper in all my work at Gartnavel.
In short, she has been an ideal wife for an asylum superintendent. Your beautiful
present is not only a great gratification to ourselves, it will be an heirloom for
our children, and will ever remind them of the exceeding kindness of our friends
when we left the dear old home at Gartnavel.

I need not say more; I cannot find words to express what I feel about this
great gathering and your most generous gifts. I can only thank you with all
my heart.

The unveiling of the medallion portrait referred to took place at Gartnavel on
October 7th, and was performed by Sir James Marwick in the presence of 300
guests, among whom were many members of the medical profession, including
Sir W. T. Gairdner. The medallion—a striking likeness—is placed in the
wall of the recreation hall of the East House. It is a profile in oxidised silver
set in a marble tablet, and was executed by Mr. Gilbert Bayes, of London.

Lord Provost Chisholm, who presided, referred to the feelings of respect,
admiration, and affection which, through a long series of years, had gathered round
Dr. Yellowlees, and to the debt which the City of Glasgow owed to him as one of
its skilful physicians.

Sir James Marwick, in unveiling the portrait, asked the directors of the asylum
to accept it and to allow it to remain on the wall as a memorial.of one who had
served the institution for twenty-seven years with fidelity, distinguished ability, and
success.

Dr. Gourlay, as the senior director of the asylum, thanked them most heartily
for the happy thought and the generosity of which it was the outcome in placing
on the walls of the asylum a work of art, a thing of beauty in itself, and a portrait
of one who for so many years had been the trusted adviser of all those who found
a home in that beneficent institution.

Sir John Sibbald said that the memorial of Dr. Yellowless which would dwell
most in their minds was the Royal Asylum at Gartnavel, and the impressions
which had been left on the hearts and minds of all who had been associated with
Dr. Yellowlees in his work.

Dr. Yellowlees, in returning thanks fora replica of the medallion, presented in
the name of the subscribers by Professor McKendrick to Mrs. Yellowlees, said
the kindness of his friends and professional brethren had awakened feelings which
it was altogether impossible to express in words. He could only say that he had
always tried to do his duty, and that in spite of all its anxieties and responsibilities
his work was always more a joy than a burden. If during these twenty-seven
years he had lessened the sorrows and troubles of his patients, and if he had been
able to increase the prosperity of that noble institution, it would not matter
whether his work seemed obscure and unobtrusive rather than ornamental and
conspicuous. The medallion at least secured that he would not be easily forgotten.
He would try to be worthy of the kindness that placed it there.

A vote of thanks to the sculptor, proposed by Sir John Cuthbertson, was
followed by a programme of music, and the proceedings terminated.

FLOWER’S PATENT AUTOMATIC HAND-LOOM.

This interesting invention is, so far as we know, unique, in that it represents the
steam-power loom without the steam, and, being automatic, represents the born
skilled weaver when operated by the novice of a few days’ experience. It is claimed
that Flower’s Automatic Loom can be driven through the usual working day by a
girl of 14 or 15 years, and that the wider looms of 60 to 100 inches reed space
scarcely require more effort than those for narrower width weavings. The machine,
having been properly “ set up,” is simply kept in motion by a rocking cast of the

Digitized by

Google

212

NOTES AND NEWS.

[Jan.,

slay, yielding from forty to eighty picks per minute, the operator’s intelligence being
chiefly occupied watching for broken threads and other minor accidents common
to all forms of looms. In the Flower Looms there is no expensive outlay on boilers,
furnaces, or engineers, nor are there the serious risks under the Employers’ Liability
Acts. Thev are constructed to make tweeds, frieze, flannels, and other textile
fabrics. They have been very successfully introduced into several lunatic asylums
in England and Ireland, as agreeable and diverting occupation for the afflicted in¬
mates, affording at the same time substantial relief to the ratepayers, excellent
pure wool clothes being produced at remarkably small cost for the wear of the
patients and for uniform clothing of the attendants. The Flower Looms are said
to be slowly making way within the weaving trade, and are likely to be largely
used for native industries, wherever a group of four or five or more looms can be
instituted, each five or six being served by a beaming or warping machine, necessary
to insure even weaving and even wear. The makers are Messrs. Robert Hall and
Sons, of Bury, and the latest pattern loom may be seen at work in the Technical
Instruction Department of the Exhibition.

The Flower Loom exhibited at Cork has been purchased for the Cork District
Asylum, and a second is ordered from the makers.—From the Irish Times , Sep¬
tember 22nd, 1902.

OBITUARY.

Joseph Raymond Gasquet.

We regret to record the death of Dr. Joseph Raymond Gasquet, which took
place at his residence in Brighton on the 13th of August.

He w’as 64 years of age, and had suffered for very many years from a tryiug
and painful affection, which he bore with most exemplary patience and fortitude
throughout. Although his death was not unexpected, yet his loss is not the less
keenly felt by his friends and acquaintances, for no one who came in contact with
him could fail to appreciate his uniform kindness and sympathy.

Dr. Gasquet prosecuted his medical studies at the University College Hos¬
pital in London, and graduated with distinction at the London University in
1859. After a few years spent in general practice in London he accepted the
post of Medical Officer to St. George’s Retreat at Burgess Hill, on the opening
of that asylum; this necessitated his leaving London, and he settled in Brighton
in 1867. He took an active part and keen interest in the management of St.
George’s Retreat during its growth and development, and only when increasing
infirmity compelled him did he retire from active work, about three years ago.

Always taking the keenest interest in the advances of medical science, his inti¬
mate knowledge of French, German, and Italian enabled him to follow its pro¬
gress abroad. With the idea of keeping the younger members of the profession
in touch with the advances in medicine, and as a sort of post-graduate work, he
started a small society among some of the practitioners in Brighton, for the
reading and discussion of papers ; this society continues to flourish.

He contributed various papers to the medical journals, and for many years
supplied the Italian retrospects for this Journal, but almost all his leisure hours he
devoted to philosophical studies, and he looked on this as his relaxation and
pleasure. His perfect knowledge of the classics enabled him to become most
familiar with the older and more modern schools of thought. He had, however,
to a marked extent the diffidence and retiring disposition of a deep student, and
so it is to be profoundly regretted that he left but few records of his study and
impressions.

Jules Falret.

Jules Falret died on the 28th of June, 1902. He was a son of Jean Pierre Falret,
one of the most distinguished pupils of Esquirol, and was born in the month of
April, 1824, in the private asylum of Y r anves, founded by his father and Fdlix

Digitized by v^.ooQLe

I903-]

NOTES AND NEWS.

213

Voisin, of which asylum he became a superintendent, and where he lived and
died. Interne des H6pitaux de Paris in 1S47, he was chosen in 1867 as a physi¬
cian of the old Hospice de Bicdtre, where he remained until 1884, when he suc¬
ceeded to Moreau de Tours at the Salpdtridre. Elected as a member of the
Socidtd Mddico-Psychologique de Paris in 1854, he was president of that associa¬
tion for 1889. In the same year he presided over the meetings of the International
Congress of Psychiatry. He became an honorary member of our Association in
1865.

Jules Falret was one of the most distinguished alienists of our time. Some,
perhaps, acquired a higher reputation who did not possess his worth; for he was
a very modest man and a thorough gentleman, averse to every form of puff and
quackery. He liked to receive his friends and pupils in his hospitable home, and
all regarded him with affection. His leisure time was devoted to the Patronage
des Alidndes, an after-care association created by his father fifty-seven years ago.

Some of Jules Falret’s principal books and notices are as follows:

Recherches sur la folie paralytique et les diverses paralysies generates (thdse
inaugurate, Paris, 30 mai, 1853).

“ Des diverses paralysies gdndrales ” (Archives ginirales de midecine , fdvrier,

* 855 ).

“ De la catalepsie ” (Archives ginirales de midecine, 1857).

La paralysie generate est une forme spiciale de maladie mentale (discours pro-
noncd k la Socidtd Mddico-Psychologique, le 25 juillet, 1858 ; Annales , 1859, ***»

P- *25).

“Du diagnostic differentiel des paralysies gdndrales ” (Archives ginirales de
medecine, 1858).

Principes d suivre dans la classification des maladies mentales (dfccours pro-
noncd h la Socidtd Mddico-Psychologique, le 26 novembre, i860; Annales M.-P.,
1861, t. vii, p. 145).

“ Etat mental des dpileptiques ” (Archives ginirales de midecine , i860 et
1861).

“ Sdmdiologie des affections cdrdbrales M (Archives ginirales de midecine,
octobre, i860).

“ Theories physiologiques de l’dpilepsie ” (Archives ginirales de midecine,
fdvrier et mai, 1862).

“ Les asiles d’alidnds de la Hollande” (Socidtd Mddico-Psychologique, stance
16 ddcembre, 1861 ; Annales , 1862, p. 312).

0 La colonie d'alidnds de Gheel n (Socidtd Mddico-Psychologique, stance du 30
ddcembre, 1861 ; Annales, 1862, p. 138).

“ De la responsabilitd morale et de la responsabilitd ldgale des alidnds ” (Socidtd
M.-P., seance du 30 mars, 1863 ; Antiales, 1863, p. 238).

“Des divers modes d’assistance applicables aux alidnds ” (Socidtd M.-P., sdance
du 12 decembre, 1864; Annales, 1865, p. 248).

“ Troubles du langageet de la mdmoire des mots dans les affections cdrdbrales”
(Archives ginirales de midecine, numdros de mars, 1864, e * suivants).

“ L’amndsie” (Dictionnaire encyclopidique des sciences mi die ales, 1866, iresdrie,
t. iii, p. 275).

“ L’aphasie ” (idem, t. v, p. 605).

“ La fonction du langage articuld ” (Archives generates de midecine , aoAt,
1866).

“ La consanguinitd ” (Archives ginirales de midecine , fevrier, 1865, et
suivants).

" Folie raisonnane, ou folie morale ” (Socidtd M.-P., sdances du 8 janvier et du
29 octobre, 1866; Annales, 1866, p. 382, et 1867, P* 68).

“ Des asiles spdciaux pour les alidnds dits criminels ” (Socidtd M.-P., sdance du
16 novembre, 1868; Annales, 1869, p. 136).

“ Des alidnds dangereux” (Socidtd M.-P., sdance du 27 juillet, 1868; Annales ,
1869, p. 86). '

“ Les ldgislations dtrangdres sur les alidnds, et les rdformes proposdes k la loi de
1838 ” (Archives ginirales de midecine , octobre, 1869).

“ Affaire Jeanson, accusation d’incendie et de meutre ” (Socidtd de mddecine
ldgale, 1869).

“ Cas d’aphasie, avec hdmipldgie droite, pour lequel on demande l’interdiction ”
XLIX. 14

Digitized by v^.ooQLe

NOTES AND NEWS.

214

[Jan.,

(Societe de m£decine legale, stance du 23 novembre, 1868, et Annales d'hygiene,
1869, p. 430).

“ Emploi de bromure de potassium k haute dose chez les epileptiques de
Thospice de Bic6tre” (Societe M.-P., seance du 28 juin, 1870; Annales, 1871,
p. 161).

“ La responsabilite legale des ali^nds ” ( Dictionnaire encyclopedique des sciences
mtdicales, 1876, 3e serie, t. iii).

11 La folie k deux, ou folie communiqude (en collaboration avec Las&que
Archives gtntrales de mtdecine, septembre, 1877).

41 La folie circulaire, ou folie & formes alternantes ” ( Archives gtnfrales de mtde-
cine, decembre, 1878, et janvicr, 1879).

“Varies cliniques de la paralysie gendrale” (CongrPs international, 1878,
p. 412).

Discours d'ouverture au CongrPs international de mtdecine mentale, 1889,
p. 24.

44 Des obsessions avec conscience ” (CongrPs international de mMecine mentale,
1889, p. 32).

Httudes cliniques sur les maladies mentales et nerveuses (Paris, 1890).

Les alifnte et les asiles d'aliPnPs (Paris, 1890).

Henri Dagonet.

Henri Dagonet, who died in Paris on the 4th of September, 1902, was born in
Chilons-sur-Marne on the 4th of February, 1823. Having graduated as M.D. in

1849, he became in the following year superintendent of the asylum of Stephans¬
feld. In 1854 the Faculty de Strasbourg chose him as one of its professeurs-
agrSgts. He came to Paris in 1867, and entered the asylum of Sainte-Anne as
superintendent.

Henri Dagonet was president of the Soci£t6 Medico-Psychologique in 1885,
when the statue of Philippe Pinel was solemnly erected in front of the Salpfitrifere,
and he enjoyed the honour of having been chosen to hand over to the city of
Paris that monument consecrated to the memory of the illustrious philanthropist.
He had been a pupil of Renaudin, and was acquainted, during his long, laborious,
and successful life, with such men as Ferrus, Morel, Lasfcque, Mittermaier. He was
the son and he was the father of a distinguished alienist (Dr. Jules Dagonet is one
of the superintendents in Sainte-Anne).

Inside and outside his speciality he was a man held in universal esteem. For
some years his health was failing, and he was not able to attend the meetings of
the Societe Medico-Psychologique. His obsequies were celebrated on the 8th of
September in the town of Verdun.

Some of Henri Dagonet’s principal books and notices are as follows :

44 Remarques medico-tegales sur un cas de folie simuiee ” ( Annales M.-P. 1848,
t. xii, p. 87).

44 Monomanie ; extension graduelle du delire; ddmence consecutive ” (Annales
M. P., 1849, t. i, p. 468).

Considerations mtdico-ttgales sur Valiination mentale (thfcse inaugurate, Paris,
1849).

44 L’hydrotherapie appliqu£e en traitement des alien£sstupides ” ( Annales M.-P.,

1850, t. ii, p. 343).

44 Pathoglnie de la folie ” ( Gasette mPdicale de Strasbourg, 1850).

44 Quelques donn£es scientifiques nouvelles en alienation” (Gas. de Stras¬
bourg, 1850).

44 Lettre de Vienne ” (Gas. med. de Strasbourg, 1851).

44 Rapports medicaux sur I’asile de Stephansfeld ” (Gas. m&d. de Strasbourg .
1851 k i860).

44 Influence de la situation morale dans la chloroformisation ” ( Gat . de
Strasbourg, 1852).

44 Le cholera k l’asile de Stephansfeld ” (Gas. de Strasbourg, 1854).

44 La section de psychiatrie au CongrPs de Gottingen” (Gas. de Strasbourg

1854)-

44 Statistique sur l’alienation mentale dans le departement du Bas-Rhin ” (Gaa.
de Strasbourg, 1855).

Digitized by v^.ooQLe

1903]

NOTES AND NEWS.

215

11 Lypdmanie de monoman iaque avec impulsions homicides” ( Annales M.-P.,
1858, t. iv, p. 185).

“ Folie ambitieuse consecutive & une blessure de la t&te ” ( Annales M.-P., 1858,
t- iv, p. 583).

“Notice statistique sur 1’alienation dans le Bas-Rhin ” (Gas r. de Strasbourg,

*859).

“ Lypdmanie religieuse et ambitieuse ” (Archives de Baillarger, 1861).

“ De la paralysie gdndrale” ( Gaz . de Strasbourg , 1862).

“Rapport medico-legal sur le nomme Lintz, inculpe d’assassinat ” (Annales
M.-P., 1863, t. ii, p. 35).

“ Les etablissements d’alidnds ” (Annales M.-P., 1863. t. i, p. 500).

“ Rapport medico-legal sur le nomme Frainier, inculpe d’assassionat ” (Annales
M.-P., 1864, t. iii, p. 36).

“ Note sur une amelioration dans le service des alienes gAteux de Pasile de
Stdphansfeld ” (Annales M.-P., 1864, t. iv, p. 92).

“ Loi de 1838 ” (Annales M.-P., 1865, t. v, p. 246).

“ Des expertises medico-iegales en alienation mentale (Mittermaier) :
analyse par H. Dagonet ” (Annales M.-P., 1865, t. vi, p. 201; 1866, t. vii, p. 198;
1867, *• **» P- 22 5 J 1868, t. xi, p. 235).

“Asiles d’alidnds” (Congrds de Rouen, 1865; Annales M.-P., 1865, t. vi,
P- 379 )-

“ Rapport medico-legal sur le nomme Seiler, accuse d’incendie volontaire ”
(Annales M.-P., 18 66, t. vii, p. 362).

“ Rapport sur l’dtat mental du nomme Pitter, inculpe d’assassinat et de tenta¬
tive de meurtre ” (Annales M.-P., 1867, t. ix, p. 423).

“Les alienes dangereux ” (Societe M.-P., 28 decembre, 1868; Annales M.-P.,
1869, t.i, p. 316).

“ Un aliene provoquant son isolement dans un asile ” (Journal de midecine
mentale de Delasienne, 1869, t. ix, p. 356).

“ Des impulsions dans la folie et de la folie impulsive ” (Annales M.-P., 1870,
t. iv, pp. 5 et 215).

“ Observation de manie ambitieuse ” (Annales M.-P., 1871, t. vi, p. 161).

De la stupeur dans les maladies mentales (Paris, 1872).

De Valcoolisme (Paris, 1873).

“ Asiles d’alienes, par le Dr. Cyon (observations et analyse) ” (Annales M.-P.,
1874, t. xi, p. 60).

" Folie morale et folie intellectuelle ” (Annales M.-P., 1877, t. xvii, p. 21).

“ Reorganisation du service des abends du ddpartement de la Seine” (Annales
M.-P., 1878, t. xx, p. 29).

“Conscience et alienation mentale ” (Annales M.-P., 1881, t. v et vi, p. 19).

“ Rdformes k introduce dans la loi de 1838 ” (Annales M.-P., 1882, t. viii, No.
de septembre).

“ Une visite k Pasile d’alienes de Dobran, en Bohdme ” (Annales M.-P., 1885,
t. i, p. 242).

“ Alienation mentale mdconnue” (Annales M.-P., 1889, t. ix, p. 406).

“Du rftve et du delire alcoolique” (Annales M.-P., 1889, t. x, pp. 193 et
337 )-

“Etude clinique sur le ddlire de persecution” (Annales M.-P., 1890, t. xii,
pp. 190 et 337).

“ L’alienation mentale chez les ddgdndrds psychiques ” (Annales M.-P., 1891,
t. xiv, pp. S, 203, et 353).

“ Observations sur les deiires associds et les transformations du ddlire (Annales
M.-P., 1895, t. i, p. 5).

“ Les sentiments et les passions dans leurs rapports avec l’alidnation mentale ”
(Annales M.-P., 1895, t. ii; p. 5).

Traits des maladies mentales (ire edition, 1862; 2e, 1876; 3e, 1894).

Digitized by v^.ooQLe

NOTES AND NEWS.

[Jan.,

216

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

The following is a list of successful candidates at the November Examination,
1902 :

Bucks County Asylum. —Male : Arthur Jerome Gibbons.

Derby County Asylum. —Females: Eliza Allatt, Mary Ann Bradley, Olivia
Maude Johnson.

Essex County Asylum. —Females : Louisa Mary Barker, Emily Jane Briggs,
Edith Choate, Millie King, Rosa Mary Pink, Emily Sharpington.

Kent County Asylum , Banning Heath. —Males: James Brooker, Richard
Gardiner, James Kerr, Stephen Tyhurst. Females: Emily Alice Birch, Laura
Simmons, Florence Emily Wilson.

Kent County Asylum, Chartham. —Female : Clara Allen.

London County Asylum, Bexley. —Males: Albert Munro Bentley, Harry Fee,
George Hamilton Smith, Charles Windmill.

Norfolk County Asylum. —Females: Nellie Bird, Elizabeth Annie Hancock,
Alice Logan.

Staffordshire County Asylum, Cheddleton. — Females : Frances Elizabeth
Beckitt, Gladys Stovin Bettinson, Julia Muriel F. Fraser, Margaret Somerville
Hope.

Somerset and Bath Counties Asylum. —Males: Alfred Maunder Blake, Henry
Robert Tucker. Females: Bessie Lily Cook, Louisa Beatrice Lee, Margaret M.
Warren.

Warwick County Asylum. —Females: Gertrude Crump, Elizabeth Jane Lewis,
Mary Richards.

City of Birmingham Asylum, Wins on Green. —Males: Frank Northwood,
William Walton.

City of Birmingham Asylum , Rubery Hill. — Males: Henry Hooton, William
Shelley. Females : Kate Fanny Gould, Beatrice Emily Harris, Rose Eleanor
Morley.

Gloucester County Asylum. —Female : Annie Garry.

Derby Borough Asylum. —Male: John Maclean. Female: Eliza Bostock.

City of London Asylum, Dartford. —Females: Fanny Field, Eleanor Jones.

Camberwell House Asylum. —Females: Margaret May Griffiths, Elizabeth L.
Strang.

Darenth Asylum. —Females: Edith Clare Baines, Rosina Gowers, Jane Jones,
Jane Parry.

Holloway Sanatorium. — Females: Ada Mary Taylor, Grace Vulliamy, Annette
A. B. Wrenford.

Northumberland House Asylum. —Male: Thomas John Dorling.

Redlands Asylum. —Male: William Whitfield. Female: Florence M. Roberts.

The Retreat , York.— Males: Martin Burke, Thomas Fulton. Female: Lilian
Jackson.

Gartloch Asylum. —Male: George D. Plenderleith. Females: Agnes Baird,
Helen Munsie Hastings.

Inverttess District Asylum. —Females : Annie Matthew Barron, Mary Helen
Furlong, Mary Arthur Lucas.

Mavisbank Polton Asylum. —Females : Margaret D. G. Blair, Barbara Grieg
Fowler, Annie Jane Macdonald.

James Murray's Royal Asylum, Perth. —Females: Grace Welsh Guthrie, Cecily
Molumby.

Perth District Asylum. —Female : Isabella Cameron.

Riccartsbar Asylum. —Male: Charles Small Still. Female: Jessie Barbara
Duff.

Stirling District Asylum. —Females: Jeannie Binnie, Barbara Dewer, Helen
Herds, Isabella T. Maltman.

Mullingar District Asylum. —Males : Matthew Brogan, William Gavin, Abraham
Gordon, James Grimes, George Newton. Females: Kate Coffey, Mary Dunne f

Digitized by v^.ooQLe

l 9 ° 3 *]

NOTES AND NEWS.

217

Janie Lyster, Bridget Malone, Annie Naughton, Annie Neeve, Frances Jane
Somerset.

Leavesden Asylum. —Female: Frances C. Crouchley.

The following is a list of the questions which appeared on the paper:

1. What are the principal parts of the brain ? How are they connected with
each other and with the spinal cord ? Of what is the brain composed ?

2. Describe an ordinary epileptic fit ? What points should be specially
observed for report to the Medical Officer ? What treatment would you adopt
before medical aid arrives ?

3. What precautions should be adopted to prevent the spread of diarrhoea in
an asylum ?

4. What are hallucinations ? Give examples of their occurrence. In what
ways may a patient’s conduct be influenced by them ?

5. What bones form the thorax ? What separates the thorax from the abdomen ?
What large organs does the thorax contain, and what are their relative positions V

6. What changes take place in the blood as it passes through the tissues of the
body generally ? What changes take place in it as it passes through the lungs ?

7. Describe a case of melancholia or mental depression.

8. How would you act in a case of (a) a patient’s clothing catching fire; (6) a
simple fracture of the bones of the leg; (c) attempted suicide by hanging.

9. What do you understand by the word antiseptics ? Mention those chiefly
used, and state what precaution should be taken to prevent accident in connection
with the storing of these substances ?

10. What precautions should be observed in the nursing of patients suffering
from consumption ?

Next Examination for Nursing Certificate.

The next examination will be held on Monday, May 4th, 1903, and candidates
are earnestly requested to send in their schedules, duly filled up, to the Registrar
of tlie Association not later than Monday, April 6th, 1903, as that will be the last
day upon which, in accordance with the rules, applications for examination can
be received.

Note .—As the names of some of the persons to whom the Nursing Certificate
has been granted have been removed from the register, employers are requested to
refer to the Registrar in order to ascertain if a particular name is still on the roll
of the Association. In all inquiries the number of the certificate should be given.

For further particulars respecting the various examinations of the Association
apply to the Registrar, Dr. Alfred Miller, Warwick County Asylum, Hatton,
Warwick.

NOTICES OF MEETINGS.

Medico-Psychological Association.

General Meeting .—The next General Meeting will, through the courtesy of Dr.
Legge, be held at the Derby County Asylum on Thursday, February 12th, 1903.

Several Committees will meet on the nth, and on the morning of February 12th,
in Derby.

The following papers have been promised:

“ The Stereoplasm of the Nerve Elements : A Study in Nerve Dynamics,” by
Dr. Andriezen.

'* Lunacy and Law,” by Drs. Ernest W. White and T. Outterson Wood.

South-Eastern Division .—The Spring Meeting will be held, by the courtesy of
Dr. Harding, at Berrywood Asylum, Northampton, in April, 1903.

XLIX. 1 5

Digitized by

Google

2 iS notes and news. [Jan., 1903 .

South-Western Division .—The Spring Meeting will be held, by the courtesy
of Dr. Benham, at the City Asylum, Bristol, in April, 1903.

Northern and Midland Division ,—The Spring Meeting will be held, by the
courtesy of Dr. Menzies, at Cheddleton Asylum, Leek, on Thursday, April 30th,
1903.

Irish Division .—The next meeting will be held in Dublin on Wednesday, January
28th, 1903.

APPOINTMENTS.

Allen, Sydney Chalmers, M.B., B.Sc., appointed Assistant Medical Officer to the
Lunatic Asylum at Seacliff, New Zealand.

Fennell, Charles H., M.A., M.D.Oxon., M.R.C.P.Lond., appointed Assistant
Medical Officer at Darenth Asylum.

Marr, Gordon William S., M.B.Syd., appointed Assistant Medical Superinten¬
dent to the Hospital for the Insane, Goodna, Queensland.

McKelvey, Alexander N., L.R.C.P.&S.I., appointed Assistant Medical Officer
to the Lunatic Asylum, Auckland, New Zealand.

McLean, John Barr, M.B., B.S.Melb., appointed Assistant Medical Superinten¬
dent to Hospital for the Insane, Toowoomba, Queensland.

O’Brien, John A., M.B., appointed Acting Medical Superintendent to Kew
Hospitals for the Insane, Victoria.

Reid, William, M.A., M.B., Ch.B., appointed Junior Assistant Medical Officer
to the Burntwood Asylum, Lichfield.

Row, Linford E., M.D.Brux., L.R.C.P.&S.Edin., appointed Medical Superin¬
tendent to the Hospital for the Insane, Goodna, Queensland.

Taylor, Frederic R. P., M.D., B.S.Lond., appointed Medical Superintendent of
the New East Sussex Asylum at Hellingly.

Whittington, R., B.A., M.B., B.Ch.Oxon., appointed Medical Officer to the
Warneford Asylum, Oxford.

Digitized by v^.ooQLe

THE

JOURNAL OF MENTAL SCIENCE

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

No. 205 [XT] APRIL, 1903. Vol. XLIX.

Part I.—Original Articles.

Bacteriological and Clinical Observations on the Blood of
Cases suffering from Aciite Continuous Mania. By
Lewis C. Bruce, M.D., Murthly, Perthshire.

Two years ago, when the toxic theory of the causation of
insanity was attracting attention in this country, I made a
series of observations on the blood of acute recent cases of
insanity with the object of ascertaining whether organisms
were ever present. In no case, with the exception of one of
general paralysis, did I ever find an organism in the blood.
It occurred to me, however, that if I could make an aseptic
necrotic area subcutaneously, the serum and pus in such an
area would be a suitable nidus for the growth of organisms
circulating in the blood, and that by aspirating the serum and
pus and placing it in suitable nutrient media one should be
able to grow such organisms, if present. Acting upon this
theory, I took a case of acute mania—an adult woman—and,
with antiseptic precautions, injected into the soft tissues of the
flank 2 c.c. of turpentine^ 1 ) An abscess formed, and on the
third day after the injection I aspirated some fluid, consisting
XLIX. 16

Digitized by v^.ooQLe

220 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS, [April,

of blood-serum and pus. A couple of drops of this fluid were
then added to each of four tubes containing 8 c.c. of sterile
nutrient broth. These tubes were incubated for forty-eight
hours, when they showed slight turbidity, and upon micro¬
scopical examination the broth was found to contain a pure
growth of a small diplo-bacillus.

Since then I have made twenty-four similar observations, and
have isolated this diplo-bacillus in seven cases. Table I
shows the varieties of mental disease in which the observations
were made. It will be noticed that this small diplo-bacillus
has been obtained almost exclusively in cases of acute con¬
tinuous mania in adults.

Dr. Houston kindly examined the organism, and gives the
following description :—“ A small, short bacillus occurring
singly, in couples and short chains; stains very feebly by
Gram’s method. A stroke culture on agar shows a white
growth with no special characters ; later acquires a yellow tint;
on gelatine the growth tends to remain somewhat circum¬
scribed, with sinuous edges. Later, it becomes pitted and
wrinkled and skin-like in character ; eventually assumes a
pale yellow colour, and later slow liquefaction sets in. In
broth it forms a uniform turbidity, but the growth is not very
abundant. In litmus milk at 3 7° C. it gives a slow alkaline
reaction. It is not fatal to guinea-pigs in doses of 5 c.c. broth
culture inoculated subcutaneously.”

My own observations on the organism are as follows :

The method of obtaining the diplo-bacillus is as follows :—
A small quantity of the serum and pus from the necrotic area
is extracted with a hypodermic needle and syringe, and a few
drops are added to each of four tubes containing 8 c.c. sterile
broth. The tubes are incubated for forty-eight hours at 37 0 C.,
at the end of which period they show a slight turbidity if the
bacillus is present. I have seen the bacillus take seventy-two
hours to show in the broth. If a hanging-drop culture of the
broth be now examined, it will be noticed that the bacillus
tends to grow in chains and also in clusters, and that it is
slightly motile. If stroke cultures be now made from the
broth upon agar, the bacillus grows in from thirty to forty
hours in the form of little gelatinous colonies, which later
become opalescent. If a sub-culture be made again on agar
from these colonies, the growth appears as a thin whitish line

Digitized by v^.ooQLe

1 903]

BY LEWIS C. BRUCE, M.D.

221

in about twelve hours. The bacillus holds Gram’s feebly, and
does not take up any of the commoner dyes well. A stab
culture in gelatine grown at 20° C. liquefied the gelatine in
sixty days.

I am indebted to Mr. Richard Muir, of Edinburgh University,
for much valuable assistance and instruction in this part of my
work.

The organism is not fatal to rabbits, guinea-pigs, or white
mice. Two kittens were fed every second day for four months
upon 4c.c. of broth cultures. Their growth was slow, and
they were thin and poorly nourished. When the cultures were
no longer added to their food they improved in appearance,
and are now apparently healthy and well developed.

Agglutination tests were made with the blood of five patients
suffering from acute mania. The results were unsatisfactory,
but partial agglutination seemed to occur in every case. The
blood-serums of five members of the nursing staff were used in
controls, and in only one of these was there any clumping of
the bacillus, even at the end of twelve hours. The dilution
used in all the agglutination tests was i in io.

I have examined bacteriologically the skins of ten cases of
acute insanity, and have never isolated the diplo-bacillus. I
have also made plate cultures from the faeces of six cases of
acute insanity. In one I isolated an organism presenting all
the characters of the diplo-bacillus, and in two of the other five
cases I saw an organism corresponding to the diplo-bacillus in
size and staining reaction, but failed to isolate the growth.

I have been tempted to place these results before you in
the hope that the same organism may be detected by other
workers. If it is obtained by others exclusively from cases of
acute mania, there may be grounds for believing that there is
some connection between the organism and the disease.

What was the effect of the abscesses upon the patients ? I. In
twenty-three out of the twenty-four cases the abscess induced
a febrile attack within twenty-four hours after the injection of
the turpentine. In several cases the temperature rose as high
as 102° F. 2. In no case was the patient the worse
physically for the abscess, and in many cases there was marked
benefit.

To refer again to Table I, it will be seen that the patients
who benefited most were those suffering from acute mania.

Digitized by v^.ooQLe

222 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS, [April,

The only patient among the ten suffering from acute mania
who did not recover or improve had been ill for over six
months before the abscess was made. The average duration
of the illness in those who recovered was three and a half
months. Some of the results in cases of acute mania were so
satisfactory from a recovery point of view that I never hesitate
to induce an abscess in every case of acute mania which does
not rapidly improve under ordinary treatment. Out of the
whole twenty-four abscesses I only had to open one which
became septic accidentally. A few of the abscesses ruptured,
but the majority became absorbed, and I am of the opinion that
the abscess should not be evacuated, as even after all acute
symptoms have subsided it apparently acts as a stimulant to
leucocyte production, which is Nature’s method of assisting
recovery In these cases. I do not wish you to think that I
ignore the effect of the febrile attack and the subsequent
stimulus to nutrition which follows febrile attacks, but I am
satisfied that it is through the leucocyte action of the blood
that Nature effects recovery in all cases of acute mania. I have
examined in the last two years the blood, and especially the
leucocytes, in fifty cases of acute insanity. The observations in
each case were not single ones, but made continuously for
weeks and months. To assist in this work I have trained
several members of the nursing staff, who have been of great
service in preparing slides and cover-glasses, making and stain¬
ing films, and even, in some cases, of counting leucocytes by
means of Thoma Zeiss’s haemocytometer.

To-day I propose to describe the changes which occurred in
the leucocytes in fourteen acute continuous cases of mania
occurring in adults. I start on the hypothesis that anything
between 6000 and 10,000 leucocytes per cubic mm. of blood
is normal, and that the usual percentage of the polymorpho¬
nuclear leucocytes is about 70 per cent . The numerical counts
were made with Thoma Zeiss’s haemocytometer, and thirty or
forty fields were counted upon each enumeration, and the
results were frequently checked by duplicate counts and con¬
trol counts on healthy blood. The films were stained with
eosine and methylene blue—eosine and haematoxylin—Leish-
man’s stain and Jenner’s stain. At each differential count
never less than 200 leucocytes were counted. I have divided
my observations as follows :

Digitized by v^.ooQLe

1903.] by LEWIS C. BRUCE, M.D. 223

1. The leucocytosis which occurs in a patient who recovers
without interference. (Chart I.)

2. The leucocyte changes which occur in a patient who does
not recover, but becomes chronic. (Chart II.)

nd o

4 >

S 2 «

2 s
2 0
2 a

3-5

"S-

frt

*■8 .
c~ g
- fia
8 «*■©

5o$
rt o o
x

O .A

fe*

3 c —

•a " g

4 J U .

5 SLg
.S SS
!

«§£•

3. The leucocyte changes which occur when an abscess is
made in a recent case, and is followed by recovery. (Chart III.)

4. The leucocyte changes which occur when an abscess is
made in a chronic case which does not recover. (Chart IV.)

Digitized by v^.ooQLe

224 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS, [April,

I. The leucocyte changes which occur in a patient who
recovers.

If you are fortunate enough to observe the leucocytes in a

recent case of mania from the very commencement, you find
during the first few days of the disease that the leucocytosis is
high, say 18,000 to 20,000 per c.mm. of blood, and that the
percentage of polymorphonuclear cells is 70 or above 70 per

Digitized by v^.ooQLe

1903.]

BY LEWIS C. BRUCE, M.D.

225

cent., and never lower than 60 per cent. Nature apparently
makes a vigorous effort at the commencement of the disease
to counteract the toxaemia by pouring leucocytes into the
system. The higher the leucocytosis, within certain limits, and
the higher the percentage of polymorphonuclear cells, the
better is the prognosis. If the patient does not recover at
once the leucocytosis falls slightly to anything between 12,000
and 16,000 leucocytes perc.mm. of blood, and the polymorpho¬
nuclear cells rarely reach 70 per cent. This state of affairs may
last for weeks, and gradually leads into the stage of recovery.
When the patient shows signs of recovering a curious change
sets in in the leucocytosis. Instead of the leucocytosis dimin¬
ishing, it increases, and the percentage of polymorphonuclear
cells rises. In a favourable and rapidly recovering case these
cells may be as high as 80 per cent. A still more curious
thing occurs when recovery is actually complete—the leucocy¬
tosis persists, but the percentage of polymorphonuclear cells
again falls to between 60 and 70 per cent. It is impossible to
say how long this leucocytosis persists, because one cannot keep
a recovered patient indefinitely under observation. All I can
record is that all the recovered cases of mania discharged since
these observations were begun have been discharged with a
high leucocytosis. Is this leucocytosis a protective leucocy¬
tosis ?

2. The leucocyte changes which occur in a patient who does
not recover.

The changes which occur are slow, and go on for months
with many fluctuations, but shortly they are as follows:—The
leucocytosis tends to remain between 12,000 and 16,000 per
c.mm., with occasional rises and falls, but the percentage of
polymorphonuclear cells tends to fall until finally, after the
disease has lasted for one or two years, the proportion of poly¬
morphonuclear cells may be anything from 20 to 50 per cent.
There is always a proportionate increase of lymphocytes.
With an exacerbation of the disease there may be increased
leucocytosis, with a rise in the percentage of the polymorpho¬
nuclear cells, but such an increase is very temporary.

3. The leucocyte changes which occur when an abscess is
made in a recent case and is followed by recovery.

Within six hours after the subcutaneous injection of the
turpentine the polymorphonuclear cells may show a marked

Digitized by

Google

2 26 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS, [April,

relative increase. In twenty-four hours the leucocytosis is dis¬
tinctly increased, and the percentage of polymorphonuclear
cells remains high, i. e. they are both actually and relatively
increased. In forty-eight hours the leucocytosis is still higher,
rising in various cases to 30,000, 40,000, or even 60,000

AUG SEPT OCT

Chart III.—Showing the leucocyte changes in a recent acute case of continuous
mania in which a turpentine abscess was induced, and which recovered rapidly.

per c.mm. of blood, while the percentage of polymorphonuclear
cells remains above 80 per cent ., and this is generally the
maximum of the leucocytosis.

Mental improvement appears to be in proportion to the
leucocytosis, i. e . the higher the polymorphonuclear element the
more marked is the mental improvement. For a varying

Digitized by v^.ooQLe

I 9 ° 3 -]

BY LEWIS C. BRUCE, M.D.

227

period after the forty-eight hours the leucocytosis remains
high. For instance, in one case in which an abscess was in¬
duced on August 21st the leucocytosis by the end of Septem¬
ber had never fallen below 22,000 per c.mm. This patient
made a rapid and excellent recovery. As recovery advances,
however, the percentage of polymorphonuclear cells generally
falls until it reaches somewhere about 60 per cent ., and the
lymphocytes are slightly increased.

4. The leucocyte changes which occur when an abscess' is
made in a chronic case.

OCT.

Chart IV.—Showing the leucocyte changes occurring in a case of chronic con¬
tinuous mania after the subcutaneous injection of turpentine.

Twelve hours after the subcutaneous injection of the tur¬
pentine there may be a fall in the leucocytosis with a slight
relative increase of the polymorphonuclear elements. Twenty-
four hours after the injection there is a decided rise in the
leucocytosis, but the polymorphonuclear cells show a very
slight relative increase. In forty-eight hours the leucocytosis
is markedly increased, but the increase of polymorphonuclear
cells may not reach 70 per cent . By the end of seventy-four
hours in the case shown in the chart, the leucocytosis was
showing a tendency to fall, but the polymorphonuclear cells

Digitized by v^.ooQLe

2 28 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS, [April,

were relatively increased, and by the end of 122 hours the
leucocytosis was distinctly falling and the polymorphonuclear
cells were again below 70 per cent. Thereafter there was a steady
fall of both the leucocytosis and the percentage of the poly¬
morphonuclear elements. This patient showed no mental im¬
provement. By comparing Charts I and III it will be seen
how the formation of an abscess simulates and surpasses the
leucocyte production which naturally occurs when a patient
recovers, and a comparison of Charts III and IV illustrates
graphically the differences in the resistive powers of a recent
acute curable case of mania and a chronic case, whose energies
have been sapped by long-continued disease.

These observations do not apply to the condition of mania
in patients suffering from “ folie circulaire,” nor to mania the
result of alcoholic poisoning.

1. If these blood observations are correct, they practically
prove that acute continuous mania is an acute infective condition,
and that when recovery takes place a condition of immunity is
established.

2. They prove that, although the patient apparently recovers,
the disease remains latent; hence the persistent leucocytosis, a
point which might be of great importance in life-insurance
examinations.

3. An examination of the blood is a valuable aid to
prognosis.

Let us say a case of mania has lasted for a month, and
remains maniacal and sleepless. The blood examination gives
a leucocytosis of 14,000 per c.mm. of blood, with a percentage
of 60 or below 60 of the multinucleated cells. The chances of
an immediate or early recovery are poor. On the other hand, if
the blood examination gives a leucocytosis of 18,000 or 20,000,
with the multinucleated cells in a percentage of 70 or above
70, the prognosis is good. It is as well, when examining the
condition of the blood to aid prognosis, to examine the blood
on at least two consecutive days.

Digitized by v^.ooQLe

1903 -]

BY LEWIS C. BRUCE, M.D.

229

Table.

Cases.

Sex.

Age.

Mental disease.

Organisms.

Remarks.

Adolescent mania

Diplo-bacillus

Arrested the attack.

>> »>

Very temporary benefit.

tt >>

Diplo-bacillus
and cocci

Recovery.

M II

Diplo-bacillus

Recovery.

Sterile

Arrested the attack.

II II

Diplo-bacillus
and cocci

Recovery.

II II

Diplo-bacillus
and cocci

Recovered, then be¬
came depressed.

If II

Sterile

No immediate benefit,
but patient made good
recovery.

II II

Slightly less excited.

II If

No immediate benefit,
but made good re-

Puerperal mania

CUVcijr.

Marked benefit; rapid

Adolescent epileptic

recovery.

Arrested the attack.

ma^ia

Adolescent mania

No benefit.

Chronic mania of
adolescent

Cocci

Very slight benefit.

Adolescent mania

Sterile

Recovery.

11 ii

Diplo-bacillus

Temporary benefit.

General paralysis

Sterile

No benefit.

11 11

„

11 11

„

11 11

Cocci

11 11

Excited melancholia

Sterile

Marked improvement.

22 i

, •*

Temporary benefit.

n 11

No improvement.

1 24

11 11

1 '*

”

(*) Dr. Ford Robertson points out to me that G. Albertotti (Annali di Freniatrice,
1896, pp. 23 and 147) has already utilised turpentine abscesses as a method of
treatment. I utilised the turpentine in the first place to induce an aseptic abscess
for bacteriological observation.

Discussion

At the Meeting of the Scottish Division, December, 1902.

Dr. Ireland. —I regret that Dr. Clouston has had occasion to go away on some
business, and he has asked me to take the chair. 1 must say that by his absence
we will miss some very pregnant observations, which he no doubt would have
made. I remember in the first edition of his book on mental diseases he pointed
out the probability of a cure for insanity from the consideration of cases which
recovered after certain fevers which he had observed. Now here we have
Dr. Bruce, who has experimented with a similar idea and reduced it to an exact
form, and I think that some of our members should repeat these observations
made by Dr. Bruce. I have got some hopes that they will be confirmed, and we

Digitized by v^.ooQLe

230 BACTERIOLOGICAL AND CLINICAL OBSERVATIONS. [April,

all ardently wish that that should turn out to be the case. The only suggestion
I could make is that Dr. Bruce apparently has only employed turpentine to create
the abscess.

Dr. Bruce. —Yes.

Dr. Ireland. —He might try some other substance. Turpentine has very
peculiar properties, and it is possible that this might have a certain effect on the
blood. I therefore think that if there was an abscess formed in some other way
it would confirm the conclusions which Dr. Bruce has come to if the results were
identical. I have no doubt that a number of gentlemen will have remarks to
make on this very pregnant paper.

Dr. Yellowlees. — I have nothing to say except to express my emphatic
admiration for the work done and my very hopeful views as to what may come
out of it. If I were a young man like Dr. Bruce I would work at this with all my
soul. I am sorry I have not time to offer any remarks, as I have to go to the
same meeting as Dr. Clouston has gone to. I have pleasure in proposing a hearty
vote of thanks to Dr. Bruce for his admirable paper.

Dr. Easterbrook. —I have much pleasure in seconding Dr. Yellowlees' vote of
thanks to Dr. Bruce, and know that his inquiry has involved much time and
work. I have not made any observations myself from the same point of view as
Dr. Bruce. He lays great stress on the connection between the leucocytes in the
blood and the mental condition of the patient, as if the one had almost a domi¬
nating relationship with the other. I am not prepared to exactly contradict that
statement, but I must say that from certain observations I have made, I would be
more inclined to ascribe the changes in the mental condition to changes in the
cell metabolism of the brain and body generally. For example, when a patient
recovers, one of the most striking things is a gain in weight, and improved colour
and circulation. If one tries to get at the explanation of the loss in weight fol¬
lowed by the gain in weight, there is one explanation which seems pretty apparent,
and that is going back to the condition of affair in the cells of the body. Ac¬
cording to the views of Hering and other physiologists, the more catabolism that
takes place in the cell the greater is the resistance to that catabolic condition
going on in the cell—there is a tendency for anabolism to assert itself. So in acute
mania, where you have very advanced catabolism going on, that stage continues
for a certain period, and then the tendency to anabolism asserts itself, and when
the patient recovers it is increased. It seems as if one would have to go to the
protoplasm of the brain neurons as explaining the condition and recovery in the
patient. I would rather be inclined to say that it was the protoplasm of the cells
of the brain and body generally that held the secret. With regard to the leucocytes,
there may be some connection between the two, and whether they stimulate this
anabolism or not I do not know.

Dr. Macdonald. —Have you attempted any experiments in the way of injecting
the turpentine into presumably healthy individuals ?

Dr. Bruce. —I have not found any individuals who would offer themselves for
such an experiment.

Dr. Macdonald. —You might find some. No matter what chemical you may
introduce under the skin, it will certainly tend to the production of an abscess,
granted that there are pus-producing organisms in the body. It is not correct to
talk of that collection of matter which Dr. Bruce produces as an abscess. He
must first show that it contains pus-producing organisms. This diplo-bacillus
may be a pus-producing organism, but it may not be. It is most important to
have these contrary experiments.

Dr. Ford Robertson said he was of opinion that the observations that Dr.
Bruce had brought before them were of much value. They illustrated the impor¬
tance of uniting the study of the pathology of insanity with clinical investigation.
It was from researches of this nature that important advances in the treatment and
prophylaxis of insanity would chiefly come. It was easy to criticise work such as
Dr. Bruce had been doing, and he supposed that in a discussion of this kind it was
right to be critical. He agreed with Dr. Macdonald that Dr. Bruce had not laid
before them any evidence that went to prove that this bacillus had anything to do
with the causation of acute mania. The treatment of certain forms of insanity by the
artificial production of abscesses by turpentine had been advocated several years ago
in Italy (s ee Journal of Mental Science, July, 1897, p.612), and the results recorded

Digitized by v^.ooQLe

1903.] UNRECOGNISED DEGENERATE PUNISHED BY LAW. 23 I

had been excellent, but he believed he was right in stating that the treatment had been
abandoned in that country now. He would like to know if Dr. Bruce had ascer¬
tained if the bacillus he had isolated was identical with that found by Bianchi and
Piccinino in acute delirium. He was surprised that Dr. Bruce had not attributed
any importance to disorders of the gastro-intestinal tract in the causation of acute
mania. There was now satisfactory evidence that a large proportion of such cases
were really dependent upon toxic infection from the alimentary tract.

Dr. Urquhart. —Dr. Bruce’s paper has not been a simple one to write; it is a
paper which evidently has cost him much trouble, and there must have been a great
deal of arithmetical work in counting up these leucocytes in all these cases. It is
somewhat difficult for anyone to follow Dr. Bruce’s observations properly without
going to Murthly and seeing the work that is done there. Lately I had the advan¬
tage of having one patient examined there, and if the case could have been followed
up to the end it would have shown results similar to those in the fourth chart. I
hope that you will accord a very hearty vote of thanks to Dr. Bruce for making
this elaborate investigation.

Dr. Ireland. —Yes. We are, I am sure, extremely grateful to Dr. Bruce.
(Applause.)—If you have anything to say in reply, Dr. Bruce, we will be glad to
hear you.

Dr. Bruce. —I don’t know that there is much to reply to. In regard to Dr.
Easterbrook’s observations, I must say from my observations of leucocytes that I
believe their action to be just as important as changes in the protoplasm of the
cell. As to the remarks about pus-producing, it is nonsense to say that you cannot
talk of the necrotic area produced by turpentine as an abscess. You can produce
an abscess by irritants ; if what you call an abscess is a thing full of pus, then you
get it. Then as to people coming forward to have abscesses made: 1 shall be glad
to make abscesses in anyone who will volunteer. It is a very striking point that
out of twenty-four abscesses sixteen were absolutely sterile.

Dr. Macdonald. —A sterile abscess P

Dr. Bruce. —Yes. What you are arguing about is the definition of an abscess.
My definition is a dead area caused by a toxin or irritant, and that is a view now
very generally held. As my paper threatened to be too long, I shortened it, and I
did not tell you that I had made observations on the skin of acute cases and never
got this bacillus. I examined the intestinal tracts of six cases, and I got the
bacillus in three. I agree with Dr. Ford Robertson that changes or toxins formed
in the intestinal tract have something to do with the production of acute mania,
but in a whole lot of diseases, such as phthisis, you always get intestinal symptoms.
In my opinion the intestine is the point of attack of organisms if such organisms
are the cause of mania. The bacillus does not resemble the bacillus of Bianchi.
Turpentine is the only substance which produces a prolonged leucocytosis. I have
tried other substances, such as nucleic acid and cinnamate of soda, but I have not
been able to produce the same leucocytosis as with turpentine. Turpentine is not
so inhuman as you would think; out of twenty-four cases I have only had three
that complained of the pain. The great majority of these cases of acute mania
are very insensible to pain ; they don’t seem to feel it. I take a small quantity of
carbolic acid, which makes the skin anaesthetic and purifies it at the same time, and
I inject the turpentine at this spot. After three or four days the pain and inflam¬
mation are gone, and you have a big swelling which acts as a stimulant to leuco¬
cyte formation. I don’t think that there is anything more I can say to the criticisms
you have so kindly made.

The Case of an Unrecognised Degenerate punished by the
Law. By Edwin Goodall, M.D.

The case here dealt with is that of a man aet. 35, now a
patient at Carmarthen Asylum, formerly a ferryman. He was

Digitized by v^.ooQLe

232 UNRECOGNISED DEGENERATE PUNISHED BY LAW, [April,

admitted from prison, where he was undergoing a sentence of
twelve calendar months with hard labour, having been con¬
victed at the assizes of unlawfully attempting to have carnal
knowledge of a girl under thirteen years. He was imprisoned
on March 24th, 1902; the trial was on May 30th, and he was
removed to the asylum on July 1st, symptoms of certifiable
insanity having been first observed by the medical officer to
the prison on June 26th. The total term of imprisonment
was therefore rather over three months.

In the newspaper account of the trial the following remarks
appear:—“ Prisoner, a rough-looking man, was indicted for a
horrible assault on a little girl of somewhat weakly disposition
and intellect. It was one of those bestial cases which arise
from time to time in all communities to show to what depths
of depravity brutes in human form may descend. The prisoner
rightly deserved the twelve months’ hard labour to which he
was sentenced.” And again : “ His Lordship, addressing the
prisoner, said he thought he was very properly convicted.”

It apparently occurred to no one that the accused, as well
as the person assaulted, might be of weak intellect.

Whilst at the prison the man was placed on the treadmill for a
time, and also put to pick fibre, but he could not even do this,
being, the chief warder reported, too dull and slow. The
doctor also described him as dull, heavy, and slow, dirty and
slovenly ; he could not be got to keep his cell clean. Noticing
symptoms of insanity finally, the medical officer wrote a certifi¬
cate, describing hallucinations and delusions connected with
the events of the trial. Transferred to the asylum, the mental
state was found to be one of congenital deficiency, with recent
disturbance superimposed, and characterised by depression,
visual and aural hallucinations, fear-inspiring delusions, agita¬
tion. The cause of these latter symptoms, in the opinion of
the prison medical officer, was worry in connection with his
trial. To which I add as an aggravating cause the regime
of his prison life.

Much difficulty was experienced in getting out the family
history. The following only was elicited :—The father drank
heavily and died in apoplexy; several of the family also drank;
one aunt died paralysed. As regards the patient, the relatives
considered that he was right enough in mind—which is not
surprising. They stated that he at times drank heavily, and

Digitized by v^.ooQLe

1903]

BY EDWIN G00DALL, M.D.

233

then was rough and violent. The prison officials informed us
that he had been in gaol on nine previous occasions—seven
times for drunkenness, once for indecent language, once for
theft.

The patient was submitted to anthropological examination,
according to a scheme which the present writer brought before
the Psychological Section of the British Medical Association
in 1901, and the results were compared with the average
results in thirty-two normal persons from the same district as
patient. These normal cases, I may be permitted to remark,
were laboriously and slowly collected, and submitted them¬
selves with a more or less good grace to a minute examination
of three to four hours each on the exhibition of silver and beer.

The work of preparing a standard of comparison from
healthy persons in different districts of the country will be heavy
and tedious, unless divided between many collaborators.

I give here a summary of the conditions presented by the
patient. First as regards measurement. Out of 68 measure¬
ments of the trunk, limbs, head, and face, he showed
difference from the normal standard of from 5 mm. upwards in
35, or one half. Eight other measurements could not be taken
because of either acquired deformity interfering therewith, or
resistance offered by patient. In 22 of the 35 the difference
was over 1 cm., in 13 of which it was over 2 cm. In the
great majority of the cases of difference above 5 mm. the
measurement in patient was less than normal, there being a plus
measurement only in 7 out of 35—namely, in the length of
the hands (1 cm., and 1 cm. 5 mm. above average), of middle
fingers, length and breadth of ears, length of ear-implantation,
naso-lambdoidal arc, and greatest distance between great
trochanters. In the height-measurements of the head and
trunk the patient fell below the average. The facial measure¬
ments were from 5 mm. to 1 cm. 8 mm. less than normal
in the following :—Breadth between the external angles of
the eyes, distance of chin-point from root of nose, of same
point from the nose-lip angle, of same point and mouth-
fissure, distance between the external angle of the eye and
angle of the mouth, the greatest breadth across the malars.
All except 7 of the 27 facial measurements (several of
which were in duplicate) showed differences from the normal,
+ or —, though less than 5 mm. A point brought out

Digitized by v^.ooQLe

234 UNRECOGNISED DEGENERATE PUNISHED BY LAW, [April,

was the symmetry of the two sides of the face, which was
equal to normal. All the cranial measurements which could
be taken (7) showed differences from the normal, and more
than 5 mm. in 4 out of the 7. The difference was on
the minus side in 4. The left hand was longer than the
right by 5 mm., whereas in the average of normal cases the
hands were equal, there being a difference of 5 mm. (right or
left) in only five cases. Patient was not left-handed.

Next, as regards the descriptive signalment. In 50 out of
some 11 5 headings under which the description of the state of
the body as regards stigmata is considered, deviations from the
average conditions were found—43 4 per cent . The principal ones
only need be given here. Cranium generally, including fore¬
head, narrow, with fronto-parietal flattening ; occiput also flat.
A long, narrowish face. Eyes : palpebral fissure of small verti¬
cal dimension, especially on one side ; asymmetry in direction
of palpebral fissures ; asymmetry in model of upper lid ; ditto
in position and direction of eyebrows ; exceptional disposition
of pigment in iris. Peculiarities in size, shape, and direction of
certain teeth—namely, upper and lower incisors and canines.
Growth of hair about scapulae. Unilateral flat foot, and excep¬
tional length of second and third toes. Malformation of chest.
Malposition of pinna, both sides ; malformation of the helix
of ear and its fossa, both sides. Blood-circulation defective,
with local varicosity. Incessant irregular (voluntary) move¬
ment of various muscles, especially frontal and ocular ; the
same (involuntary) of tongue on protrusion.

Thus in 50 per cent, of the observations coming under the
heading of “ measurements,” and 43*5 per cent . of those noted
under “ descriptions,” the patient showed departure from the
normal standard. To this statement there has to be added
the qualifying remark that in the majority of the vertical
measurements (“ height-measurements ” of the scheme), and in
certain cranial ones, many of the normal cases showed varia¬
tions from the average equal to those observed in the patient.
Whilst it is, of course, most desirable to multiply as much as
possible the number of normal observations, and to ascertain
carefully up to what point, on either side of an average figure,
variations may normally occur, these desiderata appear most
urgent in the case of the peculiarly variable height-measurements.

The above qualification notwithstanding, due weight must

Digitized by ^.ooQle

1903 -]

BY EDWIN GOODALL, M.D.

235

be accorded to the facts that variations from an average
occurred in this case in so large a percentage of the two classes
of observations comprising the signalment; and that the
difference from the average was considerable in such a large
proportion of instances.

The deviations from the normal as regards the mental state
have already been alluded to.

It may be added that the acute and recent mental symptoms
have passed off, leaving the indications of congenital deficiency.

The signalment of this case, therefore, furnishes numerous
indications of defective physical conformation, the complement
of the evidence of mental inadequacy.

The conclusion pointed to by the examination as a whole is
that the patient is a defective —minus habeus , as French authors
have it; zuriickgeblieben , or minderwerthig ; after the Germans,—
and as such not fully responsible.

I put forward the following propositions :—It is an antiquated,
inefficient, and unscientific system which permits of the punish¬
ment of a person of this kind. Punishment in such a case is
bad on moral, economical, and scientific grounds. The procedure
adopted, which is doubtless common in similar cases—namely,
repeated imprisonment and discharge after a short term—is not
only useless, but injurious to the individual concerned, and
unjust towards society. But even when a long sentence is
passed, the prison, with its lack of educational treatment and
its atmosphere of punishment, is not the proper place for a
case such as that described. An adequate knowledge of
mental disorders and of anthropometric methods on the part of
prison medical officers would prevent the punishment of such
cases, and, better still, prevent their going up for trial. I
assume, of course, that the authorities concerned would be
sufficiently enlightened to pay regard to the representations of
their medical officers ; that the manifestation of zeal would
not be blasted by an official frown.

A comment as regards the trial of this individual and his
like. In the present instance there was only one other case,
and that of a light nature, on the calendar ; and it might well
have been that the pomp and circumstance with which the
holding of the assizes is surrounded, and the attendant expense,
would have been lavished upon a trial the holding of which
was surely quite unnecessary.

XLIX. 1 7

Digitized by v^.ooQLe

236

NOMENCLATURE OF MENTAL DISEASES, [April,

I submit that this individual, a defective, required, not
punishment, but educational treatment, mental and physical,
with the teaching of an occupation if possible ; and that it was
in the first instance a case for a reformatory, upon the lines of
the State Reformatory of New York at Elmira. For an
account of this I may refer to the last edition of Dr. Havelock
Ellis’s work on The Criminal\ from which I gather that the
system of Elmira is being extended over the United States.

If the patient developed satisfactorily he would be allowed
out on trial to do work previously found for him. Otherwise
he would be detained, preferably under the system of an
indeterminate sentence of an unconditional kind. Should he
show symptoms pointing to the need for asylum care, he would
be transferred to the asylum.

Lastly, as regards anthropometric observation in such cases.
“ A change in the intelligence, a change in the body,” said
L£lut, in 1844. “The blot upon the brain will show itself
without; ” and it probably does so in a more exact sense than
the poet imagined. It is a correlation to be expected, I appre¬
hend, that between cerebral deficiencies and bodily stigmata
(superficial, and of internal organs). At the annual meeting of
the Association of German Alienists at Munich, in April,
1902, Wolff, Basel, read a paper, with demonstrations on
animals, upon the experimental evidence of the influence of the
nervous system upon developmental processes,(*) which bears in
an interesting manner upon this point. If there be outward
and visible signs of inward and spiritual defect (and my case,
I submit, though but one, goes to answer this in the affirmative),
then it is our business to find and demonstrate them. And
such demonstration will probably be our best argument before
the sceptical legal fraternity in our endeavour to prove mental
deficiency and irresponsibility.

(*) Allgem . Zeitschr.fur Psychiatric, Band lix, Heft 5.

Nomenclature of Mental Diseases. By A. R.

Urquhart, M.D.

I HAVE ventured to suggest that we should now consider what
we are going to do about the classification of mental disorders.
Lately, the Royal College of Physicians of London decided to

Digitized by LjOOQle

1903-]

BY A. R. URQUHART, M.D.

237

revise the Nomenclature of Diseases , and publish another edition.
The President of this College is on the Committee; as is also
Dr. Savage, our colleague in London, who has taken much
interest in this question. I was somewhat surprised the other
day when I asked for a copy of the Nomenclature of Diseases
in the Royal Medical Society of London, to find that they
did not have a copy in their library—a book which is supposed
to guide the profession in the statistical registration of diseases.
In 1896, for the third edition, an attempt was made to reform
the nomenclature of mental diseases, under the direction of Dr.
Hack Tuke and Dr. Savage. In its present state it is still
unsatisfactory. The classification with which we have to deal
is as follows :—First, there is “ idiocy (cretinism), and then mania
(acute or chronic), delirious, hysterical, puerperal, epileptic,
traumatic, syphilitic, gouty, from either acute or chronic disease,
alcoholic, plumbic, or other poisons.” Acute is an absurd
word, because we specially want to mark the duration. Acute
should be rendered Recent. Then there is “ melancholia (acute
or chronic), delirious, hypochondriac, climacteric, puerperal,
epileptic, syphilitic, acute, other diseases.” Then there is
“dementia (primary or secondary), senile, climacteric, puerperal,
epileptic, traumatic, syphilitic, acute, other diseases.” Then
there is “ mental stupor , anergic, delusional.” Then there is
“general paralysis .” That is not a mental disease. Lastly, there
is “ delusional insanity

I refer now to Skae’s classification, and always desire to speak
of that with the utmost respect, because it was Skae who first
in this country adequately drew public attention to the fact that
insanity in various forms might be regarded as variously depen¬
dent on physical diseases. Taking the last variation of it from
Dr. Clouston’s Manual, it runs through the arrangement familiar
to you, with a supplemental list of anaemic insanity, Bright’s
disease, and so on. The whole is mixed up in an olla-
podrida, the different forms having no scientific relations to
one another.

When Dr. Robertson, of Larbert, heard that I was to speak
on classification, he kindly sent me the papers which have
been handed round, showing that he had approached the
subject from very much the same point of view as myself.

The most important recent development for us is the toxic
causes of insanity, and the question now is whether we have

Digitized by ^.ooQle

238 NOMENCLATURE OF MENTAL DISEASES, [April,

advanced so far as to tabulate these toxic causes. Some of
them are indubitable; and I think that, as time goes on, we
shall be able to increase the number of cases under toxic causes,
and certify them with greater correctness.

There is no doubt whatever that we must, as yet, stand by
Griesinger’s classification, and arrange mental disorders from the
point of view of symptoms. Broadly, we have never got
beyond that, and we would be doing well, I think, generally to
continue to use the words and the classification which he for¬
mulated. Meynert tried to introduce a pathological classifica¬
tion, and I did my best for some years to pigeon-hole all cases
under that tentative scheme, but had to give it up, because the
time is not yet ripe. The question to-day is whether we can
improve upon Griesinger’s classification, connecting it with
Skae’s classification ; that is to say, adopt a classification which
will characterise the symptoms, and which will also indicate
the etiology, exclusive of the facts of heredity, which, of
course, should be noted in every case. The benefit of de¬
scribing our cases more minutely, and without cross-entries,
would be undoubted. The classification, of course, must be
logical—I cannot classify rivers, horses, blacksmiths, in one
gross lot. There must be some sort of definite relation in the
classification, and I think that we might agree on the main
features. The proposed scheme which is now before you is
not evolved out of my inner consciousness ; it is the result of
an extended examination of our records in case-books and
clinical sheets. We have been using it in Murray’s Asylum
for four or five years, and have found it to be a practicable
method of dealing with the classification of cases of insanity.
As above indicated, the facts regarding heredity are noted in
addition to the symptomatic and other etiological details, as
well as the facts regarding neuroses.

It is difficult to decide what constitutes neurosis, e.g. whether
such diseases as apoplexy are to be excluded. It is remarkable
how many of our patients have had ancestors who have suc¬
cumbed to apoplexy; and I think it should be included amongst
neuroses, as well as the more ordinary forms of hypochondria,
somnambulism, etc. I have not attempted to deal with these
in detail, because the College does not include these milder
cases of disorder, but we must consider them in regard to the
revised statistical tables of the Medico-Psychological Association

Digitized by v^.ooQLe

1903 -]

BY A. R. URQUHART, M.D.

239

now in progress. I had the advantage of hearing the first
debate of the committee which is preparing these tables, and
it seemed to be full of promise. There will be more useful
results if men will put down only what they know, and only
deal with figures that are true. There is really a necessity for
that discrimination. I hate the word “ idiopathic.” It is a mere
attempt to cloak our ignorance. Therefore you will not find
that word in this scheme. Far more effective is the term
“ unknown,” frankly stated.

Diagnosis of Mental Disease, as Classified.

1. Melancholia—recent, chronic, recur¬

rent.

(a) Simple (without delusion).

( b ) Hypochondriacal.

(d) Delusional.

(e) Excited.

(/) Resistive.

(g) Apathetic.

( h) Abstinent.

(i) Suicidal.

(j) Homicidal.

2. Mania—recent, chronic, recurrent.

(a) Simple.

(A) Hysterical.

(d,) Acute delirious.

(e) Delusional.

(/) Abstinent.

(g) Suicidal.

(A) Homicidal.

3. Confusional insanity.

4. Stupor.

! a) Primary melancholic.
b) Primary anergic (P lethargic),
(c) Secondary.

5. Periodic (? alternating) insanity.

(a) Circular, intermittent or con¬
tinuous.

(b) Katatonia.

6. Delusional insanity (paranoia)—pri¬
mary progressive, or secondary.

(a) Grandeur.

(A) Suspicion.

(d) Persecution.

7. Volitional insanity.

(a) Obsessions.

(b) Impulsive.

8. Dementia.

(a) Primary.

(b) Secondary.

9. Idiocy and imbecility.

Note .—The above classification is descriptive of mental symptoms, purely
clinical, and, 'proceeding on the decision of Griesinger, “ the natural basis of
classification must be founded on observed facts—states of depression, elevation,
or weakness.”

To correlate mental with bodily conditions, the following should also be used :

Etiological Classification.

a. Epochal—

(a) Adolescent.

( b ) Climacteric.

b. Exhaustive.

(«) Pregnancy, puerperal, lacta¬
tional.

(b) Masturbation.

(rf) Over - exertion, mental and
physical.

(e) Neurasthenia.

c. Visceral—

(a) Anaemia.

(b) Cardiac.

(<?) Ovarian and uterine.

(<?) Other visceral disorders.

d. Toxic—

(a) Exotoxic—alcohol, morphia,

cocaine, lead, etc.

(b) Autotoxic by deficiency—myx-

cedema, cretinism, ovarian,
etc.

rheumatism, chorea, diabetes,
albuminuria, etc., P constipa¬
tion.

Digitized by v^.ooQLe

240

NOMENCLATURE OF MENTAL DISEASES, [April,

(rf) Microbic — syphilis, phthisis,
septicaemia, fevers, influenza,
etc.

B. Degenerative—

(a) Developmental arrest, mental
and physical—idiocy, imbe¬
cility.

(A) Morbific habits of life.

(<f) General paralysis of the in¬
sane.

(e) Other organic diseases of

the encephalon — atheroma,
thrombosis, embolism, apo¬
plexy, tumours, etc.

F. Accidental—

(a) Traumatic.

( b) Insolation.

nubial, post-operative, etc.

(<f) Deprivation of the senses.

( e ) Communicated.

G. Unclassified—

(a) General.

( b ) Metastasis.

Note .—The facts of heredity should be noted with this classification, either
insanity or neuroses—anaesthesia, hyperaesthesia, capricious temper, eccentricity,
hysteria, hypochondria, neurasthenia, insomnia, somnambulism. Other manifesta¬
tions of cerebral or nervous instability or disease, e.g. apoplexy.

1. I now suggest that the first class ought to be “melan¬
cholia” and separated into recent, chronic, and recurrent cases,
reserving the word “ acute ” to indicate the severity of sym¬
ptoms rather than the duration of the disorder. Acute
delirious mania is a very marked form of mental disorder
which requires no further symptomatic indication, but “ acute ”
signifies that it is something more than recent. Then we have
to consider whether the word “ recent ” will be held to include
cases that have occurred within twelve months or within six
months ; the term “ recurrent ” must also be defined for our
statistical purposes. In my opinion, a second attack may be
considered a relapse, but a third attack should be classed as
recurrent. This arbitrarily affects the duration of the disorder.
In a recurrent case we must go back to the date of the first
attack as a basis. It is not quite clear whether this should be
done in reference to a second attack ; perhaps my custom to
give the benefit of the doubt and state the shorter period may
be upheld.

Then melancholia in this suggested nomenclature is divided
into simple, hypochondriacal, hysterical, delusional, excited,
resistive, apathetic, abstinent, suicidal, and homicidal. These
are descriptive words as regards the form of mental disorder.

2. “ Mania ” is similarly dealt with, as follows :—Mania
(recent, chronic, recurrent), simple, hysterical, acute, acute
delirious, delusional, abstinent, suicidal, and homicidal. 3.
“ Confusional insanity ” is inserted here in deference to the
generally expressed desire of the meeting. 4. Fourth, we have
“ stupor” primary melancholic, primary anergic (? lethargic),

Digitized by v^.ooQLe

I903.] BY A. R. URQUHART, M.D. 241

secondary. Primary anergic is an unsatisfactory term, but I
have seen no better suggested to differentiate it from that
stupor which is the result of an intensely delusional condition.
5. Fifth, we come to 44 periodic insanity" (circular), intermittent
or continuous, katatonia. 44 Alternating insanity" has been pro¬
posed as a more definite term for this class of cases. 6. Sixth,
we have “ delusional insanity " of grandeur, suspicion, unseen
agency, persecution, querulous. 41 Paranoia " is suggested as a
more convenient term—primary progressive, or secondary. 7.
Seventh, we recognise 44 volitional insanity" obsessional, impul¬
sive, moral. 8. Eighth,there is 44 dementia" primary,secondary.
9. Ninth, 44 idiocy and imbecility .” Imbecility is not a statutory
word ; if a patient is returned to the Board of Lunacy under
form A 1 as an imbecile, that is not accepted, because the
imbecility may be too slight to justify detention. The term
must be strengthened by facts indicating insanity . Dr. Robert¬
son has divided these cases into high-grade and low-grade
degenerates.

If you* accept this scheme, it is further necessary to supple¬
ment it with etiology, beginning with the facts of heredity, so
that the case is further explained on your being informed
whether the mania is (a) Epochal —adolescent, climacteric, or
senile ; or (b) Exhaustive —pregnancy, puerperal, resulting from
masturbation, sexual excess, over-exertion, mental, physical
neurasthenia ; or (c) Visceral —anaemia, cardiac, pulmonary,
ovarian, etc.; or (d) Toxic — exo-toxic , alcohol, morphia, etc.;
auto-toxic y by defect, myxcedema, or by excess, acute rheu¬
matism ; microbic —phthisis, syphilis, etc. ; or (e) Degenerative
—epilepsy, general paralysis, etc. ; or (f) Accidental, traumata,
etc. ; or, lastly, (G) Unclassified, general, and metastatic.

Sometimes there is no difficulty in placing cases ; e.g. a young
lady became maniacal after a double ovariotomy. Treated
with ovarian extract she rapidly recovered. Similarly, ovarian
extract relieves certain cases of insanity at the climacteric. It
is the cure for this autotoxic mental disorder by deficiency.
We may well refer to the work of Schroeder van der Kolk, in
the middle of last century, in which he correlated mental dis¬
order with somatic conditions, and specially sympathetic mania
proceeding from the colon. We know how common intestinal
disorder is in our practice, how the bacteriological importance
of this condition has been insisted on by Dr. Ford Robertson.

Digitized by ^.ooQle

242 NOMENCLATURE OF MENTAL DISEASES, [April

Is this condition to be described as autotoxic by defect ; by
defective protection against the toxic elements ; or by excess
of these elements ? I trust that Dr. Robertson will give us
some indication of his opinion on this point.

I think that we might venture to recommend some such
scheme of classification as now submitted to the College of
Physicians through our representative on the new committee
appointed by the College, and that we should ask our Statistical
Committee to consider it for their purposes.

Discussion

At the Meeting of the Scottish Division, in the Royal College of Physicians,

December, 1902.

Dr. Ireland. —We may congratulate ourselves that we have had three subjects
for discussion to-day, each of which might have filled an ordinary meeting. I don’t
know any man in the Association whom I would trust more to draw up a classifica¬
tion of insanity than Dr. Urquhart, who has great experience, great clinical skill,
and great learning in the lore of insanity. When I first became a member of this
Association, and that is some time ago, there was a great deal of discussion regard¬
ing the classification of insanity. Dr. Skae’s classification was the one which was
most favoured here, and Sir John Batty Tuke improved on Dr. Skae’s. There
was also a memorable debate between Sir J. Crichton Browne and Dr. Clouston on
this subject. I would be very well pleased to see the younger members take an
interest in classification, which is a very important question. I quite agree with
Dr. Urquhart that you still must classify by the symptoms. There is talk of
a scientific classification of insanity based on pathology, but we are not ripe for
that, although, as time goes on, our classifications based on symptoms are bound
to be deposed by the advance of pathology. Take myxoedema, for example; Dr.
Urquhart has separated idiocy from dementia. Sporadic cretinism goes along with
myxoedema; it has the same pathology, and we cannot afford not to take notice of
the connection between the two. 1 also would remark upon Dr. Urquhart’s classifi¬
cation that in almost every book which I have read upon insanity, general paralysis
is treated as a special form. Now here Dr. Urquhart puts it in the etiological list
so far as divided, syphilitic and other forms of general paralysis. Perhaps he is
right, but general paralysis has such specific symptoms that he would be a bold
author who did not treat of general paralysis in one of his chapters. As to the
term “ imbecile ” not being recognised by the Board of Lunacy, it is mentioned in
a report that under certain regulations a licence shall be given for the education of
imbecile children. Here the word is used by the Board of Lunacy.

Dr. Robertson (Larbert).— I have been called into this discussion quite acci¬
dentally. I saw from the billet that Dr. Urquhart was to speak on classification,
and sent to him the classification which I adopted, and which is very similar to his.
The point about “ imbecility " which has cropped up just now is not a question of
whether the term is recognised or not. The reason of the objection of the Board
of Lunacy is that it is not allowable to send imbeciles to asylums. Those who are
sent to asylums are insane. An imbecile is not an insane person by the law. Im¬
becility is not recognised as a form of insanity in the Statute, but if you enter on
the certificate that the person is imbecile and insane, then that will be accepted.
The term imbecile is useful as signifying a difference of degree between imbecility
and idiocy; an imbecile is not such an idiot as an idiot, ana there is a lesser degree
of feeble-mindedness. I suppose that this discussion is to assist the Registrar-
General in classifying the causes of death. The curious thing is that in asylums
mental diseases are never stated as the causes of death. No one certifies melan¬
cholia as the cause of death; it may be phthisis or typhoid fever, or anything
except the form of mental disease under which the patient happens to labour.

Digitized by v^.ooQLe

1903]

BY A. R. URQUHART, M.D.

243

Dr. Ireland. —Would you not state it as a secondary cause ?

Dr. Robertson. —You can enter as many causes as you please, but I do not
think that the form “ mental disease ” is ever mentioned ; yet it is in these very cases
it should be mentioned, if the tables are to be of any value. I agree with Dr.
Urquhart that in the nomenclature of insanity you should always mention the
distinct features of the insanity, the symptoms, and the etiology. No system of
nomenclature is perfect, but it is very imperfect if you only mention one feature.
There is no difficulty in stating that a person suffers from melancholia brought
about by alcohol or some other cause, and such a statement gives a much more
accurate and complete knowledge of the disease than the mere fact that it is melan¬
cholia. With regard to the proposed position of general paralysis, Dr. Ireland
says that it is usually given under a heading of its own, and that Dr. Urquhart has
placed it in the etiological list. I think that the mental symptoms should be stated,
and say that a patient is suffering from acute mania or from dementia with general
paralysis. Although it is general paralysis, that is no reason why you should not
make a statement as to the mental symptoms under which the patient is labouring;
there may be symptoms of melancholia or dementia. Then, if I might criticise the
table of suggestions, I should say that periodic insanity is not a distinct type of
insanity according to symptoms. It is either melancholia or stupor, and to put it
down as a separate variety is quite wrong, from the point of view of symptoms.
You are taking one feature’of insanity, its periodicity, and placing it in a distinct
class, whereas with regard to all the other varieties you are taking the symptoms
and not the periodicity. I would not include periodic insanity as a type of insanity.
Then I think there is an omission. We in this country for a long time past have
been guided by Dr. Clouston’s book with regard to the classification of insanity,
and very properly so; but he has also omitted cases which are more confused than
maniacal. These have been referred to, but I think that Dr. Clouston has not laid
the stress on this particular class of cases that he might have done. The patients
appear to be more or less demented, but we do not use the term dementia because
the patient recovers; we cannot use the term stupor, and I think the term “con¬
fusion ” accurately describes the condition. In my opinion there should be recogni¬
tion of a new form of insanity under that heading. I have called it delirious
insanity, and classify it into simple and acute delirious insanity.

Dr. Easterbrook. —I desire to call attention specially to one point, and that is
the use or abuse of the word “acute” in psychiatry, as meaning “ severe.” The
word “ acute ” is used in the terminology of other diseases as referring mainly to
duration, and as the antithesis of chronic. It should be similarly used in
psychiatry. Every disease may be regarded as the action of an irritant on the
organism. On the one hand we have the intensity of the irritant, and on the other
hand the duration or length of time during which it acts. These are two distinct
aspects, and the classifying adjectives that are used in clinical descriptions are, as
regards intensity , mild or simple, moderate, and severe; and as regards duration ,
acute or recent, subacute, and chronic. In cases of mania, if you use these
qualifying adjectives from the combined points of view of duration and intensity,
you can describe all cases with precision and accuracy thus. A person may be
suffering from mild or simple mania, or moderate mania, or severe mania, according
to its intensity; and according to its duration, from acute or recent mania (say up
to six months), or subacute mania (say six months to two years), or chronic mania
(say any period over two years). Combining these two aspects in any particular
case, a person may be described, with a clear conception of the condition present,
as suffering from acute (recent) mild mania, acute moderate mania, acute severe
mania, and similarly for subacute and for chronic mania; and also for melan¬
cholia, stupor, and so on. As an instance of the abuse of the term “ acute ” in
psychiatry, it is common to see a chronic maniac during a relapse of severe mania
described as in a state of “ acute mania.” Now a lunatic can hardly be described
as both “ chronic ” and “acute” at the same time without an abuse of language.

The Secretary. —My difficulty is to know when a case is one of melancholia and
one of mania. If you get a case of acute mania it is all right, and you can classify
it, and if you get recent melancholia you can classify that; but there are a great
number of cases which lie on the borderland. In fact, to such an extent does this
occur that I am beginning to believe in the American idea that melancholia and
mania are different phases of the same disease. I go against Dr. Robertson's

Digitized by

Google

244

NOMENCLATURE OF MENTAL DISEASES. [April,

opinion that periodic insanity should be cut out, because I think it differs entirely
from the continuous mania that you get in the adult and from the ordinary forms of
melancholia. It has many different symptoms. I think that confusional insanity
is an omission from the table, and it should be added.

Dr. Urquhart. —It is there.

The Secretary. —Not as a heading.

Dr. Urquhart. —No, but it comes under these symptomatic types.

The Secretary. —But the confusional insanity I refer to is a distinct type of
disease. A paper was written on the subject by Dr. Conolly Norman, and quite
recently I have seen several cases. I believe it to be a disease by itself. The
patients have a distinct febrile attack, which is followed by many symptoms, many
of which are nervous symptoms. It is one of the few forms of insanity in which
you do get nervous symptoms. It is a form of disease that is easily diagnosed
once you have seen it and have had the symptoms pointed out to you. I think
there ought to be a number 9 in the table. I am thoroughly in favour of Dr.
Urquhart’s scheme, and I think that this classification should be adopted. It is a
great advance on the old classification, and of course if we are to wait until we
reach finality, then we will almost have to wait until the end of time.

Dr. Turnbull.— I would like to refer to the question which has been raised
regarding congenital insanity. Two or three years ago, if you made returns to the
General Board of Lunacy in which only congenital imbecility was certified, your
reports were returned to you for amendment. Surely that is not done now?
Lately I have sent in returns of congenital imbecility, and they have not been sent
back to me for amendment. Then as to the word imbecile not being statutory,—
no more is the word mania, which we often use. If you look up the Statute you
will find that the person who comes under the Lunacy Acts is a person certified
by two medical men ; and it does not say what the exact mental condition is.

Dr. Robertson (Larbert).—The Statute says that you shall not admit imbeciles
into asylums. Asylums are for insane people, and not for imbeciles.

Dr. Turnbull.— But where is the definition of insanity which excludes con¬
genital unsoundness of mind P

Dr. Robertson. —The law excludes imbeciles. You may say that it is some¬
thing else.

Dr. Turnbull. —I speak subject to correction, but when the point was raised I
looked into the Statute, and you will find that there is no definition making a
distinction between so-called ordinary insanity and congenital insanity.

Dr. Robertson. —You have to certify the patient.

Dr. Turnbull. —But you have to state what the patients are suffering from.
My impression is that of late the General Board have not adhered to the practice
referred to. I have sent papers certifying congenital imbecility only, and they
have not been returned to me, although, of course, when I did find mania added to
the congenital insanity, then I put in both. Speaking more to the subject of the
paper, we have to take a symptomatic classification, because one founded on
pathological processes, which would be the ideal, is not possible in the present
state of our knowledge. The cross-classification according to causes which
Dr. Urquhart introduces adds much to the value of his table. A point one feels
is that all these classifications are only temporary. A patient may be suffering
from mania at one time and melancholia at another, and therefore the classifica¬
tion is so far imperfect, but it is the nearest one can come to perfection at present.
I agree that confusional insanity should be added to the list. It is somewhat
different from what we understand by melancholia, mania, dementia, and stupor.
The clinical group indicated by periodic insanity is, I think, properly included.

Dr. Robertson. —You have a classification there according to symptoms.
Now periodicity is not a symptom ; I would call it either mania or melancholia, or
what it was at the time. I quite recognise the clinical type; it is not a new form.

Dr. Urquhart. —This discussion is extremely valuable to me, because it is a
criticism of these proposals. I maintain that general paralysis is not . a mental
disease We must report it separately, and it is proposed in the new tables to
return it like epilepsy, in a column by itself, so that, for instance, you will be able
by these new tables to tell how many cases of general paralysis are syphilitic
and how many are not; you will be able to combine the various cases in a table
in a way you could not ao formerly, even in large asylums. Periodic insanity was

Digitized by v^.ooQLe

! 903-] CARE ETC., OF PERSONS OF UNSOUND MIND.

245

inserted to meet a common and frivolous objection to all classification—namely,
that you cannot tell what an acute maniac will be in the future; therefore you
must not classify him as an acute maniac. Katatonia is surely as clearly to be
differentiated as confusional insanity. I am perfectly willing to place confusional
insanity after mania as No. 3 of the list. It is a very definite disorder, and might
therefore be removed from the subordinate position originally assigned to it.

Dr. Robertson. —Seeing that you have mentioned the figures just now, I think
that stupor should come in after mania. I would make stupor No. 3.

Dr. Urquhart. —Then about this question that Dr. Easterbrook raised; it does
not very much matter to us whether we use the term “ recent ” or “acute” if we
are agreed as to the meaning of each.

Dr. Easterbrook. —Yes, and that is why we should keep acute as meaning
recent.

Dr. Urquhart. —I fancy from what I heard the other day that “ recent ” will be
adopted. I am afraid you cannot get rid of the term “ acute ” in favour of “mild,
moderate, or severe.” If the Board of Lunacy have accepted “ imbecility ” only
in a return from Dr. Turnbull, it has been accompanied by strong certificates.
There is no doubt that “ imbecility ” is not a statutory term, and unless you add
something to bring it within the statutory meaning it will not be accepted, for im¬
becility does not necessarily mean that degree of mental unsoundness which
demands detention in an asylum. “ Imbecile children ” are mentioned in a Scot¬
tish Act, as Dr. Ireland said, but I presupposed that the debate was in reference to
asylum returns.

Dr. Robertson. —Imbeciles have been distinctly excluded.

Dr. Turnbull. —I would like to get the reference.

Dr. Urquhart.—I think that our division should recommend this classification
generally, without committing themselves to the details, for the consideration of
our committee in London. That is all I desire to be done with it. I shall approach
the President of this College myself.

Dr. Ireland. — I daresay there would be no objection to Dr. Urquhart’s classi¬
fication as a whole ; in fact, there has been a general approval of it, and there would
be no difficulty in recommending what he has suggested.

Dr. Easterbrook. —As the only member of the Statistical Committee present,
I can assure you that it will be submitted for their consideration. I suppose that
that is all that one can do, and I would mention to them that it met with general
approval here.

Dr. Ireland. —Of course Dr. Urquhart knows about paranoia? It has been fre¬
quently patronised in this country. You put that under delusio'nal insanity ?

Dr. Urquhart. —Yes, but that will be a question for the Statistical Committee.
It is a much more convenient term than “ delusional insanity,” but whether it should
be accepted finally I am not prepared to say.

Dr. Ireland. — I remember one German putting half of his cases down as
paranoia.

Dr. Urquhart. —Probably he was pleased with the blessed word.

The Care and Treatment of Persons of Unsound Mind
in Private Houses and Nursing Homes f) By Ernest
W. White, M.B.Lond., M.R.C.P.Lond., President Elect
of the Medico-Psychological Association of Great Britain
and Ireland ; Professor of Psychological Medicine, King’s
College, London; Resident Physician and Superintendent,
City of London Asylum.

My paper to-day is the natural outcome of the address by
Sir William Gowers upon “ Sanity and Insanity, Lunacy and

Digitized by v^.ooQLe

246 CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

Law, the Views of a London Hospital Physician, particularly in
regard to Private Patients,” given at our last general meeting
in London. The discussion which followed was hardly worthy
of the subject. Most of the earlier speakers, although eminent
general physicians, had had little or no experience in the care
and treatment of the insane; therefore, when the turn came for
those practically acquainted with mental diseases to speak, the
hour was advanced, the audience was weary, and an all too
exacting brevity resulted.

To-day the alienist's side of the question can be fairly stated.
My wish is to deal with it as briefly and appositely as possible,
in order that the discussion may be as thorough as we can
make it. I hope all who have had practical experience of
single care, and of the treatment of mental cases in nursing
homes, will assist us in our search after truth, that the best
results may accrue to those who suffer from this, the saddest
form of human ailments. I propose to treat the subject by
a series of questions and answers, with illustrative cases here
and there.

What is certified single care ? It is the care and treatment
of a duly certified person of unsound mind in a private house.
The forms for admission are identical with those for the admis¬
sion of a private patient to a public or private asylum or
registered hospital. There is a like order made by a judicial
authority. The medical attendant takes the place of the
medical officer in institutions, and must visit at stated intervals
and make the customary reports to the Commissioners and
Visitors in Lunacy. A registered practitioner with whom a
single patient resides cannot act as medical attendant. The
residence is approved by the Commissioners in Lunacy, and
the patient visited periodically by them and the medical
and other visitors for the county or borough. Chancery
patients are visited by the Lord Chancellor's Visitors in
Lunacy. Facilities of access are given to friends by Statute.
Thus abuses are guarded against, and there is efficient official
supervision.

What are the advantages of certified single care? They
seem to be—

1. Privacy.

2. Domesticity.

3. Secret visits of friends.

Digitized by v^.ooQLe

1903-] BY ERNEST W. WHITE, M.B. 247

4. Avoidance of the stigma of treatment in a lunatic
asylum.

1. Privacy. —The rich and well-to-do try their utmost to
keep secret the mental breakdown of any member of the
family for well-known reasons ; hence single care at a distance
from home is the desideratum.

2. Domesticity. —The upper classes often dread the contact
of their relatives with other insane patients, and complain of
the lack of the comforts of home life in public and private
institutions. These objections are now removed by the villa
residences attached to public and private asylums and hospitals
for the insane.

3. Secret visits of friends. —In single care the relatives, if so
disposed, can visit unobserved, and much more frequently than
they can in an asylum or hospital.

4. Avoidance of stigma of insanity. —The sting of certifica¬
tion is in the magisterial inquiry. Young and inexperienced
justices often investigate the cases more fully than is necessary.
They place too little reliance upon the facts contained in the
medical certificates. The terrors of certification are thereby
increased. The form of the medical certificate needs revision ;
the term “ alleged lunatic ” should be removed. The word
“ asylum ” should be applied only to an institution for
M the chronic and incurable insane.” “ Hospital for mental
diseases ” should be used for an “ institution for acute and
curable cases.” The terms “ lunatic ” and “ lunacy ” should
be removed from the Statutes, “ person of unsound mind ” and
u insanity ” taking their places. For years past the terms
“ lunatic, lunacy, and pauper ” have been forbidden at the City
of London Asylum, and the word “ asylum ” only used for
statutory purposes.

What are the disadvantages of certified single care ?

1. The absence of skilled medical treatment

2. Unskilled nursing.

3. Monotony.

4. Insufficient moral control.

5. Interference of friends.

6. Limited supervision.

7. Want of tact and business capacity on the part of the
custodian.

1. The absence of skilled medical treatment. —The general

Digitized by v^.ooQLe

248 CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

practitioner as a rule knows but little of the treatment of
mental disease. Psychological medicine has only recently
become compulsory in the medical curriculum. Moreover I am
sure you will all agree with me when I state that the knowledge
of the proper treatment of mental diseases is not to be acquired
in the rounds of general practice or in the consulting room,
or even, at present, within the wards of a general hospital.

2. Unskilled nursing .—The nurses (male and female) having
charge of single patients have, as a rule, had no special train¬
ing in the management of mental cases, and, although perhaps
hospital trained, are quite unqualified for the work. No nurse
is qualified to undertake a mental case in single care unless
possessed of the nursing certificate of the Medico-Psychological
Association, which is a recognised guarantee of efficiency.
The responsibility with single patients is the greater because
the nurse, from want of skilled supervision, is so frequently
thrown upon her own resources.

3. Monotony .—We all know of the many associated amuse¬
ments and means of recreation provided in institutions for the
insane. How dull must be the life of the patient in single
care in this respect!

4. Insufficient moral control .—The moral decadence of the
upper and upper-middle classes when insane is far greater than
of the agricultural and industrial populations. Sedentary life,
luxury, and high living tend to bad habits. Self-abuse is far
more common amongst private patients than amongst the rate-
paid. The moral control—I would rather term it “school
discipline ”—of our institutions is one of the most potent
means we possess for successful treatment. The day is appor¬
tioned out to meals, employment, recreation, and amusements.
The will is made subordinate to others, bad habits are corrected,
and in many instances our patient is thereby conducted back
to rational health.

We admitted in October last a lady who had been under
certified care since the previous January—that is, for upwards of
nine months. Upon admission she had hallucinations of hear¬
ing, her expression was vacant, she walked about aimlessly,
did nothing, was faulty in habits, wet, etc., and was drifting to
dementia. We put her under proper discipline, roused her
from her lethargy, gave her shower-baths morning and evening,
which have been continued to the present time. To-day

Digitized by v^.ooQLe

I903-]

BY ERNEST \V. WHITE, M.B.

249

(December 15th) she is industrious with her needle, bright and
thoughtful of others, takes part in the associated amusements
and recreations, plays the piano and sings well, has regained
her self-respect, and is most tidy in her appearance and dress;
in fact, is rapidly approaching convalescence and discharge, to
the intense delight of her relatives and friends. (She left
recovered on February 6th.) Now in single care the sufficient
moral control of such a case as this is wanting.

5. Interference of friends .—With single patients the friends
either get them removed as far from home as possible, satisfy
themselves that they are well housed, well clothed, well fed, and
kindly treated, and visit them only when obliged, for sympathy
for the insane relative generally quickly dies ; or the patient
may be visited much too often, the treatment of the medical
attendant and management by the nurse being interfered with,
to the great detriment of the chances of recovery.

6. Limited supervision .—Certified single patients are taken for
profit by needy practitioners, decayed ladies, etc. The official
supervision of these custodians is limited. How can we
guarantee in all cases humane treatment by nurses ? also proper
food and environment at all times ? We must remember the
best mental trained nurses remain in the asylum service or
become attached to the better nursing institutes of the
metropolis. Therefore we have not always the most reliable
people in charge of the patients under consideration. On the
contrary, it is an absolute fact that in a great number of cases
the nurses in charge have not had any mental training whatever ;
frequently they are hospital-trained nurses who are sent out by
institutions to whatever case may turn up. I have heard also
of asylum laundryrtiaids posing as mental nurses on the books
of such institutions.

7. Want of tact and business capacity in the caretaker .—
Decayed ladies and retired nurses are not possessed of much
business capacity, tact, or energy in the duties of the house.

What is uncertified single care ? It is the taking charge of
a person of unsound mind (not under certificates) in a private
house or nursing home. I believe hundreds of insane patients
of the upper and upper-middle classes are at the present time
under care and treatment without being certified in the various
counties of England and Wales, not to say the Channel Isles and
near the Continent. What happens is this :—A member of a

Digitized by

Google

2 50 CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

family, probably with neurotic inheritance, develops mental
symptoms. The parents dread certification, and, because of the
so-called “ stigma of insanity,” avoid as long as possible the
alienist physician being called in, but consent to a “ nerve
specialist ” being consulted. To the neurologist the patient is
taken ; he duly prescribes and advises. After a short time the
symptoms become more pronounced and home treatment is
impossible ; the patient must go away. Then the assistance of
the decayed gentlewoman is sought, that she may undertake
the remunerative care of the insane person ; or a nursing home
is selected, with which some practitioner in a suburban or rural
district is connected. The neurologist sees the case from time
to time in consultation. He considers himself well qualified to
treat this form of disease, and in the interests of humanity (as
Sir William Gowers tells us) is accessory to an evasion of
the law. Ultimately, in many instances, owing to an exacer¬
bation of the symptoms (some attempt at suicide or homicide,
etc.), certification becomes imperative, and to a recognised
institution for mental diseases the patient is sent. It is from
these cases many of us have to glean our recoveries, and a
difficult task it is at so late an hour in the day of disease. Let
us consider two or three cases to illustrate uncertified single care.

Several years ago I was asked to see a lady patient suffering
from an attack of acute mania. She was at a farmhouse at a
short distance from a country village. Upon arrival I jumped
out of my trap and was walking through an orchard to the
house, when I beheld the patient among the fruit trees, but in
the broiling sun (it was early in August). On either side of her
was a hospital nurse, the one pulling one way, the other the other.
The patient, a fine muscular young lady of twenty-five years,
was semi-nude, with many bruises of the neck, chest, and arms;
her hair was dishevelled, her clothes were untidy and torn, and
she did not appear to have been properly washed and attended
to. Sedative medicines had been given, even to nausea. All
were of no avail. The nurses had not had asylum training;
the patient was not taking sufficient food ; the bowels were not
properly looked after ; and she was not under proper moral
control, although physical control was by no means wanting.
Secrecy was the order of the day, so to this out-of-the-way place
she was sent, and visited by a medical practitioner daily. The
case had been drifting for about ten weeks. I told the father

Digitized by

Google

1903 -]

BY ERNEST W. WHITE, M.B.

251

the patient ought to go to an institution for the insane, and she
went without delay. She improved at once, and was dis¬
charged, recovered, within two months. This lady has had no
relapse, but has since attained success as an authoress.

I will now give you a case of uncertified single care in which
the alienist even failed, and you will see the reason. Six years
ago I was asked to visit in consultation a lady suffering from
puerperal insanity. The attack had occurred five weeks after
parturition, and the symptoms at first were a mixture of mania
and melancholia. The patient had a very bad family history.
The father died of general paralysis of the insane, a brother
had for some years been insane, and a sister has since had an
attack of mania from which she has recovered. The family is
one of typical neurotic inheritance. We had ample means at
our disposal, and an excellent opportunity offered for treating
an acute case (uncertified) under the most favourable condi¬
tions, for the house was a large old manor-house with extensive
grounds, surrounded on all sides by a wall some ten to twelve
feet high. We converted a suite of rooms on the ground-floor
into quarters for our patient, who took exercise for hours daily
in the old-world gardens, and we secured trained nurses for
night and day duty (one had been trained at the City of
London Asylum) ; in fact, converted a most suitable residence
into a complete private asylum for one patient. The family
medical attendant visited twice a day. I met him in consulta¬
tion three times a week. This went on for two months.
Sometimes the patient was better, sometimes worse. At last I
said to myself, “ This patient won’t get well here. She is
not under sufficient moral control. She knows she is at
home, in the home of which she has been mistress for years ;
she does not therefore subordinate her will to others. She
must be certified and go to a private asylum.” The husband,
who was tenderly attached to his wife, but a man of sound
common sense, agreed with me at once; not so, however, the
mother-in-law! I then proposed that another alienist should
see the case with me, and the husband said, if he were of the
same opinion as myself, the patient should go from home, even
at the risk of the ire of the mother-in-law. The consultation
was held, we agreed, and the patient went to a private asylum
to improve quickly, and to recover under moral discipline in
about three months.

XLIX. 18

Digitized by v^.ooQLe

252 CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

And now let us consider a case of uncertified single care in
which a good and permanent recovery resulted. Some sixteen
years back I was consulted regarding a physically healthy
young lady who had developed suicidal tendencies and homi¬
cidal impulses. She had threatened to drown herself, and had
attempted to strangle her sister, with whom she was sleeping.
There was no inherited tendency to mental disease. The
causes were indolence, self-indulgence, and the habit to which I
have alluded as so common in the upper classes. The relatives
begged that she should not be certified. Fortunately I knew a
medical man who had been an assistant medical officer in a
county asylum, and who thoroughly understood the require¬
ments of our patient. Into his house she went, and was never
left night or day. In the morning she had a shower-bath on
rising. After a light breakfast she was taken for a long ride
on a double tricycle with her trained companion. After the
midday meal she had another tricycle ride, wet or fine. A
diet was arranged with limited animal food. The bowels were
carefully regulated, and a suitable night draught given when
needed. She improved steadily, and recovered completely in
about four months to remain well ever since. In this instance
an alienist directed the case with a skilled medical attendant,
and trained nurses saw the instructions carried out.

Next let us consider a case where a young lady suffering
from incipient insanity was in a nursing home, uncertified, under
the charge of a mental nurse for two months, at the end of
which time she had to be certified and sent to a public asylum
receiving paying patients.

A lady was admitted into the City of London Asylum in
July last suffering from melancholia. She was, on admission,
agitated and emotional, heard voices which told her of
unfortunate occurrences to her friends, thought she had been
very wicked, was troublesome with her food, etc. After moral
and medicinal treatment she steadily improved, and was
recommended for discharge as recovered on December 15th
last, then having been convalescent a month. She weighed on
admission 7 st. 11 lbs., and on discharge 9 st. 11 lbs. She
told me that in the nursing home nothing was done for her,
and the life was painfully dull and monotonous ; the nurse sat
near her all day doing her needlework and seldom spoke, but
watched her carefully. There were three other ladies in the

Digitized by v^.ooQLe

* 903 -] BY ERNEST W. WHITE, M.B. 253

house, of whom she saw but little; she thought they were
mental cases.

What are the advantages of uncertified single care ?

1. Avoidance of the so-called “ stigma of insanity.”

2. Secrecy.

3. The so-called continuity of medical treatment (doubtful
if unskilled).

4. Freedom from contact with other persons of unsound
mind.

5. Domesticity.

What are the disadvantages of uncertified single care ?

1. Insufficient general and moral control of the patient.
There is no legal power of detention, for the patient is in full
possession of civil rights.

2. The patient’s property is not safeguarded from unworthy
relatives, solicitors, medical men, caretakers, and nurses.

3. Frequently there is unskilled medical treatment, or none
at all.

4. Unskilled nursing as a rule.

5. Monotony in some out-of-the-world place.

6. Interference of friends.

7. Want of official supervision.

8. Incapacity of caretaker.

The want of official supervision is perhaps the most serious
of these disadvantages, for I have heard of inhuman and cruel
forms of personal restraint which have been used upon these
unfortunate patients, even since the passing of the Lunacy Acts,
1890-91, and is not this what we should expect with no
official supervision? In 1893 we sent two nurses to a well-
known southern seaside resort for a private patient who had
been acutely insane, but uncertified, for seven weeks. The
nurses found the patient roped by the wrists and ankles to the
four corners of the bed. She was in a filthy state, and she
had been tied down for days. Men had been called in to
assist in the roping process. The patient’s wrists and ankles
were much marked, bruised, and abraded. The hospital nurses
in charge of the case were afraid of their lives, but upon our
nurses clearing the room and removing the ropes, the patient
accompanied them without a murmur, and gave no trouble on
the journey.

I have heard of another lady being roped to a bedstead like

Digitized by v^.ooQLe

254

CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

a monkey to a pole, with just sufficient rope to allow her to
attend to the calls of nature.

We recently admitted a lady who for months had been at a
seaside resort with a caretaker, in whose house a room had
been fitted up as a strong-room, with iron bars in place of the
lower panels of the door. An occasional peep at the patient
was taken through the “ grille.” This, I presume, was supposed
to be curative treatment under single care. The physician
who was an eye-witness in the last two cases is present to-day,
and will verify my statements with fuller details. Let there
be no disguising the fact, mechanical restraint of an advanced
type is often resorted to with uncertified patients in single care
by unskilled nurses and heartless caretakers. We, who know
how the excited patient frets and struggles even to exhaustion
under mechanical restraint, and how fearfully it reduces the
prospect of recovery, must raise our voices in no uncertain
strain, in the interests of suffering humanity, against any
relaxation of the law which will open the gates any wider to
such barbarisms.

What is the suggested notification of mental cases ? It is that
in all cases of mental unsoundness in which certification and
compulsory detention seem needless, and in border-line cases,
there shall be a system of notification to the Commissioners in
Lunacy by any one receiving payment to the effect that
“ A. B— is a person of unsound mind and is not a proper
person to be detained.” It has been also suggested that this
notification shall be to the local authority. It is presumed, in
the first instance, it will be followed by the visit of a Com¬
missioner in Lunacy or some one deputed by the Com¬
missioners, and, in the second, by a medical officer appointed
by the local authority.

What would be the advantages of such notification ? They
would be the same as those given under the heading uncertified
single care (vide supra).

What would be the disadvantages ? These, again, would be
identical with those given under certified single care (vide
antea) t with, in addition—

9. Increased official expenditure fr6m the necessary appoint¬
ment of deputy or district Commissioners to inquire into the
numerous class of cases which would rapidly crop up. In an
article on “ Lunacy Law Reform ” in the Lancet of December

Digitized by v^.ooQLe

I 9°3-]

BY ERNEST \V. WHITE, M.B.

255

27th, 1884, I suggested the appointment of Deputy Com¬
missioners in the following terms:—“ District experts as
medical officers of insanity, occupying analogous posts with
those of coroner and medical officer of health, with fixed
salaries, these officers to be elected from their experience in
the specialty and to be allowed to practise as pure physicians.
Their duties would be to examine all supposed lunatics in con¬
sultation with the medical man in attendance, to sign all necessary
certificates, to visit all single patients and patients in private
asylums in their districts, to report thereon from time to time
to the Commissioners in Lunacy, and so act as district agents
for the Commission, or Deputy Commissioners. They would
have power to order the discharge of any single patient, or any
patient from any private asylum in the district, should such a
course be desirable on account of recovery or otherwise. They
would also have authority to prevent the removal of any
patient by his or her friends when such removal was calculated
to be fraught with danger to the patient or others.” Many of
the suggested reforms in that article were adopted in the
Lunacy Acts, 1890-91. This was not, for the obvious reason
—expense.

10. I am afraid notification, unless under the most efficient
official supervision, would encourage a continuance of the
evasion of the law, or at least would delay proper remedial
treatment, in consequence of the patient not being under proper
moral control.

What cases are suitable for care and treatment as certified
single patients ?

1. Quiet and harmless tractable imbeciles.

2. Quiet and harmless chronic dements.

3. Certain general paralytics in the last stage.

4. Hypersensitive patients convalescing from melancholia.

What cases are unsuitable ? All others.

What cases are suitable for care and treatment uncertified ?

1. Transient cases of mania and melancholia dependent
upon drink and abuse of drugs.

2. Certain border-land cases where the symptoms are un¬
developed.

3. Other cases in which the symptoms are not severe, and
which have a definite exciting cause not likely to be long
operative.

Digitized by v^.ooQLe

256 CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

How should they be protected against abuses ? By proper and
complete official supervision. I have been for years past and
am still in favour of the appointment of Deputy Commissioners
for districts as defined above, such appointments to be made
from those skilled in the treatment of mental diseases.

What is the suggested temporary care and treatment of the
incipient insane ? In 1899 the joint Committee of the British
Medical and Medico-Psychological Associations, of which I
have been a member by your courtesy since its formation,
waited upon the Lord Chancellor at the House of Lords. It
urged the necessity of early legislation for the incipient insane.
It told him how numberless border-land cases were smuggled
away in the country, the Channel Isles, and on the Continent, to
avoid legal certification, how their chances of recovery were
imperilled thereby, and how the possibilities of inhuman care
existed. As a consequence, he introduced into the Lunacy Bill
of 1900 the following clause, adapted from the existing clause
in Scottish Lunacy Law:

1. If a medical practitioner certifies that a person is suffering
from mental disease but that the disease is not confirmed, and
that it is expedient, with a view to his recovery, that he be
placed under the care of a person whose name and address are
stated in the certificate, for a period therein stated, not
exceeding six months, then during that period the provisions
of Section 3 1 5 of the principal Act shall not apply.

2. The certificate must not be signed by the person under
whose care the patient is placed.

3. Where a medical practitioner signs any such certificate he
shall within one clear day after signing it send a copy of it to
the Commissioners, and the Commissioners may visit the
patient to whom the certificate refers.

I believe this clause with its three sections will meet all the
requirements of the case for the insane of the upper and upper-
middle classes, provided the Deputy Commissioners above
named be appointed.

As several of the county and borough asylums are at the
present time admitting private patients in large numbers, would
it not be well that the voluntary boarder system appertaining
to registered hospitals and private asylums should be extended
to public asylums ? There are many patients, incipient and
border-line melancholic cases, who lack self-confidence, and who,

Digitized by v^.ooQLe

1903-]

BY ERNEST W. WHITE, M.B.

257

if they can place themselves under the sheltering wing of an
institution giving them medical and general supervision, will
rapidly regain their mental balance, and thus escape certifica¬
tion. Those who have had ample experience of the voluntary
boarder consider the legislation regarding him has been pro¬
ductive of much benefit.

Having surveyed the subject in detail, we must now consider
the various points, not already discussed, to which allusion was
made by Sir William Gowers.

The contemplation from the train of the wall of Hanwell
Asylum we are told prompted him to lead a crusade against
the existing Lunacy Laws. He thought of those the wall
excluded and those it included. Now the wall of Hanwell
(the oldest of our London county asylums) is an anachronism!
The asylums of to-day have no walls ! and while the buildings
include those committed to the humane and skilled care of the
medical officers for treatment, they do not exclude those who
desire to gain knowledge regarding mental diseases. The love¬
lorn Kentish cavalier, when he wrote in his prison in West¬
minster the lines, the first of which Sir William quotes, little
thought they would be applied to an asylum for the insane
some 250 years later on. Let us contemplate these lines.

“ Stone walls do not a prison make,

Nor iron bars a cage;

Minds innocent and quiet take
That for a hermitage.

If I have freedom in my love,

And in my soul am free,

Angels alone that soar above
Enjoy such liberty.”

We do not acknowledge the walls as part of our treatment
to-day! Nor are iron bars necessary in institutions for the
insane. They appear, as we have seen, to be only required for
uncertified patients in single care! Our cavalier, although
imprisoned, was happy withal in the freedom of his thoughts.

Sir William Gowers tells us that in many cases certification
is harmful and unnecessary. Many of us differ from him upon
this point.

We recognise in certification the means of placing the patient
under proper control for treatment, and we are satisfied that the
chances of recovery are, in many instances, greatly increased

Digitized by v^.ooQLe

258

CARE, ETC., OF PERSONS OF UNSOUND MIND, [April,

thereby. The cases quoted by him as suitable for treatment
without being duly certified were peculiarly unfortunate. They
all had delusions of persecution, and these patients, as we
alienists know, may at any time become actively homicidal or
suicidal by impulse. They should certainly all have been under
certificates, both in the interest of the public and of them¬
selves. Sir William Gowers states that every patient received
for payment and uncertified is a free agent—can leave or be
removed at any time. Such is not my experience with uncer¬
tified insane patients in single care. Furthermore I do not
admit that certification is in any way disastrous to the patient,
or the painful distress to the friends it is stated to be.

Sir William speaks of the “ divorce of psychological medicine
from general medicine.” There is no divorce! They have
always been separate and distinct, and must remain so from the
very nature of mental disease, and the treatment demanded.
The moral side of this treatment is all-important, the medicinal
only accessory, and that in quite a minor degree. The days of
chemical restraint and of the exhibition of medicinal nostrums for
insanity are past and gone. We have too many proofs of the
value of our more enlightened system to wish to revert to them.
Let the general body of our profession make themselves
thoroughly acquainted with this system ; they will then recog¬
nise the vital importance of the daily contact of the mental
physician with his patient, to control the management and
moral treatment of the case, the necessities of which are ever
varying.

We are told that the “ master of method ” is necessary for
the full and proper development of the normal mind of youth ;
that a scholar who has not had training as a schoolmaster is
unequal to perfecting a student’s education in classics, mathe¬
matics, or the higher sciences. How much more, then, must the
“ physician of method,” trained by long experience and daily
contact with the insane, be essential for the re-education of the
abnormal mind, for the replacing of the unhinged mind upon
its hinges, for the dispelling of the hypochondriacal delusions of
the melancholiac, and for the calling back to mental life again
of the £#rtJ7-demented patient in mental stupor ! Speaking
after thirty years’ experience as a public asylum physician and
thirteen as a lecturer on mental diseases, I would state unhesi¬
tatingly that to comprehend the vagaries of the mind diseased

Digitized by v^.ooQLe

1903]

BY ERNEST W. WHITE, M.B.

259

to lead that errant mind back to health, and to recognise the
means by which this end can be attained, are problems only to
be solved by those who have made the insane their intimate and
lifelong study.

. Note appended February Jth.

Sir William Gowers has just published in pamphlet form
his address of November 20th, 1902, with a Note. I observe
the title is altered. It now reads, “ An Address on the Pre¬
vention of Insanity.” Would not “ On the Evasion of Insanity ”
be more appropriate? In the Note he draws attention
approvingly to Sir William Church's suggestion that notifica¬
tion should be to the local authority, the facts of each case to
be subsequently investigated by the medical officer of health
or some other official appointed by the local authority. What
does the medical officer of health know of mental diseases ? Is
he qualified to decide such a case? And who is the other
official suggested ? Who but one skilled in the treatment of
insanity is qualified to decide whether the conditions under
which the patient is placed are such as are likely to promote
recovery, or whether certification is necessary in his or her own
interest ? Sir William Gowers is in error when he states that
provision is already made for the reception of border-line
patients as voluntary inmates of public asylums. At present
voluntary boarders cannot be taken in county or borough
asylums, but only in registered hospitals and private asylums.
He tells us, moreover, that it is a sarcasm to suggest that
patients on the verge of mental derangement would place
themselves in lunatic asylums. Is he not conversant with that
large class of cases of incipient melancholia in which the
patient lacks self-confidence and self-reliance, is imbued with a
sense of impending trouble, and consequently eagerly seeks
admission into a private asylum as a voluntary boarder, and
expresses a feeling of relief when under the sheltering wing of
the institution ? The limitation Sir William Gowers takes
objection to in connection with the clause for the treatment of
incipient insanity, “ that no person under this section shall
receive more than one patient at the same time,” is in accord¬
ance with the principle of the Lunacy Acts, 1890, 1891, that
private asylums are to die out by gradual extinction, for no

Digitized by

Google

26 o

LUNACY AND THE LAW,

[April,

new licence can be granted. To receive more than one patient
would constitute a private asylum. Sir William Gowers
objects also to the sanction of the justice of the peace being
necessary, and adds that “ such a sanction could only be a
useless formality.” He forgets that it is right that the liberty
of the subject should be taken only by some mode of judicial
procedure.

(*) Read at the General Meeting, February 12th, 1903.

Lunacy and the Law.Q ) ByT. Outterson WoOD,M.D.Durh.,
F.RX.P.Ed., M.R.C.P.Lond., Senior Physician, West End
Hospital for Nervous Diseases, Welbeck Street, Cavendish
Square, W.

It augurs well for the success of the action taken by the
Conjoint Committee of the British Medical Association and
this Association with regard to the amendment of the Lunacy
Law, to enable cases of recent (incipient) insanity to be legally
treated in private care, without being certified as lunatics, that
the Lord Chancellor inserted into his proposed Lunacy Bill a
clause to meet our requirements, in the very terms I advocated
at the annual meeting of the British Medical Association in
1896.

The importance of the subject must be my justification for
bringing before this Association some features in connection
with it from a practical point of view. I look upon the
question for my f present purpose as being divided into two
sections only, for I intentionally leave the rate-aided class to
be dealt with elsewhere.

Section 1st .—The proposal to extend the provisions of the
present law so that incipient cases of mental disorder may
legally, and without delay, be brought under skilled care and
treatment without certification ; and

Section 2 nd .—The suggestion that cases admittedly certifi¬
able, or even already certified, may be placed in single care
without the so-called stigma of certificates ; or if already
admitted into an asylum, they may be taken out and placed

Digitized by v^.ooQLe

1903-]

BY T. OUTTERSON WOOD, M.D.

26 l

in the house of some relative or impecunious person, and kept
there for profit, and not necessarily for cure—for it is not
suggested that these patients may be curable.

Now, sir, with regard to the first section, which deals with
cases of recent (incipient) insanity, I would divide them into
two classes: (a) those who are amenable to reason and advice,
who are absolutely uncertifiable, and who can to a great extent
take care of themselves ; and (b) those recent cases of a mild
type in which the mental warp is more pronounced, who may
require removal from home, who are almost certifiable, or who
may even have harmless delusions, who require a certain
amount of moral restraint, and who may object to the control
necessary for their proper treatment. With regard to Class A,
no alteration of the law is necessary; these patients are as
capable of treatment outside the Lunacy Law as any ordinary
medical case. I have to deal with a large number of them as
out-patients at the hospital, and I have no difficulty whatever
with them.

It is with regard to Class B that the law requires amend¬
ment, to enable us to obtain the legal control of the patient ;
and a system of notification seems to me the best to meet the
requirements of such cases. This, however, is no new idea.
I have for years advocated a relaxation of the present law in
order that incipient, doubtful, or undeveloped cases might,
under suitable conditions, and at the earliest moment, be
brought under that expert care and treatment which experienced
alienist physicians know to be so necessary for the arrest of the
disorder and the cure of the patient. Upon this point I am
glad to think we are all agreed. It is the adoption of a
principle that has worked well in Scotland for many years, and
I know of no reason why, under proper conditions, and with
the necessary safeguards of skilled supervision, it should not
work equally well in England and Wales ; the order of a
magistrate on this side of the border taking the place of the
order of the sheriff, as in Scotland, for the legal detention of
the patient for a definite period. There is, however, one point
upon which we must insist, and it is that wherever these cases
are so placed, whether it be in a doctor’s house or not, they
shall be at once notified to the Commissioners and be placed
under their official supervision, as well as that of some skilled
and independent local authority,appointed by the Lunacy Board.

Digitized by v^.ooQLe

262

LUNACY AND THE LAW,

[April,

Above all, vve must be certain that it shall not be merely a
matter of boarding them out in so-called medical homes or
private houses, kept by unqualified, inexperienced, and untrained
persons, but that we shall have some guarantee that they will
be properly cared for and looked after by those who have been
trained in some recognised institution for the insane, or whose
competence is assured by long experience, and who shall be
approved of by the Commissioners ; and further that they shall
be nursed and attended, not by hospital nurses who have had
no asylum training, but that their nurses shall be asylum
trained, and preferably that they shall hold the certificate of
the Medico-Psychological Association for proficiency in nursing
and caring for those of unsound mind.

It is absurd to imagine for one moment that such cases as
these can be properly treated by persons with no special
knowledge of, or experience in, all the details of the moral
control these persons require, and we must speak out with no
uncertain voice in our condemnation of any attempt to mini¬
mise this, the most vital part of their treatment. The periodic
visits of a consultant are practically useless as regards the
supervision of these details, which are of daily, even hourly
importance for the cure of the patient. This, of course, we
cannot expect physicians, however eminent, to appreciate who
have not made a special study of the care and treatment of
mental disorders. It is the absence of this special knowledge
on the part of the hospital physician which will permit him, on
the one hand, to give these, the most difficult of all cases to
manage, into the care of inexperienced people of limited means,
or hospital nurses with no asylum training, who do not know
what to do with them, who cannot understand the constant
supervision and the unceasing vigilance they require, who are
unable to anticipate a suicidal impulse or an outbreak of
homicidal violence, and who will either rush in terror from the
room at an outburst of excitement or will resort to the in¬
judicious and unnecessary use of mechanical restraint; or, on
the other hand, to give them up to the tender mercies of the
keeper of some medical home or nursing institution who has
never seen the inside of an asylum, who does not hesitate to
send out hospital-trained nurses to acute mental cases, and un¬
trained domestic servants as trained mental nurses!

Gentlemen, I am speaking of things of which I have personal

Digitized by v^.ooQLe

1903]

BY T. OUTTERSON WOOD, M.D.

263

knowledge, and in my opinion, instead of the law being made
more elastic with regard to these transparent frauds, it should
step in and compel every nursing home or institution receiving
such cases as these to be placed under some official supervision.
If this were done we should hear less of the fatalities which are
of such frequent occurrence, and which help to fill the columns
of the daily Press. While, therefore, we advocate the early
treatment of cases of incipient insanity without certificates, let
us endeavour to make sure it will be carried out in such an
efficient manner that there shall be no excuse in future for the
smuggling away of what are termed “ borderland ” cases, or
those deliberate evasions of the law which have been alluded to,
and even boasted of, before the members of this law-abiding
Association, and which have in so many instances been followed
by fatal results.

I will now turn to the second section of the subject,—I mean
the suggested extension of this system of notification for
incipient cases, so as to make it applicable to chronic certifiable
cases of insanity and to those already certified and living in
institutions for the insane. This, in my opinion, would be a
dangerous innovation. It is sad to reflect that at this time of
day we are compelled to reiterate the arguments of our prede¬
cessors in this Association against the unwisdom of such a
retrograde step, and that the cruelties of mechanical restraint
must again be brought forward to steady the minds of well-
meaning but ill-informed philanthropists and bring into bold
relief the danger of giving a free hand to those impecunious
persons who bombard us with applications for the care of this
class of patient. One of those individuals who was anxious to
obtain the care of such an one endeavoured to impress upon
me that blindness and being crippled would not matter. I
presume if the unfortunate patient was blind he could not see
and criticise his food and surroundings, and if crippled he
could not escape, and would require less expensive supervision!

It has been suggested that the relatives of many certified
patients should take them out of asylums because they are not
dangerous to themselves or others, and that they could under¬
take the care of such cases as well or even better than they
could be cared for in an asylum, without the “stigma” attaching
to them of being certified lunatics. This, to my mind, is mere
sentiment ; nothing can alter the fact that the patients are

Digitized by v^.ooQLe

264

LUNACY AND THE LAW,

[April,

insane, whether they are certified or notified ; and whether the
fastidious friends like it or not, the fact remains. My experi¬
ence through a long series of years spent among the insane is
that more downright cruelty and neglect are often inflicted
upon such patients by friends and relations owing to their
ignorance and incompetence, and through judgment giving way
to feeling, than is possible under the splendidly humane
treatment of such cases in our institutions for the insane,
private as well as public, which are a credit and an honour to
our country.

In support of this statement permit me to give you an
account of a case which came under my notice a short time ago—
a refined young lady of some twenty years of age, who, to save
the “ stigma ” of certificates, was placed in charge of a hospital
nurse in a so-called medical home, and who, because she was
anxious to leave her room, had an ingenious waistband buckled
round her to which was attached a half-inch rope sufficiently
long to allow her to attend to the calls of nature. This rope
was firmly fastened to the bedstead. The nurse explained to
me that but for this contrivance she would not have been able
to leave the patient alone ! Comment upon this case, which
was one of certifiable insanity (and I certified her), but not
dangerous to herself or others, is needless to members of this
Association. Take another case, which I also certified and
sent to an asylum—a young lady aged twenty-two years, who
was kept in a private house to save certification, in charge of a
hospital-trained nurse. She was in a state of acute mania ; she
had bitten the hand of the untrained lady in whose home she
was detained, because she endeavoured to hold her down by
force. This hospital nurse had an untrained young woman as
an assistant. The patient was curled up in bed, jabbering inco¬
herent nonsense, her hair unkempt, and she was unwashed and
dirty ; the room was barely furnished and most uncomfortable,
and the window was strongly barred. As I was leaving the
apartment I found each panel of the door, excepting the one
below the lock, was protected by a stout half-inch deal screwed
securely over it, and the door showed evidence of violence.
On examining the door from the outside I found the panel
under the lock was made to slide in a groove, with a knob on
the outside to draw it backward and forward, and over the space
left when the panel was withdrawn were three strong iron bars.

Digitized by v^.ooQLe

1 903]

BY T. OUTTERSON WOOD, M.D.

265

On inquiring of the nurse the use of this ingenious device, she
informed me that it was to enable anyone sitting outside the
room to see what the patient was doing inside !—a convincing
confession of incompetence ! I confess to being somewhat
shocked at such a condition of things occurring in the closing
months of 1902. But, gentlemen, these are the evasions of the
law we must expect to increase and multiply if the law is made
“ more elastic ” with regard to cases of certifiable insanity
without adequate official supervision.

I do not wish to weary you with a recapitulation of further
instances of the inhumanity of ignorance, which are only too
well known to us ; but I venture to say that, if the supervision
of the certifiable insane in single care by the Commissioners is
in any way relaxed, we shall soon have a recrudescence of those
scandals which brought on to the Statute-book the Lunacy Law
as it now stands. No perfunctory visitations of the physician
can prevent them. Only within the last month I had three
applicants for the post of nurse to a mental case, and in view of
the question I have raised of asylum-trained nurses being so
necessary for the care of mental cases, permit me to describe
to you the kind of persons these three applicants were.

No . 1.—A lady, quite untrained, but with some years*
experience in private cases, wonderfully self-confident, and
largely possessed of the audacity of ignorance. When I asked
her if she was trained she said, “ Oh no!” she didn’t believe in
trained mental nurses ; they only irritated the patients. When
I asked her what* she would do if the patient happened to
become violent, she said, “ I would look at her—that would be
quite enough ! ”

No. 2.—Another lady, untrained, who, when I asked her
what she would do if the patient became violent, said, “ I would
pull her arms back and tie them with a towel.” I mildly
suggested that that might not be enough ; then said this
untrained lady, with a knowing look, “ I would get a strap with
hooks on it and hook them back! ”

No. 3.—A tall, strongly built lady, very much satisfied with
herself and her powers, who would take any case, male or
female ; she was a trained hospital nurse whose only knowledge
of mental training was gained by three months in a county
asylum some years ago, and a few months in the insane ward
of a workhouse. When I asked her what she would do if the

Digitized by

Google

266

LUNACY AND THE LAW.

[April,

patient became violent, she said very decidedly, “ I am quite
competent to do some ' policemaning' if necessary!” I thank
that lady for the word “ policemaning ; ” it is so suggestive of
truncheons and handcuffs, and such like trifles! It is these
and such as these gentle, untrained, impecunious ladies into
whose care the friends of patients are asked to deliver them.
Yet they all had testimonials from the friends and relations of
former patients ! Then there is a further view of the subject,
which the following incident illustrates, and it is a pretty
example of another method of evading the law. A friend of
mine, at the request of his patient’s relatives, called a physician
in consultation upon a mental case which required certification
to legalise the necessary control. u Oh, you must not certify
it,” said the physician; “ call it hysteria, and you can do what
you like with it.” “ That is all very fine,” said my friend
indignantly, “ but the woman is a lunatic and ought to be
certified.” “Call it hysteria,” reiterated the physician, and away
he went, leaving my friend to treat a case of acute mania as
hysteria. But very soon the crockery ware began to fly about,
and the “ hysterical ” patient had to be promptly certified and
sent to an asylum. “ Call it hysteria ” indeed ! We have
arrived at a serious state of things if consultants, either unable
or unwilling to recognise a case, of acute mania, can bring
themselves to call it “ hysteria ” in order that they may pander
to the pride and prejudice of fastidious relatives who look upon
this, one of the most affecting disorders that can afflict a fellow-
creature, as a crime, or something to be ashamed of. Is it not
rather the duty of a consultant to support the medical prac¬
titioner in his endeavour to induce the relatives of the sufferer
to take a sane view of her malady, and do their best for her,
rather than hand her over to such untrained and unreliable
people as I have described, to be “ policemaned ” as a case of
“ hysteria” ?

They who have spent their lives in endeavouring to amelio¬
rate the condition of the insane must not stand by without
protest and allow a reversion to those methods of barbarism
which would be bound to follow any relaxation of the law,
without something more to protect the unfortunate patients
than the mere visits of a physician, who may have no special
knowledge of the care and treatment they require. Above all,
we must be satisfied that those who are allowed to take charge

Digitized by v^.ooQLe

1903 .] NOTE ON A NEW CASE-BOOK FORM. 267

of insane patients are properly trained and competent to do
justice to their charge.

The point upon which the whole question hangs is that of
adequate supervision. It is a very simple one. The Com¬
missioners in Lunacy have all the facts in their possession.
There is no need for any commission of inquiry about the
lunacy laws. We know quite enough about them already.
The appointment of Deputy Commissioners, together with local
expert representatives of the Board in centres of the population,
will, in my opinion, meet every requirement. By these means
the vagaries of those who take charge of cases of doubtful or
confirmed insanity will be held in check, and the friends and
relatives will be controlled and guided by the firm but kindly
supervision of trained experts, who are qualified by long
experience to guide and direct them in the right way.

(') Read before a general meeting of the Medico-Psychological Association held
at the County Asylum, Derby, February 12th, 1903.

Note on a New Case-book Form.Q') By W. R. Dawson,
M.D., F.R.C.P.I., Medical Superintendent, Farnham House,
Finglas ; Examiner in Mental Diseases, University of
Dublin.

There are two systems of recording cases in use in asylums.
The first, dispensing with all but a very few headings, notes
the facts in consecutive order, and their value or worthlessness
depends entirely on the experience of the writer. The second
(of which the method employed at the Murray Royal Asylum,
Perth, is the most thoroughgoing example) seeks by numerous
printed divisions to ensure that no fact of importance will be
missed. Those who support the former urge that multiplica¬
tion of headings encourages a mechanical and perfunctory
manner of case-taking, that the resulting record is scrappy and
disconnected, that intelligent amplification of salient features
is sacrificed to the noting of many unimportant facts, and
lastly that, as the divisions are never all filled in any indivi¬
dual case, the case-book presents an untidy and ill-kept
appearance. It must be admitted that there is a good deal
xlix. 19

Digitized by v^.ooQLe

268

NOTE ON A NEW CASE-BOOK FORM,

[April,

of truth in these objections ; but, on the other hand, when we
consider that asylum notes are often taken by inexperienced
assistants, for whom some guide is essential, and that even
those of larger experience are sometimes in danger of forget¬
ting to record the isolated facts, the expediency of using some
method of meeting these difficulties is obvious. The free use
of headings certainly does this, while at the same time it
enables facts of the history, often hard to elicit at first, to be
entered in their proper sequence from time to time, according
as they are discovered; and lastly, headings greatly facilitate
reference.

In the case-book form which I venture to bring under your
notice I have endeavoured to secure the advantage to be derived
from numerous headings, while at the same time avoiding, as
far as possible, the drawbacks of this system. Thus an effort
has been made, while omitting nothing of importance, to avoid
excessive subdivision, and to allow a certain amount of scope
for enlarging on individual points of importance. Proper
connection and sequence is sought for by following, as far as
possible, the chronological order of events in recording the
history, and what Easterbrook would call the " natural” order
in noting the symptoms ; while lastly, the printing and
arrangement of the headings have been manipulated with a
view to minimising the ugliness of blank spaces.

The points to which special attention may be drawn are the
following :—

What may be called the administrative (in contradistinction
to the medical) facts are placed in a division distinctly marked
off from the rest of the notes, the name of the disease being
also placed here for convenience. Next comes the family
history, and then the personal history up to admission. Under
the latter I take first the general facts regarding the patient as
an individual, including such matters as sex, race, religion,
occupation, age, disposition, habits, and so forth, for all of which
this seems to me to be the right place ; then the previous
health, under which previous mental attacks are first noted, and
then nervous and other diseases, and, in the case of a woman,
facts about menstruation and confinements. Lastly the present
illness is dealt with, the only special point under this head
being the arrangement by which certain symptoms of practical
importance are conspicuously noted. (The space left for the

Digitized by v^.ooQLe

1903]

BY W. R. DAWSON, M.D.

269

general account of the symptoms and course has been found
scarcely sufficient, and I should now give up three or four more
lines to it.)

In describing the 44 State on Admission” I have adopted sub¬
stantially the order advocated by Easterbrook, though some¬
what modifying the details. Thus we commence with certain
general facts observable at once on seeing the patient, and
such as cannot well be included under other heads (< e.g ,., weight
and temperature). We then go on to those which are revealed
by further external examination of the body, and finally take
the internal systems one by one, beginning naturally with the
nervous system as being of primary importance to the alienist;
and for this reason also this division is considerably elaborated,
the facts being grouped, as will be seen, under the headings
44 mental,” “ sensory,” 44 motor,” and 44 reflex.” (As regards the
first of these subdivisions it may be stated that the notes under
the first four sub-headings are intended to indicate not only
the presence or absence of the symptoms named, but also, if
present, their mode of manifestation, i. e. y the patient’s appear¬
ance, words, and conduct.) It does not seem necessary to
multiply headings in the case of the remaining systems (circu¬
lation, respiration, digestion, and the genito-urinary), which
any qualified man should be accustomed to examine and
write notes upon ; except, therefore, for one or two points
having a special bearing on mental disease, only the leading
heads are given, but space is left for the chief facts. Any
matters of special importance can be enlarged upon on the
following page, some mark being made under the appropriate
heading to indicate that this is done. Treatment is also left
for the next page, on which the progress of the case, etc., is
noted.

It will be seen that, when the forms are bound up, two
pages—blank except for the spaces to receive the patient’s
name, and the dates—are left for the remaining record. This
is frequently sufficient, but in my own case-books I have had
blank leaves with the same ruling bound in at the end of the
book, the pages being numbered consecutively to those of the
regular forms. The notes can then be continued on these,
the page being entered separately in the index. From 100
to 200 forms, with a supply of blank pages, make an ordinary¬
sized case-book. Separate forms are convenient for taking

Digitized by v^.ooQLe

270

NOTE ON A NEW CASE-BOOK FORM,

[April,

rough notes of the case on admission, to be subsequently
written in and expanded ; and of course any of the more
elaborate systems of preliminary note-taking, such as Wilson's,
may be worked in connection with the case-book.

The form has been in use at Farnham House for over sixteen
months and answers well, though experience shows that one
or two details might be improved, the most important being
the increased space required for the history, as already men¬
tioned. Of course some further modifications would be
necessary to adapt it for public asylum purposes.

In conclusion I may say that, while drawing up the plan, I
had the advantage of studying the case-book forms of several
of the leading asylums of these kingdoms, the best features of
which (or what seemed to me to be such) I have tried to
incorporate in it; but I am most of all indebted to Easterbrook's
instructive paper entitled, “ A Plea for a more Natural and
more Uniform Clinical Method,” published some years ago in
the Edinburgh Hospital Reports , to which I have already
alluded.

Headings of the Case-book Form.( 8 )

NAME—DISEASE —Termination—Date of Admission—
Hour—Date of Discharge (or death)—Last Residence—By
whose authority sent—Medical Certificates : I.—2.—Address
of Nearest Relative—.

FAMILY HISTORY. Heredity (direct or collateral) to
Insanity, Nervous Disease, Alcohol—Phthisis, Rheumatism,
Gout, etc.— Longevity—

PERSONAL HISTORY. General. Sex—Race—Re¬
ligion—Occupation and Position—Age—Marriage—No. of
Children (i) Alive—(2) Dead—Age of youngest Child—Mis¬
carriages—DISPOSITION and ABILITY—HABITS, espe¬
cially as to Work—Food—Alcohol—Sleep—Amusements—
Previous Health. PREVIOUS ATTACKS. No.—Age on
first—Kind, with Date, and Place of Treatment—OTHER
NERVOUS DISEASES OR SYMPTOMS, Fits, Chorea,
etc.—OTHER DISEASES. Syphilis—Rheumatism—Gout
—Fevers, etc.—MENSTRUATION—CONFINEMENTS.—
Present Illness. Duration—Supposed Cause—TIME AND

Digitized by v^.ooQLe

1903-]

BY W. R. DAWSON, M.D.

271

MODE OF ORIGIN.—SYMPTOMS AND COURSE.
Epileptic ?—Suicidal ?—Dangerous ?—Destructive ?—Wet and
Dirty ?—Tendency to Wander ?—Sleep—Appetite—Bowels—
TREATMENT—.

STATE ON ADMISSION General. Height—Con¬
formation—Fatness—Muscularity—Weight—Hair—Eyes—
Expression and Complexion—Aspect and Apparent Age—
Temperature—Skin, Bones, Joints, etc. Wounds, Bruises,
Eruptions, Swellings, Fractures (especially of Ribs), etc.—
Nervous System. MENTAL. Exaltation or Depression—
Excitement or Stupor—Enfeeblement—Impulsiveness—Atten¬
tion-— Coherence—Response to Questions—Memory ; Recent
—Remote—Hallucinations—Delusions —Insane Habits, Pro¬
pensities, etc.—SENSORY. Touch (including Muscular Sense,
etc.)—Taste—Smell—Hearing—Sight—Field of Vision—
E YES. External—Pupils—Fundus— MOTOR. Gait—

Muscular Power—Paralysis—Co-ordination—Tongue—Speech
—Handwriting—REFLEX. Knee-jerks—Circulation. Pulse
—Blood-pressure—Heart—BLOOD—Respiration. Rate—

Lungs,etc.—Digestion. Appetite and Thirst—Tongue—Teeth
—Palate—Liver, etc.—Genito-Urinary System. URINE.
Quantity — Reaction — S.G.— Colour—Deposit — Odour —
Albumen—Blood—Sugar—Bile—Microscopic—.
TREATMENT AND PROGRESS.

(*) Read at meeting of the Irish Division, May 23rd, 1902.—( 3 ) Each page of
the sheet measures about fifteen inches by ten inches. Page 1 is blank except
for the head-line. All the headings except the last are printed on the two centre
pages (2 and 3), the lines being ruled a quarter of an inch apart. To afford room
enough for the history all the headings after and including “ State on Admission ”
should be printed on the third page. All four pages have a space for the patient’s
name at the head. The space for “ Medical Certificates: 1.— 2.— ” is only in¬
tended for the names of the physicians signing them; their 11 Facts indicating
Insanity ” can be filled in verbatim under the history of the present illness, if
desired. Sufficient space (two or three lines in some cases) is of course left after
the various headings, but a feature of the form is that the headings are distributed
over the page, and not simply printed in columns one under the other; the
object being to minimise the unsightliness of any blank spaces. Between
“ Bowels” and “Treatment,” on the second page, at least eleven or twelve lines
should be left, as seven, the present number, has been found insufficient for
recording course of case up to admission. Under “Genito-Urinary System”
space is left after “ Microscopic ” for recording other symptoms connected with
this system. “Treatment and Progress ” is printed at the head of page 4 of the
sheet. There are thus, as pointed out above, four pages, two with headings fol¬
lowed by two blank, for the record of each case.

Digitized by ^.ooQle

272

NOTES ON HALLUCINATIONS,

[April,

Notes on Hallucinations . II. By Conolly Norman,

Richmond Asylum, Dublin^ 1 )

When last I discussed the question of hallucinations before
the Academy of Medicine, I detailed an interesting case in
which hallucinations of many of the senses occurred, and the
auditory hallucinations were confined to one ear, which was
deaf.

A similar state of affairs exists in another case, which pre¬
sents certain further points of interest. Briefly summarised, it
is as follows :—

Case i . —Delusions of occult influence; thought-reading; utilisa¬
tion of patient's faculties by others , etc. Hallucinations of various
senses. Unilateral auditory hallucinations coinciding with
unilateral deafness . Psycho-motor hallucinations involving the
graphic centre. —M. N—, male aet. 32, single, has been a soldier.
Admitted (from a workhouse) February 13th, 1900. Family
history could not be ascertained.

On admission.—Patient gives this history of himself: He joined the
Royal Field Artillery when twenty years of age. He remained in the
service for over eight years, and served seven years in India. Had
sunstroke three times. Since he came home he has had “an attack of
malaria, with enlargement of the spleen.” He has recently been a
fortnight in prison “ for being drunk and swearing in the streets. ,, He
was obliged to swear “on account of the annoyance in the ear.”
“ They keep talking to me and asking questions. They can read
every thought that is in my head. I believe that this system of tele¬
graphy, the system of communicating with one another, is at work in
the Transvaal. The Boers have this power, and are able to read our
despatches at a great distance.” He cannot say who it is that can
read his thoughts, save that it is a man and a woman. He gets most
annoyance from the man. He thinks that these people are out of
“ the Female Hypnotic School.”

Patient’s appearance is healthy. His hepatic and splenic dulness
are increased. His heart and lungs are healthy. (Had rheumatic
fever four years ago.)

Patient is lame of right leg and has extensive scars about the knee.
This is due, he says, to a gun-carriage falling on him some years ago.

February 20th, 1900.—Believes that he must have been hypnotised
some time. “This fellow [he has no idea who he is] can always talk
to me and hear what I am saying. He can always find me out. If I
am reading a paper they can read it at the same time. It is said to be

Digitized by CjOOQle

BY CONOLLY NORMAN.

1903 ]

273

some system of wireless telegraphy, but I think it is a trick. I’m
certain it is human voices,” etc.

February 24th, 1900.—Overheard to-day using extremely abusive
and threatening language, directed at some individual whom he would
beat and kick, and so on, and whom he repeatedly called, “ You

blackmailing b-He said he was tormented by this person, who

knew everything he thought and spoke it aloud to annoy him.

February 28th, 1900.—“They annoy me as much as ever. I know
they belong to some society. They want to know why I don’t join
the Freemasons; and what would be the use, because they could tell
every thought in my head. When I’m talking to a stranger they tell
out my character. It is always in the right ear.”

Patient is reported as frequently answering these voices in an angry
tone.

March X3th, 1900.—Patient talks in a very confident way about
his annoyances. “ I won’t get rid of them, because some one has got
hold of my head and they won’t let it go.” He hears these voices both
by day and night, when he is awake. “ They are all kinds of voices ;
they can read every thought in my head. Whatever I am reading is
read by them in a whisper beside me.”

April 13th, 1900.—Patient is sometimes very noisy, answering the
voices he hears. He says there is a conspiracy against him to try and
get some money out of him. “ They tell me to go to the Freemasons’
School, and they would get money for saying that I was selling secrets.”

May 13th, 1900.—Continues to complain about these voices that he
hears in his right ear. “ Even playing draughts they can tell the moves
on the board.” “ If I take up a paper they can read it with me.”
These are a man’s and a woman’s voices, and they annoy him day and
night. He very frequently stops working to shout out curses at the
owners of these voices.

June 13th, 1900.—When his eyes were being examined he remarked,
u I used to do that myself in the glass, and I saw people in my eyes
looking at me; they can see everything I am doing and read the
paper in my hand.” “It is like ventriloquism.” “It is by wireless
telegraphy.”

August 13th, 1900.—Says, “ It’s no use; I can’t get rid of these voices
at all. They are always questioning me, and telling me I am a bad
character.” “ It is all this wireless telegraphy, and I have only to shut
my eyes and shake my head and they can put some people in front of
me, so that sometimes I can see two priests and sometimes other
people. They are now deceiving me, and I don’t know who they put
in front of my eyes, as they change them so often.” He produces a
small piece of wood and says, “ The centre of that there was a piece
of glass taken from the eye of a sea-gull, and it has a map of the world
on it,” etc. On a later occasion he presented me with a piece of dark
green glass, a fragment of a broken beer-bottle, I think, saying that by
holding in a particular light he could see figures (“of the blind”)
moving about in it, and that thereby he knew what was going to happen
(? delusional interpretation of simple light effects). Pupils = both a
little eccentric : react to light. K. J.’s much +.

November 14th, 1900.—Patient talks about “ a lot of blackmailers.”

Digitized by v^.ooQLe

274

NOTES ON HALLUCINATIONS,

[April,

“ Mind readers, they could read the book in your hand.” “ I hear
their voices in my ears the whole time threatening to expose my
character.”

February 13th, 1901.—Says he still hears voices ringing in his ears,
accusing him of various deeds, viz., murder, etc. He says that he is
being made the medium through which a conversation is carried on
between two persons. Says he can see the figures depicted in his
brain and eyes. Says the voices are due to being hypnotised when he
was young.

March 15th, 1901.—Says that when he reads the newspaper or books
blind people read his thoughts; thus the blind, who themselves cannot
read, are enabled to read through him and through his mind. When he
shuts his eyes he can see these people—that is, their images—in his
brain, and he knows they are able to read his thoughts because they
speak what he thinks, and they repeat aloud the things which he is
reading.

August 13th, 1901.—He has had voices speaking in his right ear.
They kept calling him by name and accusing him of murder. He
hears voices speaking to him from above, which are in communication
with people outside the wall.

February 13th, 1902.—He is noisy and excited at times. He hears
voices telling him that he murdered Samuel Childs. When he shuts his
eyes he can see all these people in his head.

January 6th, 1903.—Being questioned as to the relations with the
blind (see entry of March 15th, 1901), he gives the following account of
himself:—“When I shut my eyes the blind move my hand—my right
hand—as if I was holding a pen, and so they make me write their
thoughts.” He exemplifies this by closing his eyes and moving his
right hand along the table with the fingers in the attitude of holding a
pen, but he says they do not make him actually write with a pen—he
would not do that for them,—and that he feels the movements of his
fingers and hand wherever his hand may be; when his hand is in his
pocket, for example—or if his hand is under his head,—only his eyes
must be shut. “ In this way the blind can communicate with each
other through me.” “ I see the blind in two ways—I see visions in my
head and I see them spread over my body [this appears to mean
superimposed upon him like an incubus], and I can also see them
trying to photograph with a camera the objects in front of me. They can¬
not see unless what I see, but they try and photograph that.” “ Besides
the blind, a man and a woman talk to me; sometimes, but not always,
they talk indecently. Sometimes, being foreigners, they cannot under¬
stand the person who speaks silently to them from upstairs, and so they
go on talking nonsense, thinking they are talking good English. This
talk is mere abuse or nonsense, but not the gabble of idiots. I often
hear, but cannot understand them.” “ They copy my thoughts and
speak them over. If they move their tongue I feel it in my mouth.”
“ The man that torments me has got hold of the dry plate of my photo¬
graph, and makes use of it to influence me and communicate with me.”
“ The blind have a special sense more than we have—that is, their
senses are more acute,—and so they know things that we cannot, and
they call that thought-reading and wireless telegraphy, but it is not.”

Digitized by v^.ooQLe

1903-]

BY CONOLLY NORMAN.

27 s

“ They give me pains in various parts ; there is a knee-screwing machine
and a hip-screwing machine.” “They make me taste bodies that are in
the ground; sometimes I have been made smell very bad smells, but I
don’t want to speak of that, for I think that was an accident. Some
of ihe poor blind creatures were short taken, and made a mess.” “ I
feel them touching my fingers, and sometimes they change the feelings
of the whole of my body to somebody else’s.” To the above account
of writing the thoughts of the blind, he adds : “ I know it is not I who
am writing, because I do not know what they are going to write; I only
know it by the spelling of the words they make me write.” With
regard to the voices which he hears, he says that when they speak close
to him low and confidentially they always speak only in the right ear,
as if they were at his right shoulder; but sometimes they speak from
far away, from some distance in front of him or above him, and then he
does not notice that they speak more in one ear than in another. He
seems perfectly deaf in the right ear, a fact of which he is unconscious,
and when the watch is placed to his right ear he says, “ It is not going.”

The well-known aurist, Dr. R. H. Woods, was so kind as to
examine his hearing for me, and reported as follows :

“ I examined the patient whom you sent me and find that his
deafness is of the middle ear catarrhal variety, associated with
Eustachian obstruction. In the right ear he has lost his hear¬
ing for a watch ; in the left his hearing distance is 4/36 of
normal. In the right ear Rinne's test is — 10, whereas it ought
to be + 25 ; in the left ear it is +5. The drums are slightly *
retracted, particularly the right. I was able, with a little per¬
suasion, to pass a Eustachian catheter on the right side and
verify the diagnosis of Eustachian obstruction. The right ear
is the one in which he complains of* voices/ and it is in the
right ear one would expect trouble from tinnitus. Whether
this complaint is his translation of auditory irritation that ordi¬
nary people would call noise or not, I am unable to say—
probably you will be able to judge. As far as the objective
condition of his ear is concerned, the case is a common-place one.”

In this case we have, with very exquisite delusions of occult
influence, hallucinations of various senses—visual, tactile, general
sensibility, olfactory, and auditory. Of all these the last alone
appear to be unilateral. The distinction that the patient
makes between voices near and distant is interesting, as his
hallucinatory state is quite analogous to the ordinary condition
of a person who is deaf of one ear and does not distinguish the
fact with regard to distant noises, but observes it when the
noises are near.

Digitized by

Google

276

NOTES ON HALLUCINATIONS,

[April,

I do not propose at present to add anything to what I said
in an earlier paper on the question of unilateral hallucination,
nor on the subject of auditory hallucinations in the deaf, save
to refer as regards the latter to an interesting case recorded by
that very keen and able observer, Professor Pick, of Prague.
(I quote from an article by S^glas in a recent number of the
Annales Mtdico-Psychologiques on “ Unilateral Hallucinations.”)
Pick tells of a chronic patient who was deaf of the left ear , and
who suffered from auditory hallucinations of the right side . A
plug of wax was found blocking up the left ear ; this was
removed, and from that time the hallucinations became bilateral .
This case seems to indicate that unilateral auditory hallucina¬
tions associated with unilateral deafness are not in all cases
susceptible of the explanation which most readily offers itself—
namely, that some peripheral or nerve-trunk irritation occurring
in the deaf ear is interpreted in a delusional manner.

It is to be noted that the mystic influences in this case have
a close resemblance to the sufferings of the victims of witch¬
craft in olden times. The mystic glass also is interesting, and
is, perhaps, a reversion to a common idea, or may be due to
something that he has heard of the magic mirror of the East.
Using him as a medium, obtaining influence over him by
hypnotism, etc., recall the notions of both modern and ancient
superstitions. Getting control over him by obtaining possession
of the dry plate of his photograph, though quite contemporary
in form, is, in essence, the old notion of witchcraft, according to
which the witch had only power over a person by obtaining
some portion of their body—hair, nails, or the like.

But the chief point of interest in this case arises in con¬
nection with the existence of psycho-motor hallucinations.
“If they move their tongue I feel it in my mouth.” In
other words, the patient receives ideas not in the way our
hallucinated patients usually do, by the direct auditory centre,
but through the speech centre. This is the commonest form
of psycho-motor hallucination. Less common, and in this case
more remarkable, is the psycho-motor hallucination connected
with the graphic centre. Though his hand be perfectly still
he feels movements as if he were writing, and he recognises
the words written by the movements which he feels himself
making in forming the letters. It is curious to note that this
only occurs when the eyes are closed. I am not yet prepared

Digitized by ^.ooQle

I903-]

BY CONOLLY NORMAN.

277

to say exactly why this should be, but it appears to exclude
very perfectly the action of the visual centre. He does not see
his fingers moving or the letters which they form. It appears
to be entirely a matter of sensation of the trained movements
used to express ideas by writing. Therefore, if we accept
Tamburini’s theory of hallucination, we must believe that we
have here to deal with an irritation occurring in the graphic
centre.

In the three cases which follow, the patients describe “ voices ”
which they hear or feel in their mouth or throat or chest, but
which, whether their own voices or the voices of others, do not
come to their cognizance through their ears in the ordinary
way of hearing. These appear to be pure cases of psycho¬
motor verbal hallucination. In Case 2 it will be observed
that there are two voices, one of which the patient hears
seemingly in the ordinary way, while the other is felt rather
than heard, and is her own. In Case 3 voices are heard in
the throat and chest. They are the voices of others speaking
through the patient. In Case 4 telephones speak to the
patient from her voice inside, and also she is compelled to
repeat in her mind the blasphemous and indecent words she
hears. There is a vague notion of double voice here, ques¬
tioning and answering.

Case 2.— Hypochondriacal delusions . Occult influences,
electricity , etc. Auditory hallucinations . Double voice . Psycho¬
motor hallucination relating to the action of the vocal organs .

B. C—, female set. 60, widow, small shopkeeper; religion, Roman
Catholic. No hereditary history of mental disease. Said to have been
healthy up to the oncome of present illness. Being a dressmaker most
of her life, she was of sedentary habits. Financial circumstances were
so straitened as to give rise to anxiety. Patient's only son, in whom
her daughter states “ she centred all her affection," died three years
ago. Some six months later her mother died after a long illness.
Patient then became “ melancholy and religious." Then she began to
think everyone was looking at her in the street, and that certain people
made her unconscious and took out her heart.

Admitted December 8th, 1902.—On admission thin, with rather
haggard countenance. Expression somewhat anxious, vigilant rather
than depressed. Loud first-sound murmur, most audible at the apex.
Arteries tortuous and rigid. Urine free from albumen. She is a gentle-
mannered person, somewhat timid and suspicious, but tractable. Con¬
verses with some intelligence on general subjects, and is capable of

Digitized by

Google

278

NOTES ON HALLUCINATIONS,

[April,

talking for some time without displaying delusion. When medical
officer began to examine her chest, patient said she heard a friend’s
voice saying that such was not to be done. When she eats, her food
goes up her back. People draw it up out of her stomach. There is
“a split in her head.” Hears two voices “ in her head ” answering one
another. One is like her own voice.

December 9th, 1902.—Hears a voice abusing and using indecent
language, and then she hears her own voice using pleasant language,
such as “ God bless you.” A voice told her that it was through a slit
in her head she hears, but she cannot feel any slit. When going into
church one day she was struck across the chest with electricity; she
does not know by whom. People in the street used to speak of her as
she passed, and “ voices ” in church used to say to her, “ Go to Com¬
munion,” “ Go to Father So-and-so,” and the like.

December 15th, 1902.—Inclined to deny the voices at first; then
describes them as before. The voice which replies to the abusive
voice is her own voice. Besides the voices, she speaks of “ brine,”
which is a sort of tingling pain that runs down to her feet and toes.
Suffers also from what seems to be an abdominal sensation, which
she calls “ crickets ”—(possibly delusional interpretation of the feelings
produced by a dilated heart palpitating in the epigastrium).

December 22nd, 1902.—The abusive voice is often indecent, accusing
her of being about to have children by a priest, and the like. Then a
voice, apparently her own, replies. The tingling pain is better ; it was
electricity. She says she called it “brine,” because it gave her the
sensation of being pickled.

January 8th, 1903.—Has had fainting fits. Heart’s action very
irregular. Notes under these dates exhibit no change in mental pheno¬
mena, except that she grows less inclined to talk of her hallucinations.

February 8th, 1903.—Talks of the voices as “delusions,” and says she
is “ cured.” But says they were real. When at Communion she used
to hear them say “Your son is coming home,” and the like. The
“ electricity ” which she used to feel on her skin was a feeling of “ soft¬
ness "—a “ creamy ” feeling. She is restless and uneasy, always impor¬
tuning to be sent home.

March 3rd, 1903.—Hears the voice of one of my colleagues constantly
at night, telling her she will soon be going home. Thus she heard him
tell her last night that she would go away to-day, and she consequently
expects to go. The voices are conveyed by “ a fluid.”

March 6th, 1903.—She talks spontaneously and by preference of
nothing except of getting home, repeating this topic over and over
again with a monotony resembling that of the melancholic. Questioned
steadily, however, she admits that she still at times hears abuse and
indecency; then hears her own voice saying prayers and blessing her,
and telling her not to mind. “ It is the voice of God, for it is always
good, but it comes like my own voice, speaking so that I can hear it.
You could not hear it, for I do not speak, but I hear it and feel it.
The answer to the cursing comes to me in my own voice, and when I
feel it I at once know that God is supporting me against the cursing.”
She added, returning to her favourite topic, “ I don’t hear anything now
except Dr. Cullinan telling me I shall go home.”

Digitized by v^.ooQLe

1903]

BY C0N0LLY NORMAN.

279

CASE 3.— Neurasthenia. Hypochondriacal delusions. Psycho -
motor hallucinations relating to the action of the vocal organs .

C. D—, female aet. 36, single, artisan class. No hereditary taint
ascertained. She is stated to have had “ water on the brain ” when she
was ten years old. This affection was characterised by stupor and
delirium. She was always afterwards “ delicate and nervous,” restless,
and inclined to roam about in an aimless way. She was observed to
have a peculiar habit of staring at her hands, probably associated with
some hypochondriacal ideas. It is impossible to determine when the
present attack began; it appears to be merely an exaggeration of her
habitual condition. Medical certificate states that she thinks her body
is dried up, and that she hears voices in her head.

Admitted August 29th, 1901.—On admission she was emaciated and
pale, with fixed fretful expression. Though she looked very frail no
definite signs of physical disease could be discovered, save an impair¬
ment of percussion over apex of right lung. She was fretful and some¬
what resistive; resents examination. “ It is the soul that is the matter.
I am a case for a priest.” Will not say that her soul is lost, but she has
“ saved it by prayer; it was at one time a beautiful soul.” “ I heard
beautiful voices of saints in myself.” Saw the Holy Ghost, but was
asleep then. Her “ body is drying up,” and she has “ lost her inside.”

August 30th, 1903.—Complains (untruly) that she was blistered
yesterday in a bath too hot and containing mustard. Vague hypochon¬
driacal complaints. “ Was a beautiful-bodied girl when I came here ;
had a beautiful body and beautiful limbs ; now my heart is destroyed
and every bit of me ; my skin is changed.” She heard beautiful voices
of saints coming from her own throat. She was emphatic that she did
not hear these voices in her ears, but in her throat (here she put her
hand on the epigastrium). She went on : “ The voices were voices of
saints and lady nuns, sometimes of countrywomen.” They come
specially when she is praying, but also at other times. They are as if it
is she who speaks, but the voice is not hers. She recognises several
voices quite different from her own.

September 5th, 1901.—Attributes her thin and fragile condition to
the cleansing bath she received on admission. Says she was as beau¬
tiful as a statue till then; had a beautiful bust, etc. Used to sing like
her friends, but she means “ the saints ” by “ her friends.”

September 12th, 1901.—“Body wasted; bowels closed; growing
smaller and drying up,” etc. By the gift of God she spoke with the
voice of a nun whom she knew, etc.

September 19th, 1901.—Small causes, such as physical examination,
visits of parents, etc., produce much agitation, during which she speaks
more freely than at other times of her delusions. “ Beautiful body is
quite spent,” etc. Hears voices which she describes as heard “ in my
throat and in my chest.” She has rather improved in physical condition,
and it is now noted that the lungs are clear.

September 28th, 1901.—Hears other people’s voices speaking through
her. If saying her prayers hears another person’s voice saying them for her.

October 14th, 1901.—“ I used to imagine that I spoke like saints and
nuns. I used to hear their voices in my throat and chest.”

Digitized by v^.ooQLe

28 o

NOTES ON HALLUCINATIONS,

[April,

October 29th, 1901.—She hears a lady’s voice in her chest, some¬
times when she herself is speaking, sometimes when she is not
speaking. Generally dull and very inaccurate about dates.

Notes made in November and December, 1901, show indications of
catarrhal trouble in the lungs. Under treatment by cod-liver oil, etc.,
this cleared off, and in January, 1902, she had begun to gain flesh.
During this time she remained dull and hypochrondriacal, and some¬
times spoke of her voices as “ imaginary,” “ perhaps fancy,** and so
on, and sometimes as being quite real. Hears them in the chest and
throat.

May 29th, 1902.—It is noted that she does not know where she is
living. The old hypochondriacal notions continue. She employs
herself in the workroom, sewing, etc. Usually speaks of her hallucina¬
tions as of things past.

August 29th, 1902.—“Used to hear voices,” but does not now.
Tells of them as real, but if pressed will say, “They may be imaginary.”
Dull and self-absorbed. Is almost always praying, but employs her¬
self at needlework.

March 6th, 1903.—Though rather self-absorbed, speaks freely when
questioned about her “ voices.” “ They are the voices of saints and holy
people. They come in my throat, not in my ears ; it is like as if I was
speaking, but I am not speaking, and the voices are not mine.”

CASE 4.— Persecutory delusions . Impulse to suicide. A uditory
hallucinations . Psycho-motor hallucinations relating to the action
of the vocal organs .

D. E—, female aet. 36, married, servant class. No satisfactory
family history obtainable. Her first child was born about four
months before admission (natural labour so far as is known), and
since then she has been ill. Is said to have suffered from hallucina¬
tions, visual and auditory, and to have attempted about six weeks
before to drown herself and her infant.

On admission, March 27th, 1902.—Fairly nourished, pale, pupils wide
and sluggish. She has a fixed and somewhat anxious expression, sug¬
gestive of listening. Says that she was told by telephone that her
husband is not her husband, but her brother. She says things pass
from the ceiling to the floor, but this was electricity. Did not try to
drown herself and her child, but only thought of it.

March 28th, 1902.—Little sleep, “owing to my mind; I had suicide
and everything in my head.” Also heard a “clicking” in her ears.
Often hears a voice like the telephone “ humbugging me with a lot of
questions.”

April 2nd, 1902.—Preoccupied, restless, quarrelsome. Sounds at
night like someone speaking through a telephone, saying indifferent
things with some application to patient.

April 10th, 1902.—Hears the telephones constantly—not in her ears,
but in her throat or mouth. The language is mostly abusive and vile.
While my assistant, Dr. Cullinan, was questioning her she paused to
listen to such voices, and repeated to him what they said. Afterwards

Digitized by CjOOQle

I903-]

BY CONOLLY NORMAN.

28 l

she said to me, “ The telephones speak to me from my voice inside ”
(laying her hand on her chest). “ It is like my own voice ; it is some
one speaking with my voice. I hear it in my mouth.” While I spoke
to her she assumed a listening attitude, and her lips moved a little.
Questioned, she said she had then heard the voice; it said, “ Why don’t
you marry the man that took the teeth out of your head ?” I remarked
to her that her lips had moved, and asked her whether she had not
been merely talking to herself. She said, “No, some one moved my
lips.”

April 27th, 1902.—“There are some questions answering to me.”
“Cursing and bad language.” They are tormenting and putting
questions into her head. She gives it to be understood that indecent
and blasphemous words are suggested to her, and that she is compelled
to repeat them in her mind.

May 27th, 1902.—The telephone continues to talk to her, but she
has “ put down ” the bad talk. No more dirty words and curses.
Indifferent references to her past life and surroundings.

June 27th, 1902.—Complains that she is pulled by the head at night
to make her shaky, etc.

July 27th, 1902.— Quite astray as to dates; dull and sluggish;
volunteers little information. A voice tells her her mother is here.

September 27th, 1902.—Does not yet know the names of the medical
and other officers of the asylum. While an A.M.O. was examining her
to-day, patient quite irrelevantly said, “ Bloody hell.” Asked why she
said this, replied that someone answered her back.

December 27th, 1902.—Tranquil and works a little, but does not
gain intelligence. Does not know where she is, nor the names of those
around. Says she does not hear voices now, but used to hear a voice
calling—a far-away voice.

March 6th, 1903.—“The telephones speak in my mouth. I do not
'hear them in my ear, but they talk with my voice in my mouth.”

In none of the following cases are the descriptions given by
the patients quite so exact as in the above, yet in all a condi¬
tion exists which I think is identical with the former cases.

CASE 5. — System of persecution. Neologisms . Mystic influence.
Mental action interfered with . Impulses to suicide and murder .
Pyscko-motor verbal hallucinations .

Male aet. 27, single, a post-office employ^. Father was a patient in
the Richmond Asylum, Dublin, where the present patient was admitted
July 26th, 1902. He then presented a highly-organised system of
delusion. Was the victim of persecutors, who were an American gang of
“sporers,” “spookers,” or x “ worsters.” They play upon him by means
of an “ ether connection.” They reproduce scenes on the brain like a
cinematograph.

On August 2nd, 1902, he is tormented by electrical instruments
called “ tykes ” and “ spankers,” the action of which is similar to that of
“ the corps of wireless telegraphy.”

Digitized by CjOOQle

282 NOTES ON HALLUCINATIONS, [April,

August 26th, 1902.—His sleep is disturbed; does not get proper
sleep ; it is like a stupor or torpor. This comes from the “ spooking
business.” During the two following months the notes indicate halluci¬
nations of hearing and vision.

November 26th, 1902.—“ I am an automatic lunatic; I can sing, dance,
or do anything through the wires that are acting on me.” “ They can
address me by the mouth; they can make me speak by forcing the
tongue.”

January 5th, 1903.—He tells of an attempt at suicide (truly) made
some time before his admission : “ I felt strange, as if some person had
made me subservient to his will-power and urged me to do things I did
not want to do; this, I believe, is known as mental telepathy. I was
tormented by means of a voice, the owner of which can remain at a
distance and hold up his victim to contempt. One day I was much
tormented, and an impulse which I could not resist came upon me,
when I was in my brother’s workshop, to lift up his shoemaker’s knife
and draw it across my throat. The cut was slight, but I and my
mother and brothers and sisters were all terribly frightened. More than
once terrifying impulses seized me to take a hammer and knock out my
brother’s brains. Once I took the hammer up, but I dropped it and ran
away. Afterwards my relatives were in collusion with my phantom
persecutors. I suspect also a man called R—; he is a master of wire¬
less telegraphy. Thus while a race is being run at Aintree he repro¬
duces it by wireless telegraphy in a theatre in Liverpool. It is a system
of personation. They frustrate my intellect; they worry and confuse the
mind ; they rush the intellect. They are called 1 shavers.’ They can
reproduce the incidents of your life as clearly in your sleep as if you
• were awake. They work on the mind and make one a mere automaton.
From creeping melancholy to the distorted maniac they can reproduce
every form of lunacy. They use my mouth to articulate their words.
They make me say words I don’t want to say—smutty words, for
instance,—and they make me sing silly popular songs.”

January 26th, 1903.—Said to my colleague, Dr. O’Reilly, “They can
talk to you through my mouth.” Asked to demonstrate this, he
shouted, “ Will you give over ? ” (cease), and answered loudly to himself,
“ No.” Said he could not prevent the answer that he was compelled
to give; it was not he who spoke, but his phantom persecutors
through his mouth. He is an industrious person, and intelligent in
various handicrafts, painting. Good-humoured when addressed. When
alone he is liable to loudly and angrily revile his persecutors, but he has
never been heard indulging in the automatic talking and singing of
which he complains.

Case 6 is a case which can only be abstracted here, as it is too
voluminous to be detailed. A married man, now aged about 60,
formerly a butler and of intemperate habits, has been under observation
four and a half years. He suffers from paranoia persecutoria, with well-
marked hallucinations of perhaps every sense save that of mental action.
His thoughts are not compelled, but he is tormented in every other
way. Hallucinations of general sensibility, dolorific, and of the muscular
sense; true tactile hallucinations ; thermal; hygric (hallucinatory sensa-

Digitized by v^.ooQLe

BY CONOLLY NORMAN.

283

1903 ]

tions of moisture); visceral; genital; olfactory; true gustatory ; visual
(elementary and common); respiratory; auditory (elementary, common,
and verbal). In May, 1899, he spoke of a voice that was sometimes
puffed into his mouth by the same agency that puffs smells into him,
and that acts upon his breath, but he hears it in his ears. He was
satisfied that it was not his own voice, because " it goes into me, whereas
my own voice comes out of me.” In April, 1900, he said, “ By day I
hear the voices through my # ears the way I hear you speak ; by night
they are mostly working on the breath, going in and out of the mouth.”

We seem to have here a not very fully developed condition
of psycho-motor verbal hallucination. The case is interesting
as showing very extensive engagement of sensation. The
somewhat rare hygric hallucinations are well marked (sensations
of being wetted, drenched with water, etc.). This form of
hallucination was first described by Baillarger. Ramadier, in
describing some cases, attributed it to a special form of sensi¬
bility (sense of moisture). Tambroni is disposed to think that
what he has entitled the hygric sensibility may even be localised
in the convolution of the hippocampus. Ravenna and Montag-
nini, in a careful study of the subject (Riv. di Pat. nerv. e ment .,
Sept., 1902), give a guarded support to Tambroni’s view. We
also note in this case the occurrence of respiratory hallucinations,
by which name I propose to designate those sensations of suffoca¬
tion, interference with the breathing, etc., which are so common.
It would probably be correct to consider these also as psycho¬
motor hallucinations. Perhaps the same may be said of the minor
conditions of hallucination of the muscular sense, in which a
patient complains, as occurs in this particular case, of sensa¬
tions of lassitude in special muscular groups, feeling as if his
limbs were too heavy to move, etc. It is so, certainly, as S^glas
has pointed out, with regard to hallucinations as to movements
of the limbs; and that author has dealt, in the same connec¬
tion, with the very interesting hallucinations which occur in
persons who have lost a limb by amputation and are able
not merely to feel pains in the extremity which has been
removed, but also to experience sensations as though lost
members were being flexed, extended, supinated, pronated, etc.

S^glas has suggested, no doubt justly, that hallucinations of
the muscular sense may have brought about beliefs in transpor¬
tations by witches, rides on broom-handles, etc. A case occurred
in my clinic last year in which an elderly male drunkard
suffered from hallucinations of vision (blue lights flashed upon
xlix. 20

Digitized by v^.ooQLe

284

NOTES ON HALLUCINATIONS,

[April,

him) and a sense of being transported through space at night.
He felt himself lifted up, bed and all, and carried to and fro
through the air, and then brought back again. With these
hallucinations, delusions that “ electrical parties ** were working
against him. Made apparently good recovery in about three
months.

In another recent case a woman *aet. 36, who had been
drinking, suffered from dysnoia, confusion, loss of orientation,
transient delusions, now exalted, now depressive, auditory
visual and visceral hallucinations, and entertained beliefs that
her voice was changed, and that she was carried from place to
place. The last was for a time her most prominent complaint.
Thought the transport was effected by an electric machine.
She recovered in about six weeks* time.

In another case, which I saw through the kindness of my friend
Dr. Molony, who was then Physician to Swift’s Asylum, a lady
was subjected to a very terrible form of torture. As soon as
she fell asleep she was removed to the Zoological Gardens and
handed over to the various animals, who outraged her all night.
Though this was said to have occurred in sleep, it was evident
from the distress and terror which she exhibited that the
sensations experienced were very real, and the sensation of
being transported was as distinct as the specific sexual sensations.
Subsequently, as I learnt from Dr. Molony, this poor lady, after
an illness of twelve years* duration, made a good recovery.

Returning to Case 6, we have here to note another feature
—namely, an interesting form of association of hallucinations.
“ My mind is tortured by a voice, and at the same time my body
is tortured with the practice upon it of pains and darts; the
practice does not come without the torturing voices, nor the
voices without the torturing practice.**

Case 7.—A married man set. 38, engineer, of intemperate habits,
and having a bad family history, exhibited at first what appears to have
resembled ordinary dysnoia, then developed delusions of jealousy,
and then, forgetting these, a system of persecution. Has been under
treatment for four years, and while he retains to the full his ideas of
persecution he has gradually arrived by the way of martyrdom at the
belief that he is the chief teacher of Jesus Christ and the Paraclete,
and that all the world is “ in simile ” with him, and so on. He has
been tortured by electricity, and, as he himself says, all his senses are
tampered with. He has, by the way, true gustatory hallucinations (sweet
and acid tastes) confined to the back of the tongue.

Digitized by v^.ooQLe

‘903-]

BY CONOLLY NORMAN.

285

May, 1899.—His “thoughts are anticipated and his mind known
before he speaks at all; ” his “ eyes are made looking-glasses for
others; ” further says, “ I am employed as a telephone. It is some¬
thing within me that is connected.” Talks of “a communication like
a voice—something speaking to me in my mouth and throat. The
word comes from my throat; it is not formed in my brain; it is
formed by some superior power, either your will-power or electricity.”

August, 1899.—“ All my thoughts are spoken by my tongue-soul to
every person in the world. My soul is in touch with all the souls in
the world—even silent thought.” He also talks in a not very in-
intelligible way of his “ picture thoughts.”

CASE 8. — Delusions of persecution with tendency towards
ambition . Hallucinations of general sensibility — visceral , olfac¬
tory, genital\ visual\ auditory, double voice, not very prominent
psycho-motor verbal hallucinations . Mystic influence . Tendency
to neologism, etc.

E. F—, female aet. 53, widow, taiioress, Roman Catholic. An aunt
is stated to have been insane, and patient says that a sister was epileptic.
Patient married many years ago a man much older than herself. The
marriage was childless. Husband died five years later. After a few
years she had an illegitimate child, who died at birth. Since that
event she lived a virtuous and industrious life (now for many years).
She is said to have been temperate. Her present illness is said to have
been of one and a half years’ duration.

Admitted May 23rd, 1894. She then presented numerous hallucina¬
tions and delusions. She was the subject of mysterious attacks and
persecutions, which had caused her to frequently change her lodgings
and go from place to place (persecute dkm&nageuse of Ball). “Voices”
at night. “ Darts ” of pain, more or less everywhere, but particularly
about the genitalia. Sensations of tightening, of dilatation of the vagina,
and specific sexual sensations. “ Visions,” sometimes of the machine
over the ceiling, that works all this mischief, sometimes of abominable
and impure objects. As is so often the case, she says, “ I do not see
these things; I am made to have a vision of them.” Snuff and soot are
put in tea; the food that is given is rotten. Frightful smells, apparently
faecal, disturb her. Dust is blown into her room and nearly stifled
her. Her abdominal viscera are dragged down and are tightened.
Incontinence of urine is occasionally produced. She was forced to
laugh, and forced to cry, and forced to do things. When she tried to
read, some one would read with her. People assumed her form for
improper purposes. They talked evil of her through the city, and
made her friends to shun her. They put things against her character
into the public Press. The voices were described as having a peculiar
character. They were “ drumming ” voices. A “ drumming ” voice is pro¬
duced by speaking with the lips closed and the teeth open. The person
drummed to can hear the voice, and others cannot. The voices thus
heard were some friendly, some hostile, and maintained an attack and
defence, some vilifying patient, others saying it was a shame to torment

Digitized by v^.ooQLe

286 NOTES ON HALLUCINATIONS, [April,

so excellent a woman in that horrible way. Further notes of this case
are very long and detailed, and it will be impossible to more than
indicate the most interesting points. In February, 1895, she stated
that she was bom for a high position, to which she has never attained,
and that she knew she was humbled (by her torments) in order finally
to be exalted to her proper sphere. This seems to be an example of
the not uncommon building up in a pseudo-logical way of exalted
delusion on a foundation of persecutory. The case, however, is not
one of Magnan’s dttire chroniquc , for the persecutory notions still
subsist, while the ambitious ideas have not increased and are rarely
referred to. She continues much in same condition for the past eight
years. Sometimes one particular phase of persecution is more com¬
plained of than another, but there is no real change. Asked (May,
1899) whether she heard voices anywhere except in her ears, she
laughed and replied, “ How can one hear but with one’s ears ? ” and
immediately added, without further suggestion, “ But they use my throat
as a telephone to speak their own voices through.*’ One has been
careful since then to avoid suggestion of any kind, but she occasionally
refers among her other complaints to the telephone voice inside.

CASE 9. — Paranoia persecutoria. Mystic influence. Neolo¬
gism. Hallucination of the sense of mental action. Compulsory
whispering of thoughts. Subjective sense of compulsory talk
( coprolalia^ etc.).

A. B—, female set. 23, single, of farming class; religion, Roman
Catholic. No hereditary history of insanity. Patient had convulsions
when about two years old ; otherwise she is said to have been healthy
and normal up to March, 1902. At that time she is said to have
begun complaining that people talked to her through the walls. Her
brother observes that “ she became very crafty and deceptive ” (/. e.
suspicious). Admitted October 30th, 1902.

On admission, a well-developed and well-nourished young woman,
presenting no physical peculiarity save that she is somewhat pallid.
Self-satisfied, precise in manner, and very disputatious. Though good-
humoured enough, she does not readily reply to questions, as she
prefers to interrogate her questioner, demanding to know what she
suffers from, how her mind is affected, and so forth. Says she has
slept little of late, being annoyed by “ voices ” coming through the
walls from the next house. She was also annoyed by the bishop and
clergy; they sat and willed that she should come to Confession; this
did not influence her, but it annoyed her.

October 31st, 1902.—Says “the actions and attitudes” of the young
men in the next house used to annoy her. They had a sort of
“pantomime” which she cannot more particularly describe; each had a
“ rdle; ” they “ syllable-ised ” their words, and made a smacking of the
lips. Her own family were cognizant of this annoyance, as she heard
a laugh from the next house which she recognised as being her sister’s
laugh. Also heard a voice from the next house threatening death to
her soul if she did not stand up for it, etc. Could not remain in the

Digitized by v^.ooQLe

I 9°3-]

BY CONOLLY NORMAN.

287

church after the priest had come in, because she had no control over
her talk, and everything that was said or whispered she was obliged to
repeat; a weight came over her chest, and she had to repeat all she
heard. Thinks the priests have some hand in this.

November 6th, 1902.—“ No control over my talk. Have to repeat
what I hear other people say. This is distressing, for they often say
bad things. There is ecclesiastical influence in it.”

November 13th, 1902.—“ Better. The ‘ reserve 1 part of the talking
is better. Have more control.” Still she says she has to repeat the
indecent things that were said to her through the wall at home.

November 13th, 1902.—“ The other patients repeat at night every¬
thing I say during the night.”

December 15th, 1902.—To the writer she said, “I am weakened by
influence. It must be ecclesiastical influence. In some respects my
thoughts are hindered. The free use of my thought is hindered. I
am compelled to speak in childish language, and my speech ”
(contents of) “ is influenced; besides, I have no guard on my talk.
I do not know what does it. It is mysterious; there is ‘that
other matter.’ ” (Refuses to explain this last phrase; it seems to mean
something besides priestly influence and the influence of young men.)
“ They speak, and then I have to repeat, and sometimes to reply.”
Speaks somewhat vaguely of a gramophone.

December 30th, 1902.—“The train of my thoughts is destroyed. I
can’t think without whispering the words.” Still hears the voices of
people at her home. As her home is fifty miles away she accounts for
this by means of the gramophone.

January 30th, 1903.—“I was under priestly penance; they wanted
to get my mind weakened, but could not get a thorough hold on it.
They got students to talk some kind of pantomime; sometimes I hear
it now, but it may be the patients here.”

February 28th, 1903.—The ideas are becoming more grotesque.
Says she is “ worked on by theology and medicine,” and “ suffered from
penance in a sense intermixed with medicine.” Her muscles have been
deformed since she came here. Her limbs require no renovation, and
they have been utterly deformed. Her body is lying in state, and any
deformities practised upon it (apparently by the medical staff) are
entirely illegal.

Throughout she has remained tidy and smart, rather pert and saucy,
extremely suspicious, able to work at needlework, etc., though apt to
be lazy and self-absorbed if left to herself. She never indulges in
objectionable language. Sometimes she has been heard talking to her¬
self, but the contents of her conversation cannot be known, as she at
once becomes silent when she is observed.

In many cases, as S6glas has pointed out, the accounts
which the patients give of themselves are so incoherent and
unintelligent that the mode of hallucination is rather obscure,
and yet we have strong grounds for thinking that it is truly
psycho-motor. That seems exemplified by the following cases :

Digitized by v^.ooQLe

288 NOTES ON HALLUCINATIONS, [April,

Case 10.—A male, labourer, aet. 39, married, father of eight children.
Used to drink hard; said to be sober for some years. Some two years
ill when admitted on February 13th, 1901. At first, voices, at curiously
varying distances, repeating to him everything that was in his mind
and making a toy (1. e. puppet) of him. Later on he complained of inward
dread, caused by the voices assuring him that the whole place was about
to be destroyed. Then he announced that he is filled with the Spirit of
God and is the greatest prophet since Jesus Christ; has foretold various
historical events, etc. Again, the exalted ideas recede and he is per¬
secuted—“ I suffer pains for others ; I have none of my own.” Hears
voices of girls, who use dirty language; has a heavy pressure on his
body; is 44 tormented by a system of suckage.” In July, 1902, he
said to me, “It is caused by * cheefening changes; * my mind is full of
visions ; voices roll up from my stomach and nearly choke me ; I pro¬
nounce with my tongue, but they come so quickly I can scarcely articu¬
late them and have not time to understand them as they come out;
they roll like balls out of me.”

Case ii. —Male, single, aet. 35. He is called a labourer, but he has
been some ten times in jail, as well as twice in asylums, and may be
probably classed as an habitual criminal. For the last eight years he
has, he says, been tormented with voices. He was admitted to the
asylum from prison in July, 1900, and apparently prison discipline and
abstinence, following upon extreme alcoholic excess, caused the aggrava¬
tion of an habitual state. His symptoms briefly were, on admission,
voices, flashes of light, blows on the head, bangs on the heart. He
complained also that the minds of others went out of them and were
communicated to him. There was an instrument over his head to which
he attributed the execution of all these annoyances.

In January, 1901, things had got rather worse. His head was twisted
at night by electricity. Sometimes he saw his persecutors in the air
“like a picture, but when I look again they are gone.” At that time
he stuffed his nose at night to procure sleep, for “ the electric affair
comes down through my nostrils.”

A year later he gave a fuller explanation in these words :—“ There
used to be a very strange thing coming down through my nostrils; it
was like a false breathing : it was turned into a voice, and I was
supposed to take a meaning out of it; sometimes it was calling names—
4 blackguard,* ‘son of a w—,* and the like; sometimes prayers; some¬
times (according to the humour of the place where you would be
sleeping, or according to your own humour) the words would be
friendly and call one good names; but most of it was double-meaning
things; you could take no sense out of it.”

Case 12.—Male set. 36, single, fireman on an Atlantic liner. He
has lost the sight of one eye through an old accident, but this fact has
no apparent bearing on his symptoms. His hallucinations are not uni¬
lateral. He came to consult me in the year 1901, having been at one
time in an English county asylum, from which he was discharged
unrecovered. He recognised his own mental unsoundness, but
attributed it to the machinations of persecutors. He said, “ They started

Digitized by v^.ooQLe

1903]

BY CONOLLY NORMAN.

289

those pocket reflecting kodacs with me three years ago, and illuminated
my whole system and brain and intellect. They upset my head by
this. They drew my mind and imagination ; they took my mind out
on the breath. It was my own mind which they kept repeating as they
drew it out. When I was at sea in the stoke-hole they spoke to me
through my nostrils; in this way they spoke through me to another
man. They passed all kinds of smells upon me. They prodded me
in the limbs and in the guts and in the penis. They produced sensa¬
tions of lust ” (and sexual orgasm). “ I have seen the blue flash of
light when they were illuminating my head.”

Case 13. —An old male sufferer from chronic paranoia, probably of
many years’ duration. Has been under treatment about four years.
Generally noisy, violent, and rather incoherent, with episodes of depres¬
sion and self-blame. Voices accusing him of all sorts of crimes. His
chief complaint at all times is that his tongue is always wagging. “ My
tongue is cursing me every day, and I can’t stop it; is there nothing
will control a man’s tongue ? I have my senses and can’t hold it; in
spite of me it is always wagging and cursing.” He is apt to denounce
all doctors as rogues because they cannot keep his tongue from
wagging.

S£glas, to whom we owe the phrase psycho-motor verbal
hallucinations, and to whom we are also indebted for the most
complete description of the syndrome,associates the" inner voice,”
the communication from spirit to spirit, and the like, with this
condition. I have not detailed above any cases of this condition
in which the connection between the mental impression re¬
ceived and the motions of the vocal organs was not pretty
distinctly experienced by the patient. Even thus limited, these
cases present several features of interest. Their resemblance
to each other is striking. The frequency with which the
formation of neologisms coincides with this class of hallucina¬
tion is probably not accidental, nor is the existence of the
double voice, nor is the almost invariable notion that the
patient is a machine used by external agencies to communicate
with others. The great prevalence of these hallucinations,
though they have attracted little attention from English writers,
must be apparent. Lugaro is within the mark when he says,
in a recent article, that they can be counted by tens in every
large asylum. In fact, I believe, if they are searched for, they
will be found to be among the commoner symptoms of
paranoia hallucinatoria. The study of the phenomena of
psycho-motor hallucination confirms the now generally received
doctrine of Tamburini as to the origin of hallucinations, and

Digitized by v^.ooQLe

290

NOTES ON HALLUCINATIONS.

[April,

is not inconsistent with the adoption of Tanzi’s view, which
may probably be justly considered an amplification and develop¬
ment of the opinions of the former author. But to this topic I
shall return on a future occasion. Meanwhile I must express
my obligations to my colleagues past and present, Dr. D. F.
Rambaut, Capt. Sheehan, Drs. Cullinan, Fleury, Redington, and
others, to whom I am indebted for many valuable notes among
those from which the above cases have been abbreviated.

( 1 ) Read at the Medical Section of the Academy of Medicine in Ireland, March
13th, 1903. A paper dealing in a more summary way with psycho-motor
hallucination was read at the meeting of the Irish Division of the Association,
January 28th, 1903, when the discussion here reported occurred.

Discussion

At the Meeting of the Irish Division, January 28th, 1903.

Dr. Drapes thought it unwise to seek to locate the origin of hallucinations in
any single region. As an irritation of any spot in the sensory path from a
particular part may lead to pain referred to that part, so a lesion in any region of
a sensory tract may give rise to an hallucination of the particular sense involved.
That hallucinations may have a peripheral origin is shown by their frequency in
cases of cataract, but of course they might also be of cortical origin. He referred
to a patient of his own, suffering from a gross lesion of the brain, who had curious
associated hallucinations,—a blaze of light followed by a loud report, loss of taste
in half the tongue, and certain motor hallucinations. He thought those of
delirium tremens were due rather to affection of the end-organs.

Dr. Dawson was inclined to differ from Dr. Norman as to the need for assuming
a special sense for moisture, the feeling of which was, he thought, a composite
sensation made up of those of temperature and of touch, the latter being excited
by alteration of cutaneous tension, etc. He agreed with Dr. Drapes in thinking
that hallucinations might take origin at different levels. He did not see that even
associated hallucinations need necessarily arise at a higher level than the cortical
areas of sensation, as the intimate commissural connection of centres which
commonly act together would be sufficient explanation.

Dr. Nolan was relieved to hear that Dr. Norman had the same difficulty as
himself in reconciling the various theories of hallucination. On the whole he
considered that there was a distinct evolution of hallucinations, as where a vague
noise is first heard, which gradually develops into a voice or other definite sound,
a course of events which he had seen in many patients at the Richmond Asylum.
In another case now under care the patient, who when sane suffered from retinal
disease, had hallucinations of vague shapes before his eyes. Later he became
melancholic on learning from an oculist that his case was hopeless, and then
these shapes changed to those of definite objects.

Dr. Eustace asked whether in the experience of others olfactory hallucinations
were common in general paralysis of the insane.

Dr. Norman, in replying, said that hallucinations were fairly common in cases
of cataract, and presented the usual difficulties of explanation. He and Dr.
"Dawson were familiar with a case similar to that mentioned by Dr. Nolan, in
which appearances were seen as of particles of moss falling like snowflakes before
the eyes, these being probably due to affection of the diseased nerve-endings in
the incipient optic atrophy from which the patient was suffering. The appear¬
ances became more complex as the disease progressed, taking the form of monkeys
and devils. As to the evolution of hallucinations, sometimes an intelligent history
was obtained of elementary hallucinations gradually developing into more complex
ones, which often ended in the verbal form ; sometimes, however, verbal halluci-

Digitized by ^.ooQle

1903.] CLINICAL NOTES AND CASES. 291

nations existed from the beginning. Cases of involution were even more instruc¬
tive, such as that of a woman who had suffered for some years from voices of two
persons accusing her of various crimes, but now says she no longer hears them, but
that the sound “ still comes upon her like a thought.” This could best be
explained on the supra-sensory theory of Tanzi. So complex a thing as an hallu¬
cination of the human voice could hardly originate merely in the sensory centre,
stimulation of which would only produce a sense of noise. He had met with
olfactory hallucinations in general paralysis.

Clinical Notes and Cases.

Clinical and Pathological Notes . By Dr. M. J. Nolan,
Resident Medical Superintendent, Down District Asylum,
Downpatrick.

The notes of the four cases to which I invite attention are
of general interest rather than of purely psychological bearing ;
yet I feel they may not be the less attractive to you on that
account. To others outside our specialty they may perchance
help to demonstrate the indissolubility of the physical and
mental aspects of our work in asylums. En passant it may be
remarked that it has become rather too much the fashion of
late for those who should know better to speak of our special
avocation as “ divorced ” from the pursuit of medicine proper.
For though existing modem methods necessitate a separation
a mensd et thoro , which holds the sick insane aloof from the sick
sane, yet apart from the exceptional difficulties which beset us,
our bond, with general professional work is no less binding
than that true, refined, and catholic specialism which searches
out in connection with a diseased eye, ear, or nervous system,
the concomitant manifestations of a constitutional dyscrasia.

Case i. —Swallowing of foreign bodies by a dement; safe
passage of large nails per anum; perforation of stomach by a
large bristle , which burrowed into the anterior abdominal wall
causing a chronic abscess , and necessitated surgical treatment; re¬
covery. —M. R—, aet. 43, admitted to the asylum December 15th,
1880, suffering from secondary dementia. A brother and an
aunt had been insane. He had always been regarded as

Digitized by v^.ooQLe

292 CLINICAL NOTES AND CASES. [April,

mentally deficient. On admission he was found to be very
morose, filthy in habits, addicted to masturbation, and a refuse
eater. He enjoyed fairly good bodily health ; had had no
serious illness, but now and again suffered from acute abdominal
pain, which was relieved by aperients.

Beyond a general improvement in health and conduct his
condition remained unchanged for years. In December, 1901,
he became more restless and difficult to watch, and was
observed to lose weight and colour. About this time he had
repeated attacks of intestinal colic due to ingested articles, such
as pieces of wood, balls of paper, fragments of shoe-laces, etc.
On one occasion he snatched a clay pipe from another patient
and quickly swallowed the bowl. He was then given an
abundance of bread and milk, porridge, and rice, followed after
a few days by guarded aperients, but though he passed several
small foreign bodies, such as those above noted, no trace of
the pipe-bowl could be found.

On January 26th, 1902, he was seized with very violent
abdominal pain, followed by a tendency to collapse. The
same treatment was again adopted, when he passed a small
piece of stone weighing about 14 ounces, eleven tin trouser
buttons of ordinary pattern, and two large nails (exhibited)—
one rather blunt-pointed, measuring 3^ inches, the other very
sharp, measuring 4J inches long. After an interval of some
few days, during which he was carefully watched, the treatment
was again repeated, but no other foreign bodies were evacuated.
The patient then seemed to be restored to his usual state of
health.

Some two months later, however, he developed an ovoid
tumour about i-J- inches below and 1 inch to right side of the
umbilicus. This gradually increased until it acquired the size
and shape of a hen's egg; at first hard and tense, it soon
became soft and fluctuating. An incision gave vent to some
3ij of foul pus. A minute examination of the walls of the sac
did not reveal any outlet from it, nor was there any indication of
an underlying foreign body, such as the pipe-bowl, which it was
supposed might have become encysted in the stomach, and the
tumour so formed adherent to the anterior abdominal wall. The
sac was thoroughly scraped out, treated by peroxide of hydrogen,
and antiseptically dressed from the bottom. The result seemed
at first entirely successful, but a fistula remained discharging a

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

293

few drops of pus daily, while a fungoid growth of granulations
formed round the small opening, the line of the track of the
fistula becoming meanwhile thickened and indurated. The
patient’s general health now began to decline steadily ; he lost
flesh rapidly and had repeated attacks of vomiting. On July
7th his condition became critical ; it was then decided to place
him under an anaesthetic and explore the abdomen if necessary.
Dr. Tate, surgeon to the County Down Infirmary, commenced
the procedure by laying open the full length of the sac of the
fistula. Beyond the indurated walls forming the track nothing
could be found to account for the hard mass to be felt through
the skin, and the most careful examination failed to reveal any
communication in the direction of the peritoneum. While,
however, the operator was examining with the point of his
knife along the rectus muscle, he nicked the connective tissue
between two strands of fibres and caused a strong resilient
bristle (from a bass broom) measuring 5$ inches long to spring
out. This was evidently the cause of all the trouble. The
wound was treated as before, and healed in the course of a few
days, the patient speedily regaining his usual robust health.

The points of interest are—

1. The passage of such long, sharp nails without injury to
the stomach or intestine.

2. The perforation of the stomach by the flexible bristle,
and the subsequent location of the latter in the line of the
fibres of the rectus muscle.

3. The critical condition to which the patient was reduced
by the most trivial of the ingested foreign bodies, and the
possibility that more serious surgical measures would have been
considered necessary if the simple cause had escaped the
surgeon’s observation.

CASE 2. — Cryptogenetic or septico-pycemia; suppurative cholan¬
gitis , with infection of lung , bladder , prostate , and epididymis .
General history . — The patient, D. S —, admitted August
17th, 1900, was received from Armagh Asylum, where he had
been several years. On admission he was suffering from
chronic mania, with auditory hallucinations. His general
health was good, with exception of some degree of anaemia.
His left hip-joint was ankylosed owing to tubercular disease in
boyhood. From the date of his admission until January 13th,

Digitized by v^.ooQLe

294 CLINICAL NOTES AND CASES. [April,

1901, his mental and bodily state remained unchanged. On
the latter day he had a rigor and was put to bed.

January 17th.—On examination physical signs of pneumonia
at base of right lung. Temperature 102°, pulse soft and weak,
occasionally intermittent. Turpentine stupes applied and
general stimulant treatment—beef-tea, eggs, brandy, with Mist.
Nuc. Vom. c. Tinct. Strophanti.

January 19th.—General condition improved. Moist riles
at base of right lung.

January 2 ist.-^-Continued improvement in local and con¬
stitutional condition.

January 25th.—Temperature normal; breath-sounds normal
over affected area.

January 26th.—Rigor. Complains of pain over kidney
(right), also of pain in right iliac region, and of pain running
down thigh half way to knee on anterior aspect. Temperature
102 0 . Local anodyne applications and general diffusible
stimulants given, as patient became weak after profuse sweat¬
ing ; temperature fell to 99 0 . Constipation.

January 27th.—Temperature 103*2°. Pain again complained
of in same regions ; some degree of tympanitic distension of
abdomen.

January 28th.—Temperature 104*8° Sponging and anti¬
pyretic treatment. Increased distension, relieved by castor oil
and turpentine enema. Profuse sweating. Constipated.

January 29th.—Morning temperature 101°, rising towards
evening to 103°. General condition improved; less pain locally.

January 30th. — Morning temperature 100*2°, rising in
afternoon to 102°. All pain centred over pubes ; could not pass
urine, which was drawn off; No. 9 catheter used without
difficulty. Urine high-coloured ; no abnormal constituent.

January 31st.—Temperature, morning 102°, falling to ioi°
in afternoon. Tympanitic distension again a source of pain ;
relieved by enema as before; urine drawn off.

February 1st.—Temperature rose to 102*8°; pain and dis¬
tension prominent symptoms. Pulse 108°, irregular and inter¬
mittent ; acute epididymitis on right side ; passed urine freely ;
fluid high-coloured, otherwise normal.

February 2nd.—Temperature remains at 102*8°; several
rigors. Urine passed involuntarily during night ; drawn off
to-day, contains mucus, and has ammoniacal odour.

Digitized by ^.ooQle

1903.] CLINICAL NOTES AND CASES. 295

February 3rd.—Condition unchanged ; fluid in right pleural
cavity. Serum only drawn off by exploring needle.

February 4th.—Tendency to collapse ; pulse small and inter¬
mittent ; rigors. Free fluid in peritoneal cavity, changing with
position of patient. Urine (diminished in quantity) drawn off ;
odour offensive.

February 5 th.—Patient free from pain ; pulse small and
intermittent ; heart-sounds very faint; skin flushed and moist.
Temperature falling from ioi° in the morning to 98° towards
evening. Catheter used ; flow of urine sluggish, force depend¬
ing on respirations, which are frequent and shallow. Tempera¬
ture rose at night to IO 5 0 ; weak, delirious, picking at bedclothes.

February 6th.—Died at 7.30 o’clock a.m.

Post-mortem examination, made at 2 o’clock p.m. same day,
showed congestion of base of right lung, with clear serum in
right pleural cavity. Heart fatty.

The liver acutely congested ; on the under surface a small
quantity of pus, confined by recent adhesions, and due to
suppurative cholangitis. Kidneys normal.

Prostate gland enlarged, tense, and fixed, owing to periprosta¬
titis. On cutting, pus oozed from the surface of the sections.

Microscopic examination of the liver showed fatty infiltra¬
tion, with excess of fibrous tissue between the lobules (section
exhibited) ; no abscess.

On sections of the prostate a large number of glands are
seen embedded in fibro-muscular tissue. Some are dilated
into cysts and suppurated, forming small abscesses (section-
shown).

CASE 3.— Melancholia with universal acute eczema; recovery .—
R. A—, patient aet. 43, was admitted to asylum on October
31st, 1900, suffering from recurrent melancholia of a religious
type—a Covenanter, she believed herself guilty of the worst
vices of the Court of Charles II, but expressed an intense
desire to do better. She speaks with apprehension of her
sister’s death in this asylum, and of her own previous attacks,
and is generally emotional. Her general health good—no
evident organic disease. A few weeks later she became more
distinctly depressed, and passed into a semi-stuporous state,
having little idea of time or locality. This phase lasted some
ten days—20th to 30th of November,—when she became

Digitized by v^.ooQLe

296

CLINICAL NOTES AND CASES.

[April,

brighter, ate and slept well, and engaged in cleaning the ward.
She then stated that when semi-stuporous she thought she had
died, and was in heaven. She then became depressed again
and developed an eczematous condition of pudenda, due, it was
assumed, to an irritating leucorrhcea. She was put to bed and
treated for this condition, but soon the inflammatory erythema
spread along the inner aspect of her thighs, and thence down
her legs, and upwards to the abdomen. In the course of a fort¬
night the disease completely invested her from scalp to feet, so
that she presented a perfect example of what Hebra terms a rare
variety of the disorder—namely, universal acute eczema (photo¬
graphs shown). Notwithstanding the dictum of that great master,
the palliative and expectant treatment did not promise to be a
success, as the disease lasted from week to week, and then ran
into months, the unfortunate victim in the meantime suffering
intense agony and misery from the pain, tension, and itching,
which lasted all day and the greater part of the night—the
characteristic insomnia being one of the greatest difficulties to
overcome. All this time the disease exhibited itself in its
various stages—vesicles, excoriations, pustules,—all modified by
the special regions affected. Having covered the whole ex¬
ternal integument, the disease affected the mucous surfaces in
continuity; a foul stomatitis, a muco-purulent bronchitis, catarrhal
diarrhoea, conjunctivitis and cystitis developed in rapid suc¬
cession, while the external auditory meatus became blocked.

Coincident with these conditions general constitutional
disturbance became manifest, and the patient's condition
became alarmingly prostrate. The disease had now lasted
some six months, during the greater part of which the usual
remedies were tried without effect. About the beginning of
May I commenced to treat her with ichthyol internally and
externally, and the beneficial effect became at once evident.
No fresh patches of the disease developed, the exudation
ceased, the scales were shed in enormous quantities, leaving
clean healing surfaces. By the end of May the patient was
completely rid of all traces of the disease, and rejoiced in a
satin-like skin and a complexion of the poetic “ milk and
roses ” type so rarely seen au naturel. She was discharged in
July quite recovered, mentally and physically.

The points of interest would seem to me to be—

1. The typical manifestations of a rare variety of eczema.

Digitized by Google

1 903]

CLINICAL NOTES AND CASES.

2 97

2. The apparently specific action of the ichthyol treatment.

3. The associated affections of all the orifices of the body.

4. The danger to life by constitutional effects of the toxins
produced by such extensive disease.

Just a word with reference to the mental condition. While
one must admire the keen incisive criticism of Hebra—a
quality which makes his work so valuable,—and while one
must agree with him that there is no definite relationship
between skin disease and insanity, yet it is noteworthy that in
this case the real acute bodily misery routed the apathetic
delusional melancholia. It is possible that if the mental and
bodily ailments had been approximately synchronous at the
onset, the eczema would certainly, with evident good judgment,
have been regarded as the cause of her insanity. It may
perhaps be rash to surmise that it promoted her mental re¬
covery, but that it should not have retarded it seems most
remarkable.

CASE 4.— Senile melancholia associated with fatty infiltration
of the heart, and aneurysm of aorta ; rupture into the pericardial
sac; death .—A. McA—, aet. 62. Patient was admitted from
Kilkeel Union Workhouse on February 9th, 1900, suffering from
acute melancholia of ten days’ standing, with delusions of
persecution, hallucinations of hearing, refusal of food, and
suicidal impulse.

On examination she was found to be well nourished ; she
suffered from cataract, atheroma, and very well marked arcus
senilis . Her pulse was slow, soft, and at long intervals inter¬
mittent. There was a certain degree of cyanosis, and she
suffered from dyspnoea on slight exertion. She was free from
all other evident organic diseases.

During a year under tonic treatment she improved mentally,
losing all acute excitement, sitting quietly all day and speak¬
ing little. She took food well, and improved in general health.
From February to May, 1902, her condition remained practi¬
cally unchanged, except now and again, when she became
rather more depressed than usual, wishing she was dead,
declaring she was no use, and stating that persons kept her
awake at night saying, “ It’s she that did it.”

On the morning of May 4th, when she appeared in her
usual state, on the way from Mass to the hospital she stumbled

Digitized by v^.ooQLe

298

CLINICAL NOTES AND CASES.

[April,

to the ground, but did not faint. She was raised, carried to
bed, and examined. She then complained of pain in the
cardiac region, and a sense of faintness. The heart-sounds
were extremely weak and distant, and the cardiac area of
dulness was much increased. Her pulse became small, irregu¬
lar, and intermittent, her face and limbs more cyanosed, and
her respirations shallow and frequent. Her intellect became
clearer; she spoke rationally. During the day she became
more and more asphyxiated, and her heart became more em¬
barrassed, until she sank on the morning of the 5th, all
restorative treatment proving useless.

Post-mortem examination 9 o’clock a.m. on May 5th. No
gross lesion of brain ; membranes all adherent ; emphysema
of lungs ; fatty infiltration of heart. A dissecting aneurysm
of ascending arch of aorta at base of heart had ruptured into
the pericardial sac, ( l ) which was full of blood (specimen ex¬
hibited). Fatty degeneration of kidneys. Cyst of right kidney
and cyst of right ovary.

( ! ) A like case is recorded in the Report of the Director of the Pathological
Laboratory and Pathologist to the London County Asylums, 1902.

Discussion

At the Meeting of the Irish Division of the Medico-Psychological Association,
November 25th, 1902.

After a few remarks from the Chairman—

Dr. Curran suggested that the primary morbid condition in the second case
was pneumonia, and that it was probably a case of pneumococcic septico-pyaemia.
It was probably due to the high power of resistance that the patient was able to
withstand the poison for so long,—that is, until the disease reached the transition
stage between septicaemia and pyaemia.

The Secretary thanked Dr. Nolan for his paper. With reference to the first
case, he had seen about ten ounces by measure of miscellaneous articles, such as
broken spoons, buttons, etc., which had been taken from the stomach of a lunatic
dead from some other cause. The tolerance of the intestinal tract in the insane
was remarkable. He was inclined to agree with Dr. Curran that pneumonia was
the primary condition in the second case. In a patient of his own the pneumo¬
coccus had acted so virulently as to produce superficial gangrene of the lung, and
such violent action should probably be set down to diminished resistance of the
tissues. With regard to Case 3, he would like to ask whether in the experience
of those present acute eczema was specially common in the insane. In an old
paranoiac suffering from a prolonged period of obstinate constipation he had seen
acute pustular eczema of the scalp and back of the head on one side develop
suddenly, and almost as quickly disappear without special treatment. He would
be glad to know whether others had found such cases of common occurrence.

Dr. T. A. Greene said that, as regarded the process of infection in the second
case, the patient had probably swallowed a great deal more of the infected sputum
than a sane person would have done. Alluding to the last case, he mentioned
that of a patient of his own who suffered from Bright’s disease, and had a serious
attack of convulsions. His clergyman was sent for, but, objecting to religious

Digitized by ^.ooQle

1903-]

CLINICAL NOTES AND CASES.

299

ministrations, he became very excited and died suddenly. It was found that, as in
Dr. Nolan’s case, an aneurysm had ruptured into the pericardium. He wished
to ask whether the urine in the case of eczema had been found to contain albumen,
as he had observed it in some cases under his own observation.

The Chairman alluded to the trouble caused in asylums by the habit of
swallowing foreign bodies, and mentioned a case of pica in which a floating abdo¬
minal tumour was found during life in a child, and after death was discovered
to consist of a mass of Berlin wool completely Ailing the stomach and taking its
shape. In another case, at the Richmond Asylum, the patient suddenly developed
an attack of pneumonia, of which he died. Half of the iron heel-tip of a boot was
found hooked on to the bifurcation of the bronchi, and was apparently the
cause of the pneumonia; and a number of objects were found in the intestines,
including a seven-inch teaspoon, the bowl of which lay in the hepatic flexure of the
colon, while the handle had passed through the wall and was in the interior of a
cavity formed by peritoneal adhesions. Recently a melancholic woman who had been
wasting for some time died after an attack of diarrhoea, when the stomach was
found to be Ailed with a mass of blanket-Abres, of which a smaller mass lay in the
jejunum. Passing to the second case, the speaker referred to a well-known recent
case of septico-pyaemia with pneumonia arising from a scalp wound, in connection
with which a legal authority had declared that pneumonia could not arise except
from cold 1 His experience of eczema was that it was not specially common in
the insane, but he had seen very extensive eczema take rise from the local applica¬
tion of belladonna in a private case. In the fourth case the form of aneurysm was
that which oftenest escaped detection. He had seen three cases, one of which had
ruptured in the same position as in Dr. Nolan’s patient. Another was that of an
apparently healthy old woman, who going out to defaecate on a cold night was
found lying dead after a short time, a ruptured dissecting aneurysm being dis¬
covered post mortem. A third patient, a general paralytic of long standing, had
also died during defecation from rupture of a dissecting aneurysm which involved
practically the whole aorta. Death in such cases was due to the pressure exerted
upon the heart by the blood in the pericardium, not to the mere loss of blood.

Replying, Dr. Nolan said that in his experience eczema was not more frequent
amongst the insane than in the general population. In the special case he now
reported, the urine contained no abnormal constituent. He thanked the meeting
for the kindly consideration given to his communication.

Two Cases of Abdominal Surgery in the Insane from
Attempted Suicide . By Robert Jones, F.R.C.S.Eng.,
Medical Superintendent, Claybury Asylum.

M. T—, aet. 35, a servant, of dark complexion and bilious
temperament, suffering from suicidal melancholia, whose insanity
was greatly due to privation, was admitted July, 1894, in a
weak, emotional, and tearful state, saying she was unhappy,
had nothing to live for, and wished to die. She also stated
that before admission she had threatened to drown herself.
There was some congenital weak-mindedness and a marked
retardation of mental reaction.

A month after admission she began to improve and became brighter,
taking more interest in her surroundings ; but four months later she
XLIX. 21

Digitized by

Google

CLINICAL NOTES AND CASES.

300

[April,

relapsed into a sullen, resistive manner, with a recurrence of suicidal
tendencies.

At the end of a year she appeared much better and helped in
the ward, but after some time she again relapsed, and for the next
three years she was alternately bright and depressed, with weakened
inhibition and diminished self-control, being easily upset by trifles, and
often imagining people were against her. At times, during the latter
moods, she would be impulsive and spiteful to others. She alternated
mentally between two extremes, being either acutely despondent or
violently impulsive and troublesome.

Four years after admission, and having some weeks before again
threatened suicide, she one evening told the nurses that three days ago
she swallowed, head first, a hat-pin about eight inches long, with a big
beaded head to it. She had been complaining of pain in her side for
some days, and was one day in bed. On this evening, after admitting
that she had swallowed the hat-pin, what seemed like a pin-point could
be felt through the skin of the abdominal wall, and the same evening
she was placed under an anaesthetic—chloroform—with the intention of
removing it.

When under the anaesthetic the point of the pin could be distinctly
felt, but on cutting down upon it the point moved and disappeared.
An incision was now made in the middle line from below the xiphoid
cartilage to the umbilicus for about three or four inches, which left a
quite free external opening. The incision was carried through the skin,
subcutaneous tissue, and tendinous wail of the linea alba. The peri¬
toneum was known by its fasciculation and translucency. All bleeding
was arrested in the lower angle of the wound, and the peritoneum,
which was hooked up so as to include nothing else, was then opened
upon two fingers. The pin was now seen, and found to have passed
through the wall of the stomach. It was held up and pulled outwards,
so that the stomach came well in situ . Traction was made upon the
stem of the pin in order to dislodge the head if possible, but the head
and stem refused to part. I then contemplated cutting the stem with
a bone forceps close to the serous covering of the stomach, but the fear
of subsequent damage to the mucous coat in its travels along the intestinal
canal favoured the only alternative, ws., to open the stomach itself and
remove the whole pin. On making traction upon the pin the stomach
was again brought well forward into the opening, and the part perforated
by the pin brought out of the wound. Sponges were packed well around
the wound to shut off the peritoneal sac and to steady this part of the
stomach. The stomach was then opened by an incision about a quarter
of an inch long, transverse to its long axis, and as far as possible the
blood-vessels were avoided, but several sprang as the incision was
deepened into the mucous membrane, and were at once commanded by
Spencer Wells’ forceps. Very free haemorrhage took place, and the pin
was removed. The vessels were compressed, but not ligatured, and
eight or nine sutures were inserted into the mucous membrane, the
incised edges of which were then brought together. A similar pro¬
cedure was adopted, after Lembert’s method, in regard to the peritoneal
surface, which insured the two serous surfaces being in contact. The
stomach was now returned into the peritoneal cavity, and no blood, so

Digitized by ^.ooQle

CLINICAL NOTES AND CASES.

301

1903.]

far as could be avoided, no mucus, nor stomach contents were allowed
to escape into the peritoneal sac. The outer wound was then closed
with a continuous suture.

The patient took the anaesthetic well, but was rather troublesome
afterwards, in spite of Suppos. Morph, gr. $. She went on fairly well for
the first day after the operation, but in the early hours of the morning
of the second day she had a severe sickness, which, together with
obstinate restlessness, caused the stitches to rupture, the wound to open,
and the intestines to protrude. I was immediately summoned by my
colleague, Dr. Emily Dove, and on my arrival found several coils
of the intestines out of the abdomen and the dressings removed. She
was again placed under an anaesthetic, the continuous suture was com¬
pletely removed, and the coils of intestine were each carefully washed
and cleansed. Warm aseptic sponges were soaked in boracic lotion
and boiled water; they were well wrung, and applied to the whole of
the intestines protruding, which were then returned into the abdomen.
The peritoneum was carefully “ toiletted,” the serous edges were
sutured with separate sutures, and the whole wound brought into good
apposition and thus retained by separate stout silk sutures. Iodoform
was dusted over the wound, and dry gauze well packed over this; the
abdomen was uniformly and evenly bandaged, and over all a binder
was sewn.

After this she made uninterrupted progress; the temperature never
rose above ioo°, and this only in the evenings. For the first forty-
eight hours after the second operation but little was given by the mouth,
save ice, barley water, and meat juice. At the end of the week the
bowels had twice acted naturally and the wound was satisfactory. In
another month the patient was physically quite convalescent, able to go
out of doors daily and to take an interest in her surroundings.
Mentally, however, she varied much, being either impulsively suicidal,
threatening, and destructive, or quiet, reasonable, helpful, and pleasant.
About fifteen months after the operation she was transferred to another
asylum, having been resident in Claybury just over five years. It is four
years since she has been transferred, and her mental state, I am
informed, remains unimproved.

Remarks .—There are comparatively few occasions upon
which it becomes necessary to make an incision into the
stomach, even in sane persons, and these are usually for the
removal of foreign bodies, the majority of which are swallowed
and pass down through the pylorus. When this becomes
inevitable the hospital surgeon—with experience of many and
frequent operations, with all the necessary instruments at hand,
and every desirable assistance available—contemplates such an
operation with equanimity. When, on the other hand, an
emergency occurs suddenly, with limited facilities for carrying
out aseptic precautions, and when the operation is performed
upon a person who is bent upon frustrating all his efforts, the

Digitized by v^.ooQLe

302

CLINICAL NOTES AND CASES.

[April,

operator is compelled to deliberate, and may perhaps be
pardoned for hesitating to take immediate measures until other
sources are exhausted. In this case there was no doubt what
to do and when to do it The end fully justified the procedure.
One word of warning may, however, be sounded against the
continuous suture, in which, when one part becomes loose, the
whole becomes insecure. Except with the Lembert method in
combination, I would not again use the continuous suture.

Case 2.—In contrast to the foregoing is the case of B. Z. S—,
an Arab, over 60 years of age, who accompanied the British
troops to Lower Egypt in 1888 and afterwards found his way
to England. He was admitted November 19th, 1898,

suffering from restless melancholia with marked suicidal
propensities.

He was at times frenzied with excitement, but looked exceedingly
miserable. By day he sat about with a downcast look, crouching on the
floor, and having a cringing, dependent look. Although thin, he was a
fine specimen of a Soudanese Arab. He could speak no English, but
another patient speaking his language could converse with him. In
order to obtain access to his mental condition the Professor of Arabic
from King's College, London, was requested to visit him as an interpreter.
He improved a little in bodily condition soon after admission, under
improved physical surroundings, but no marked mental change occurred
Nearly four months after admission, whilst actually under observation
in the “special” dormitory, he was found at 2.30 a.m. to have his hands
smeared with blood. Upon examination he had an irregular wound
about two inches long in the middle line of the abdomen, through the
peritoneum. Coils of intestine were lying exposed under the bed¬
clothes ; they were immediately covered with hot sponges soaked in
boracic lotion. The patient was anaesthetised (chloroform), the incision
enlarged upwards and downwards, the intestines carefully cleansed,
examined, and—with the exception of one coil, which was found to have
four punctured wounds in it, one an inch in length—were returned into
the abdominal cavity. The loop was sutured into the wound and an
artificial anus made. The patient was returned to bed with hot water
bottles, and was kept under special supervision. A small blood-stained
piece of glass was found under the patient’s bed in the morning, but it
never transpired how the injury was inflicted. The patient’s wound was
dressed the following day and appeared healthy. There was abdominal
respiration and no marked tenderness, the urine was passed naturally,
the temperature was low, but the pulse was feeble and irregular. Later
on tenderness of the abdomen was noticed, and there was less move¬
ment ; nourishment was indifferently taken, and as the patient was a
Mohammedan he obstinately refused brandy, which, with peptonised
milk, had to be given by the nasal tube. On the third day the pulse

Digitized by

Google

1903 -]

CLINICAL NOTES AND CASES.

303

was hardly perceptible, respiration was rapid, shallow, and entirely
thoracic, the general condition was very unfavourable, collapse set in,
and he died early on the fourth day after the injury.

Post-mortem .—An examination revealed every sign of septic peritonitis.
Coils of intestine were seen to be dilated and deeply injected. The
extruded coil had two large wounds, and was almost black with conges¬
tion. There was generalised purulent exudation, with recent adhesions;
about 70 c.c. of purulent fluid were taken from the pelvis. The small
intestine had three holes in it (apart from the one which formed the
artificial anus); two of these were about 10 mm. long, the other 4 mm.
The first wound was two inches above the caecum, the second four
inches, and the third four inches further.

Remarks .—With the experience of these two cases I am
now of opinion that it would have given the last case a better
chance if the “ toilette of the peritoneum ” had been carried
out after having carefully sutured the wounds in the intestine
by the Lembert method. With the means at our command at
the present time, and the experience derived from operations
after perforated gastric and typhoid ulcers, I should be dis¬
posed in future to close all intestinal wounds and to irrigate
and douche the peritoneum, effecting a systematic cleansing, as
taught by Maclaren, who directs that the folds of the mesenteric
attachments of the small intestine, the lumbar and pelvic
hollows, and all pockets should be well douched to avoid the risk
of spreading septic conditions, and that this should be done
thoroughly and in sequence from the caecum to the colon under
the liver, and from the stomach to the rectum. It remains to
be said, however, that there are some authorities who consider
that to irrigate, douche, or cleanse the peritoneum seriously
diminishes the resistance of this serous covering, and that such
a course favours the effusion of serum, which becomes the
pabulum for septic organisms introduced previously, or by the
process, or left behind after its completion.

A Case of Hebephrenia. By W. R. Dawson, M.D.(DubL),
F.R.C.P.I., Medical Superintendent, Famham House,
Finglas, Dublin.

The term “hebephrenia” was first used by Hecker(i) and
Kahlbaum many years ago to denote a peculiar sequence of
morbid mental phenomena commencing at puberty, or in early

Digitized by

Google

304

CLINICAL NOTES AND CASES.

[April,

adolescence, and considered sufficiently constant and definite to
be classed as a separate form of mental disease. The subject
has been especially studied on the Continent, but the position,
which the group of symptoms should occupy is not even yet
agreed upon. So prominent an authority as Krafft-Ebing has
stated, in the last edition of his Lehrbuch (2),that the correctness
of making hebephrenia a distinct disease still seemed to him
questionable ; while, on the other hand, Kraepelin (3) accepts the
distinction and makes hebephrenia one of the three varieties of
“ dementia praecox.”

The exact delimitation of hebephrenia has probably differed
somewhat in the hands of different writers; but, taking
Kraepelin’s description for a foundation, as being the most up-
to-date, the following would seem to represent the present
significance of the term :—

The disease always occurs in hereditarily predisposed indi¬
viduals, and typically about puberty. It may begin either with
a period of depression, in which suicide may be attempted, or
more insidiously, the patient becoming self-absorbed, morose,
and solitary, or irritable and obstinate. The patient then
grows apprehensive, depressed, and suspicious, and suffers from
hallucinations, most frequently those of hearing (which take
the form of voices or inarticulate noises), but also of sight,
smell, and common sensation. At the same time he acquires
delusions of personal unworthiness, of suspicion (poison; being
worked upon by others ; that his thoughts are not his own, etc.),
and later of an expansive character. These last are accom¬
panied by fabrications. At first the patient is quite conscious
that something is wrong, both consciousness and orientation are
little impaired, and he is quite coherent. Memory for recent
events soon shows deterioration, and judgment is early affected.
The patient becomes dull and indifferent, but is self-centred,
with mental depression and irritability. Masturbation is fre¬
quent. Conduct becomes more and more childish ; there are
bursts of senseless laughter (a very prominent symptom), and
various purposeless actions. Obstinacy alternates with facility.
Speech shows looseness of thought and confusion, and there is
a love of long words and stilted phrases. At first the appetite
is poor, sleep is disturbed, and there may be some trophic dis¬
turbances, but these pass off later. The disease is progressive,
but there are frequently remissions, especially in the earlier

Digitized by v^.ooQLe

1903.]

CLINICAL NOTES AND CASES.

305

stages. As it runs its course the mental enfeeblement increases,
but the delusions and hallucinations fall into the background
and disappear. There may be periods of excitement, however.
Marked dementia appears in from six months to several years,
and in the vast majority of the cases continues to deepen. A
few, however, recover to a certain degree, and in some others
the disease remains stationary. Thus the essential features of
hebephrenia are a progressive mental weakness beginning about
puberty, and accompanied in the first stage by mental depression,
with hallucinations and delusions, which subsequently pass off.
It appears to cover much of the ground occupied by the insan¬
ities of puberty and of masturbation in some other classifications.

The frequency of the condition is also a matter of dispute,
but it appears to be sufficiently rare to justify me in bringing
the following case under your notice :

The patient, a youth aet 18, was admitted as a voluntary boarder on
March 1st, 1902. There was some neuropathic tendency on the
paternal side. His father, who was still alive, suffers from chronic con¬
stipation. A brother died of cardiac disease.

The patient himself is said to have always been a solitary boy, but
when at school he joined in football. For the two years previous to
admission he was apprenticed to an architect, who had little business
and left him very much to himself. He lived in a hotel, being abso¬
lutely his own master, keeping to himself, and maintaining late hours
and irregular meal-times. He was a vegetarian. His only recreation
was reading. General health was good, except for chronic constipation,
and he had had no severe illnesses. He was not dissipated, but by his
own account had masturbated for four or five years, though generally
only about once a week; at one time, however, not very recently, he
did so as often as once a day. He said he had felt depressed for two
or three months, and it was noticed that he had lately found it hard to
keep warm.

On Feb. 23rd he was noticed to be a little odd, and next day he
walked about one and a half miles down the quay and threw himself
into the river. He changed his mind and scrambled out, went to a
neighbouring Sailors’ Home to dry himself, and then back to his
lodgings. His motives for this act he explained differently at various
times and to different persons : (1) he did not believe in a hereafter,
and did not expect ever to be well; (2) there was a lower and a higher
class of people, and he, belonging to the lower, ought to make way for
the higher; (3) he would never have done it had he not been drugged ;
drugs were put in his milk; (4) he did it because of religious depres¬
sion. He showed a tendency to delusional suspicion. He was sent to
a private hospital at first, but did not get on well there, and so was
persuaded to place himself under my care. According to himself, he
had not masturbated for some eight or ten days before admission, but
he was suspected of doing so at the private hospital.

Digitized by

Google

306

CLINICAL NOTES AND CASES.

[April,

He was a short, but well-made and rather good-looking lad, of a
boyish aspect for his years, well-nourished, and with a fairly developed
musculature; but he looked pale, neurotic, and debilitated. The only
stigma noted was a rather high and narrow palate. His physical state
was normal,^) except that the pulse was rapid and a systolic bruit was
audible everywhere over the heart, with accentuation of the second
sound ; but the area of cardiac dulness was not increased. The urine
showed no abnormality. He was fairly cheerful at first, and joined in
games, but said that there was no use in living, as he saw by his appear¬
ance in the glass that he was degenerating and falling in the social scale,
and that this was his reason for attempting suicide. His general
intelligence appeared to be good, however, but he failed to recognise
the nature of the institution. He seemed easily fatigued.

On the night of March 3rd he was wakeful and perspired a good
deal, and next day was depressed and complained of cold, and his
temperature was subnormal. He asked that a bullet should be put into
him if he did not recover. A mixture containing strychnine and phos¬
phoric acid was ordered. For about a fortnight after this he was in the
main depressed, but was somewhat variable, as now and then he would
brighten up. He cried a good deal, and often would not answer
questions, but he could be got to play both indoor and outdoor games.
He manifested a number of delusions—that he was being tortured, that
his sisters who visited him were not really so related to him, that poison
was given him, and things done to annoy him. He also complained of
various noises—that every one entering the room began to whistle, that
the door creaked on its hinges, and the birds made maddening noises,
and that someone was grinding a mill and making other sounds under
his window at night, the object, so far as he alleged one, being to annoy
him and make him mad. He also said that his mother had been
tortured to death, as he was being. He spoke without reserve of his
attempt at suicide, and seemed amused at some of the details, and he
frequently expressed a wish that he was dead, and once tried to keep
his head under water in his bath. Sleep was poor at night, and trional
had to be given, but he was often drowsy in the daytime. As his bowels
continued constipated, a mixture containing cascara and strychnine was
ordered on the 10th, and to this tincture of strophanthus was subse¬
quently added. His general behaviour and attitude of mind were rather
childish, and he had vague ideas of wrong done him by his relatives in
“ keeping him in the dark all his life,” as he put it, but could give no
very clear explanation of what he meant. There was no reason to think
that he was masturbating at this period, and he himself denied it and said
he never thought of it now. Cold baths were added to the treatment.

About the end of the third week he began to show improvement,
becoming more cheerful and reasonable, and eating and sleeping better,
while his bowels were kept regular by the mixture. He developed the
habit, however, of emitting sudden explosions of laughter now and then
without cause, and was sometimes emotional. He also spoke of a plot
against him, thought he was in some way the cause of epileptic fits in
another patient, and studied himself and his sensations very closely,
complaining that his lips felt stiff, and the like. He was always asking
advice on such topics as whom he should imitate in his appearance and

Digitized by v^.ooQLe

I 903 -]

CLINICAL NOTES AND CASES.

307

conduct, etc. Still he was and felt undoubtedly better both physically
and mentally, and began to find the restraint irksome. His delusions
and fancies also were more transitory, and less in evidence. The
cardiac bruit disappeared, and the sounds became stronger. He was
discharged on April 12th, greatly improved and in good spirits, and
before leaving asked for advice as to his mode of life and general con¬
duct, and professed to intend to follow it

For about a fortnight after his discharge he continued well and
natural, and helped his relations in some packing; he continued taking
the mixture, and kept up the mode of life that had been advised. He
then took a long journey to another locality, after which he was not so
well mentally, but this was perhaps partly owing to %n undue amount
of solitude. He appeared to be always brooding upon something, and
would not take much notice of what was going on around him, nor
could he be got to speak except with difficulty. He also adopted a
peculiar gait, “as if walking upon eggs.” By his own wish he returned
on May 24th, when, though looking healthy, he did not seem quite so
well as on leaving, and the cardiac bruit was again audible at the apex.
He seemed brooding, suspicious, and depressed, and was silent, only
answering questions with difficulty, and evidently wishing to be alone.
He said he was not worrying about his mental state so much as before,
but preferred not to be too cheerful, and admitted that he thought I
had been trying experiments on him, which were the cause of his having
been worse at first after his previous admission. He sometimes walked
peculiarly, placing one foot very exactly in front of the other, and he
carried one shoulder high, saying that he could not lower it. His
memory showed signs of failure, at all events for recent occurrences.
The bursts of laughter still occurred occasionally and have persisted
ever since, though sometimes with considerable intervals. At first he
said that he laughed because everything seemed funny to him, but not
long since he denied that he was laughing; “ far from it,” he added.
On the day .after admission he said he heard the voice of a person whom
he knew to be in Belfast, so that it must have been imagination. He
was much more silent, morose, and intractable than on the previous
occasion, showed a curious perversity in doing what he was asked not
to do, and was once or twice violent when prevented from doing some¬
thing. On admission he was found to have sugar in his urine, and was
dieted accordingly. The sugar had disappeared by June 18th, and has
not since returned. Simultaneously there was some slight improve¬
ment and he became brighter, and even at his worst he would always
join in games. He was masturbating about this period, and made no
secret of it or of his intention to continue the practice, as he said it
made him feel better; he said he had no wish to get well altogether.
He continued fairly cheerful, but otherwise unchanged for the next six
weeks; but the inspector insisted on his being certified, as he did
not consider him capable of understanding his position. On several
occasions he walked into Dublin with one of the assistants, and
once he wanted to go into the dissecting-room of the College of
Surgeons. He showed great indecision as to what he wanted to do in
the town, but gave no trouble about returning He continued
emotional, and would shed copious tears at times.

Digitized by v^.ooQLe

308

CLINICAL NOTES AND CASES.

[April,

In the beginning of August he began to complain again of noises in
his room at night (such as whistling and dropping of pebbles down the
chimney), which he thought were under my control. The former were
probably distant railway whistles, and when his room was changed to
the other side of the house he no longer complained of the noises.
Before this was done, however, he on several nights hammered and
made a noise in his room, apparently with a view of overmastering the
other sounds, and one night he broke the fender against the grate,
asserting that people were concealed in the chimney. The noises he
still hears, but says that they no longer annoy him. In August he also
complained of feelings of discomfort in his head, pains in his ears, and
bad smells, which he thought were not from outside, and he also com¬
plained of peculiar feelings in his face impelling him to grimace and
forcing his mouth into certain positions, some of which were uncomfort¬
able. He thought that I placed the fibres of his mouth in certain
positions, which enabled him to move his mouth into certain other
positions. The object of doing so was to call up in his own mind the
train of thought that had been passing through the minds of persons whose
faces he had seen in similar positions. This applied also to positions
of the tongue, hands, and other parts of the body. (It may be mentioned
that no grimacing had been noticed by others.) He had vague delu¬
sions about my wanting to get at his thoughts, and wanted to know
whether his saliva was not secreted by a gland different from that which
had secreted it when he first came, as he swallowed it in a different
way. He said he could think of nothing but his mental phenomena,
and has frequently asked for books on the brain in order to study the
subject. He said he was not masturbating much at this time. Later in
August he complained of being “ imposed upon ” by locking his door,
and in other ways, and showed me a notebook in which he had printed
in pencil the grounds of his complaint, which included chemicals in his
food, medicine to make the muscles of his face twitch, “ deceitous
lying,” etc., and also a note: “ If I am not imposed upon I may benefit
mankind.” Since then he has been variable, but on the whole more
silent, morose, and solitary, only answering in monosyllables, if at all,
when spoken to, and showing a tendency to ape the tricks of other
patients. His silence he once attributed to being in doubts about
everything, and he said also that I could read his thoughts, and implied
that he had not control over his own mind. He played billiards and
golf, and seemed to enjoy them, but otherwise simply mooned about.
He masturbated a good deal in the autumn, but for about four weeks
past has done so little, if at all, and for about that time he has appeared
more intelligent, and at the same time more depressed, and has been
very anxious to leave, saying that ho is getting worse. The treatment
was necessarily only symptomatic and general, and as his father wished
him to try a sort of hydropathic treatment he removed him on proba¬
tion on the 23rd inst. His heart is still weak, but there is no murmur.
The unpleasant feelings in his face have ceased. He has never given
evidence of any ideas or delusions that could be called sexual.

Thus we have a certain degree of childishness, with mental

Digitized by v^.ooQLe

1903]

CLINICAL NOTES AND CASES.

309

depression of gradual onset and not very profound degree,
accompanied by delusions and hallucinations (both of which
seem to be passing off), as well as by other characteristic
symptoms. On the whole there has been gradual mental
deterioration, with, however, one remission. The case therefore
seems to be undoubtedly one of genuine hebephrenia, although
it has not lasted long enough to show the marked dementia of
the later stages.

The relation of hebephrenia to some other forms of mental
disease is interesting. That it is essentially a psychosis of the
degenerate was first pointed out by Fink, (4) who considered
that those who suffer from it have really been affected
from birth with a slight degree of idiocy, which, latent
during childhood, becomes manifest after puberty owing to the
claims of a higher psychical activity and increased stress of
life. It is perhaps hardly necessary to assume that such
patients have always been somewhat imbecile, but in many
respects the psychosis does appear to be nearly related to
idiocy, and especially in being, at first at all events, a failure
of development rather than a mere degeneration. The resem¬
blance of the earlier symptoms to that phase of frothy
emotionalism, egotistical introspection, and sentimentality
through which most pass at puberty is evident; and, in fact, it
seems to be essentially a hypertrophy and fixation of these
normal peculiarities of the period, just as idiocy is of those of
early childhood. But it differs from idiocy in that the
dementia is progressive and eventually replaces all the other
symptoms, whether this dementia is altogether primary and
inherent in the disease, as seems to be always assumed, or
whether it may to some extent be considered secondary to the
more acute early symptoms. As the brain is always initially
a weak one, this latter suggestion does not seem improbable.
(On the other hand, imbeciles often become more weak-minded
at puberty, but this deterioration does not seem to advance
beyond a certain point.)

The resemblance of hebephrenia to paranoia is undoubtedly
considerable, but this is only true in the earlier period of the
former disorder, and the differences (especially the very marked
dementia and the temporary nature of the delusions in hebe¬
phrenia) are so marked that it is difficult to understand how they
could have been classed together. Whereas hebephrenia is the

Digitized by v^.ooQLe

3 io

CLINICAL NOTES AND CASES.

[April,

hypertrophy of the characteristics of a period, paranoia is the
hypertrophy of certain of those of the individual. I should be
inclined to consider the disease as partly a failure of develop¬
ment and partly a degeneration, but, as the degeneration is
dependent on inherent weakness, this is perhaps not so much of
a distinction as it sounds.

Lastly, it may be asked what part is played by masturbation
in its etiology. Although this habit when practised to excess
probably hastens the process of mental degradation, it seems to
me that there is no sufficient reason for holding it to be other
than a symptom of the general mental disorder.

References.

1. Hecker’s original paper was published in Virchow’s Archw , Bd.
lii, p. 394, but I have unfortunately been unable to obtain access to it

2. Sixth ed., p. 146.

3. See DefendorPs English abridgment of the Lehrbuch der
Psychiatric , pp. 152 ff. and 162 flf.

4. All gem. Zeitschr. f Psychiat. y Bd. xxxvii, p. 490.

(*) It should have been mentioned, however, that there was a small cyst on the
right spermatic cord, and that the prepuce was long, though it could be fully
retracted.

Discussion

At the Meeting of the Irish Division held at the Royal College of Physicians,
Dublin, January 28th, 1903.

Dr. Leeper asked whether suicidal attempts were frequent in the early stage of
cases of this class, as he had seen a patient in whom the disease had seemed to
manifest itself in this way or by violence. He had been trying lecithin in young
degenerative cases, and would be glad of the experience of others with this drug.

Dr. Drapes, alluding to the existing difference of opinion as to the application
of the term hebephrenia, expressed the opinion that it was misleading to assign
fixed appellations to such vague and indeterminate groups of symptoms. He was
not yet clear as to whether hebephrenia included all cases of insanity occurring at
puberty, or whether it was restricted to those associated with masturbation. He
had had cases of recurrent insanity at this period, regarding which he wished to ask
whether they were to be considered examples of hebephrenia or not. One such
patient was at first in a hilarious, exalted state, recovered from this, and returned
after a time in a condition resembling imbecility. He was sent to the sea, and is
now doing well. Another was a lad of seventeen in a demented state, who developed
paralysis and a large sacral bedsore, but recovered under thyroid treatment. Was
either of these a case of hebephrenia?

Dr. Conolly Norman agreed that the case was one of hebephrenia, and, as he
had seen the patient, wished to add, with reference to his degraded habits, that he
had a small varicocele and an elongated prepuce. Speaking of the questions
raised by Dr. Drapes, he said that although elaborate classifications of insanity
were of little worth and confusing, he thought that hebephrenia existed as a type,
and that some such attempts at classification must be made if the subject were not
to become a mere mass of endless detail. Precocious dementia had been divided
by Kraepelin into hebephrenia, katatonia, and paranoid insanity, of which he
believed iri the first two, but thought the last a mere dumping-ground for all cases
which would not conform to the other two types. In this particular case there were

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

311

a number of interesting points. The boy gave four or five contradictory reasons
for his attempt at suicide, which showed that none of these was the true reason.
Such attempts were to be set down to perversion of normal instinct, and not to any
definite reason. The group of paranoia-like symptoms which he showed at first—
notions of his thoughts being read, together with the grandiose idea that “ he might
benefit mankind,” and hypochondriacal delusions—have been assigned as evidence
of degeneration; and he agreed that the form of insanity was one of arrested de¬
velopment. Fatuous attempts at suicide are common in such degenerative cases.
He pointed out that the condition called hebephrenia is identical with a form of
insanity described by Skae under the name “ hereditary insanity of adolescence.”

Dr. Dawson, in replying, said that attempts at suicide were common at the early
stage of hebephrenia. He agreed with Dr. Drapes to a certain extent, but thought
that when a definite series of symptoms were found to arise in a certain number of
cases it was perfectly legitimate as well as convenient to give them a name. Hebe¬
phrenia did not include all the insanities of puberty or early adolescence, and it
differed from paranoia in its marked tendency to dementia and in the temporary
character of the delusions. As to the possibility of recovery, it was stated that
about 8 per cent, recover, though in many of these some mental impairment was
left. In some other cases the disease was arrested at a certain point, but in the vast
majority of cases it progressed to the utmost degree of dementia compatible with
life.

A Case of Thoracic Aneurysm simulating Mediastinal
Growth . By Robert Pugh, M.D.Edin., Assistant

Medical Officer, Claybury Asylum.

H. B—, aet. 45, single, occupation porter. He was admitted
to Claybury Asylum on June 6th, 1899, suffering from mild
secondary dementia.

Family history. —Father died insane ; mother alive and healthy ; one
brother alive and healthy.

Personal history .—Patient was bom and has always lived in London.
He had a severe attack of rheumatic fever when a boy at school; shortly
after this he developed chorea, and since that time has suffered from
choreic movements of face, arms, and legs. Ten years ago he contracted
syphilis.

Certificate .—He has no sense of decency; is dirty in his habits ; eats
out of the refuse pail; fills his pockets with all kinds of rubbish; and
steals everything he can get hold of.

Physical cottdition .—Is poorly nourished ; has numerous pigmented
scars across loins and both legs; varicose veins of both legs; first
cardiac sound impure; lungs healthy; pupils unequal, right dilated;
light reflexes sluggish; knee-jerks exaggerated; speech slurred; mus¬
cular movements jerky and inco-ordinate.

Mental condition .—His intellect is weakened; he is slow in answering
questions and stupid in his general behaviour; memory much impaired;
his general condition is somewhat suggestive of general paralysis.

Progress of case. —September 8th, 1899.—Patient is practically un¬
changed mentally, but probably some slight progress has occurred in his
dementia, as his choreic movements are much less marked.

Digitized by v^.ooQLe

312

CLINICAL NOTES AND CASES.

[April,

August 5th, 1900.—He is vacant and childish; articulates badly;
rambles foolishly in his remarks. He is slovenly in his dress and habits,
and takes little interest in his surroundings.

October 14th, 1901.—This morning patient was noticed to be suffer¬
ing from some respiratory trouble ; respirations 24, very laboured; face
blue. On being sent to bed it was found that the superficial veins of the
chest were much enlarged and engorged. There is a systolic bruit in
mitral area ; and a deficient air entry into the left lung. Breathing is
bronchial, with coarse sibilant riles. Patient had five of these attacks,
which were characterised by orthopnoea and by distension of the super¬
ficial veins of the chest. He died in the fifth attack from haemorrhage.

Autopsy .—Is fairly nourished and somewhat muscular.

Syphilis .—There is marked bronzing of both shins, associated with
former ulceration ; the scars are multiple and serpiginous ; the glands in
the groins are shotty, and there is a scar on the middle of the dorsum of
the glans penis. The right pupil is 5 mm., the left 4 mm.; the skull¬
cap is dense. Dura mater natural; great excess of subdural fluid. Pia
arachnoid opaque and thickened in the fronto-parietal region; on the
under surface and the lower temporo-occipital region it is less thickened
—the whole membrane is oedematous and strips readily, and there is
considerable excess of subarachnoid fluid. The vessels at the base are
apparently healthy, and the sinuses are empty. Encephalon, 1190
grms.; right hemisphere, 495 grms.; left, 500 grms.; cerebellum and
pons, 160 grms. There is considerable prefrontal wasting, and rather
less wasting in the remainder of the fronto-parietal region and the first
temporal convolution; it is less marked elsewhere. The lateral ven¬
tricles are dilated and a little granular; the choroid plexus is cystic;
the fourth ventricle is natural.

Thorax. —The nose is natural, but full of blood. There is a little
recent adenitis of the cervical glands. The right pleura contains half a
pint of fluid ; there are slight apical adhesions; the median aspect of
the upper lobe of the lung, and to some extent of the middle lobe, are
adherent to the aneurysm referred to below. The left pleura is natural,
except for rather more marked apical adhesions. The bronchi are
congested ; the bronchial glands below the bifurcation of the trachea are
large and fibrous (syphilitic). The right lung weighs 1028 grammes;
the lower lobe is oedematous, and contains areas of grey hepatisation ;
the middle lobe is broncho-pneumonic, and the upper lobe is oedema¬
tous. Many of the bronchioles of the lower lobe contain pus. The
left lung weighs 920 grammes; it is oedematous throughout, and the
lower lobe is also broncho-pneumonic. The pericardium contains two
and a half ounces of fluid; the heart is wasted, but the muscle is firm;
the left ventricle is slightly hypertrophied, the coronary arteries are
moderately atheromatous, the valves are natural. The arch of the
aorta is hugely dilated and typically syphilitic, being covered with
pearly white fibrotic patches. At the junction of the ascending and
transverse parts of the arch on the posterior wall is a cavity nearly two
inches in diameter which opens into a false aneurysm, the sac of which
is rather smaller than a goose’s egg in size. This aneurysm lies antero-
posteriorly, and it is compressed laterally. The right pulmonary artery
lies below, and the right bronchus behind. The superior vena cava

Digitized by v^.ooQLe

1903.] CLINICAL NOTES AND CASES. 3 I 3

lies on the outer wall of the aneurysm, and is much flattened and
constricted, its circumference, two inches from the auricles, measuring
barely half an inch. The trachea lies behind and to the right. The
aneurysm has ruptured through the anterior wall of the right bronchus at
its union with the trachea; the opening is a ragged, transverse slit, more
than an inch in length, and from its appearance necrosis must have
taken place owing to the pressure of the aneurysm ; all the neighbour¬
ing part is blackened and necrosed. The aperture from the sac of the
false aneurysm lies at its lower and median part, and consists of a
transverse slit about three eighths of an inch in length. The superficial
venous distension which was such a marked feature of the case during
life is not now visible, but on slitting open the various veins their large
diameters can at once be seen. There is no evidence that the aneurysm
has compressed any of the thoracic nerves.

Liver y 1515 grammes, congested and somewhat friable.

Spleen , 155 grammes, is very pulpy, but the connective tissue is
increased.

Kidneys, 128 grammes each, congested; cortex, 627 mm.; density
natural; a little fatty change. Renal arteries are somewhat thickened ;
there is a little early atheroma of the abdominal aorta.

The glands around the coeliac axis are very calcareous. The stomach
contains a large amount of blackened blood; the small and large intes¬
tines are natural; the bladder is hypertrophied.

Cause of death .—Immediate : haemorrhage from trachea.
Rupture of a false aneurysm, secondary to a true aneurysm of
the upper half of the ascending part of the arch of the aorta
into the right bronchus, near its union with the trachea. Other
pathological conditions : systemic syphilis, insanity with marked
dementia.

The essential feature of the case was the extreme distension
of the superficial veins of the chest. This was so extreme that
in the absence of any definite sign clearly pointing to an
aneurysm, it was impossible to definitely determine whether the
patient was suffering from a thoracic aneurysm or from syphilitic
affection of the mediastinum and its glands.

A Case of Status Epilepticus complicated with Scarlet
Fever . By George Watters Greene, B.A.Cantab.,

M.R.C.S., L.R.C.P.Lond.; Assistant Medical Officer,
Claybury Asylum.

M. L—, a lad of seventeen, was admitted into the asylum
on October 20th, 1902, with a history of epilepsy.

Digitized by v^.ooQLe

314

CLINICAL NOTES AND CASES.

[April,

On admission he was pale, weak, and exhausted, but was slowly
regaining strength when on November ist he suddenly commenced with
a succession of thirty-six fits. Two days later he had /mother succession
consisting of seventy-three fits, and on the same day he developed an
attack of scarlet fever. His temperature rose to 102*5°, and remained
about that level or a little lower for several days. He had a bright red
erythematous rash over the body, and the tonsils were inflamed and
slightly ulcerated. Meantime the fits continued with increased severity,
averaging from one hundred to two hundred a day. On November 18th
the succession of fits ceased. They had amounted in all to a grand total
of 1742, extending over a period of seventeen days. After the subsidence
of the fits the patient became very feeble and collapsed. His tempera¬
ture sank to 95° and remained between that level and 97° for nearly a
fortnight. His heart dilated, and the radial pulse was scarcely
discernible. However, with digitalis and alcohol (whisky) the patient
rallied. The former was administered in 5-minim doses every four
hours, and the latter in half-ounce doses also every four hours. This
treatment was continued with a few short remissions until December
24th, during which time the patient slowly regained strength, and at the
end of that time was able to get up.

He was practically recovered when, perhaps, the most interesting
feature of the case occurred. On January ist he developed peripheral
neuritis in both legs. There was pain on pressure, marked atrophy of
calf muscles, foot-drop, absence of knee-jerks, and, later, of electrical
reaction, and complete inability to walk or stand. The arms and hands
were also somewhat affected, and unequally. The grips of the dynamo¬
meter show forty in the left hand and seventy in the right. There was
anaesthesia in both legs, and more marked on the peroneal distribution.
There was no marked anaesthesia in the hands and arms, although reac¬
tion was slightly retarded. Muscular pain was present on pressure in
the legs. There was no characteristic mental reaction as accompanies
alcoholic neuritis. The question to be answered is, what was the cause
of this neuritis ? Three factors were capable of producing it. Firstly,
it might have been post-scarlatinal; secondly, post-epileptic; and
finally, alcoholic. Of these post-scarlatinal seems most probable, as the
fact that alcohol (whisky) was administered in moderately small doses
for a period only extending a little over three weeks, and the deration of
the neuritis was longer than is usual in post-epileptic cases. He is now,
February 18th, quite recovered. He has gained considerably in weight,
looks robust, and seems in perfect health. The fits also have entirely
ceased.

Remarks .—As stated by Percy Smith, (*) Korsakoff, of
Moscow, was the first to call attention to the fact that a special
form of mental disorder which had previously been described
as being typical in alcoholic cases, and was commonly associated
with multiple neuritis, might also occur in cases where there
was no history of alcoholism, but where there was polyneuritis
from other causes. Dr. Robert Jones has seen three cases of

Digitized by v^.ooQLe

I903-]

OCCASIONAL NOTES.

315

asylum dysentery in whom peripheral neuritis occurred in both
legs, and in whom there was analgesia and diminished elec¬
trical response. He has also recorded cases of lead insanity
with neuritis, for whom the electric bath treatment was applied.
Tiling, of Riga, quoted by Smith, suggests that polyneuritis
might result from loss of blood, puerperal toxaemia, auto¬
intoxication, metallic poisoning, and other causes. Cases of
typhoid fever with the condition referred to have also been
described, but the amnesic mental condition of alcohol was not
present. Whether a “ polyneuritic psychosis ” really occurs in
association with multiple neuritis and characteristic of it appears
unsettled. Kraepelin suggests that the mental disturbance in
these cases is not due to the neuritis, but to the effect upon the
brain of the same agent which had affected the peripheral nerves.
In the case above described the peripheral changes were very
marked, but there was no co-existing or characteristic mental
condition.

(*) “ Peripheral Neuritis and Insanity,” Brit. Med. Journ., August, 1900.

Occasional Notes.

The English Archives of Neurology.

The second volume of the Archives of the Pathological
Laboratory of the London County Asylums , edited by the
director, Dr. Mott, very fully justifies the hopes, that were
expressed at the establishment of the laboratory, of most
important help in the advancement of psychiatric science.

This volume is a monument of the vast amount of clinical
and pathological matter that is at the service of Dr. Mott and
his able coadjutors; of the huge amount of work achieved in
the laboratory, as well as of the careful critical faculty and
great ability in lucid exposition possessed by the editor and
principal contributor.

The relation of syphilis to general paralysis, which Dr. Mott
has, from the outset of his work, steadily pursued, is still the
leading subject. Dr. Mott devotes an article of over three

XLIX. 22

Digitized by v^.ooQLe

OCCASIONAL NOTES.

[April,

316

hundred pages to the exposition of his views that general
paralysis is etiologically identical with tabes dorsalis. His
views are supported by valuable papers from Dr. Joseph
Shaw Bolton and from Dr. George A. Watson.

Dr. Bolton also deals with the morbid anatomy of mental
disease in general, and Dr. Tredgold treats of the importance
of alcoholism and tuberculosis in the production of idiocy and
imbecility; and there are other papers of the utmost value and
importance.

These various contributions will be dealt with in reviews,
and we can only draw the attention of our readers to the great
importance of this work.

At last it may be said, without undue exaltation, that
England possesses a school of neuro-pathological research
which need not fear comparison with the best of its Con¬
tinental contemporaries ; and it must not be forgotten that this
is due to the liberal public spirit of the London County Council
and to the broad-minded initiative of our medical confrere ,
Sir William Collins.

The Family Care of the Insane .

Our honoured foreign colleague and associate, Dr. Jules
Morel, Physician and Director of the State Asylum at Mons,
has, in the Belgian retrospect which appears in this number of
the JOURNAL, given an account of the sessional work done at the
meeting of the International Congress for the Care of the
Insane held in Antwerp, September 1st to 7th, 1902. It was a
notable meeting of a notable body. Belgium has been ever
remarkable for the work done at Gheel, and since the founda¬
tion in recent years of the new colony at Lierneux these two
institutions have been the main attraction which that country
has offered to those who are practically interested in the care
of the insane. At the meeting in last September the question
of family care was naturally the main topic, the thread round
which hung all the discussions. What has been done in this
direction met with the enthusiastic and almost unanimous
approval of the alienists who were present, and many proposals
were considered for extending and widening the application of

Digitized by

Google

1903.]

OCCASIONAL NOTES.

317

the principle. But though the influence of the genius loci kept
this special topic in the forefront, few matters of interest to
asylum administrators were left untouched. The question of
whether institutions for the insane should be directed by
physicians or by laymen has practically little interest in
England and Scotland, having long passed beyond the region
of discussion. The training of attendants, owing to the exer¬
tions of our Association, may be said to have reached the same
stage. Unfortunately we are not as far advanced in the
question of providing special diplomas in psychiatry for
physicians. Organised and general after-care cannot yet be
considered to be within the range of practical endeavour, in
spite of all that has been done to bring it under public notice
and of the efforts that are being made in individual cases.

The numerical strength of the medical staff required in
an asylum is still a burning question elsewhere than in
England. We note with satisfaction that the Congress adopted
the estimate made long ago by a great Belgian clinical
physician, Guislain, and laid down that there should be one
resident medical officer for every hundred patients in a public
asylum.

Many other topics specially interesting to us just now were
discussed—the prevalence of phthisis among the insane, the
need for proper laboratories in asylums, the best method of
dealing with early cases with safety to patients and yet without
too much official intervention, etc.

Socially the Congress was a distinguished success. The
Belgian Minister of Justice was Honorary President, and the
Vice-Presidents included two former ministers of justice and a
former minister of foreign affairs. An admirably organised
trip to Gheel, under the management of our esteemed confrire y
Dr. Peeters, was followed by an excursion to Lierneux, where
the members were met by Monsieur Pety de Thoz£e, Governor
of the Province of Li&ge, who has always taken the warmest
interest in the colony, and by Dr. Dep^ron, the physician to
the colony. While Gheel counts nearly as many centuries as
Lierneux counts years in the care of the insane; while Gheel
lies in the flat and naturally arid Campenland, and Lierneux
is beautifully situated among the Ardennes not far from Spa;
while the language of one is Flemish and the other is Walloon;
the success that attends both seems to show that family care

Digitized by ^.ooQle

318

OCCASIONAL NOTES.

[April,

does not require very special circumstances for its inauguration.
Up to the present in English-speaking countries, with, of course,
the remarkable exception of Scotland, the domestic care of the
insane has attracted little attention. It is quite possible,
however, that before long the increasing tax imposed by the
maintenance of the insane may, through the operation of
economic considerations, bring the question to the front even
in rich countries. It is remarkable enough that although many
of the most eminent alienists of France, Germany, Austria,
Italy, Holland, Russia, and Scandinavia contributed to the
proceedings, the only papers from the United Kingdom were
those of Mr. Spence and Dr. Macpherson, dealing with Scotch
statistics; and we are informed the English-speaking persons
attending the Congress barely reached a Greek plural, if we
omit the Chinese Ambassador at Brussels, who was present at
all the meetings and followed the work with much interest, but,
save as regards the too brief English portion, with the aid of
an interpreter.

The Treatment of Incipient and Unconfirmed Insanity .

The possibility of early legislation on this subject, and its
inherent importance, must be our excuse for again reverting to
it, with no intention of anticipating the discussion on the
papers of Drs. Ernest White and Outterson Wood, at the May
Meeting.

These papers have brought out so strongly the evils of the
present condition of treatment consequent on the incapacity
of many who undertake it, that the fear naturally arises
whether the Lord Chancellor may not delay the passing of
the clause until some plan has been formed for safeguarding
its action.

Delay, however, would be greatly to be deplored, and a
little consideration will show that the operation of the clause,
even as it stands, would go far to remedy the abuses now
existing.

The danger of prosecution, under Clause 315 of the existing
Act, is without doubt a great deterrent to all persons of
standing or reputation from undertaking the treatment of any
cases in which mental disturbance is present. The result is

Digitized by v^.ooQLe

1903-]

OCCASIONAL NOTES.

319

that much of such treatment goes to those who have little to
lose by prosecution. The persons well qualified are debarred,
whilst the unqualified are encouraged.

The notification to the Commissioners in Lunacy, provided
for in the Lord Chancellor’s clause, would go far to remedy
and reverse this state of things. The possibility of inquiry
would make the friends of patients more careful as to the
qualifications of those to whom they committed the 'care of
their friends. On the other hand, the persons who really
possess experience and qualification for the work would be
encouraged, and this would tend to exclude those who are
unqualified.

To safeguard the working of the clause, therefore, some
qualification of the persons undertaking such treatment should
be necessary, but this will require consideration and experience.

The Commissioners in Lunacy in the working of the clause
would no doubt soon arrive at conclusions which would enable
them to frame regulations in regard to the qualifications
necessary for the efficient care of the incipient insane, and to
exclude those who were manifestly incompetent.

The suggestion may therefore be made, to enable the
clause to be at once passed as law, that a section should be
added enjoining the Commissioners in Lunacy to frame recom¬
mendations to the Lord Chancellor in regard to the qualifica¬
tions required of those undertaking the care of unconfirmed
mental cases.

Care of the Chronic Insane in Ireland ’

A short time ago (March 20th) a meeting was held in
Dublin of a society called the Irish Workhouse Association.
We are not in a position to say whether the proceedings have
been very fully reported or not. We should hope not; and we
must observe that this seems very probable since we find that
one reverend gentleman remarked, evidently in a spirit of
scceva indignatio, that the Christian treatment of the poor was
not an “ urgent ” question, that term being reserved for some¬
thing connected with the licensing trade or the labour interests.
We observe, however, in the proceedings as reported, that
curious kind of incoherence that so often perplexes the foreigner

Digitized by v^.ooQLe

320

OCCASIONAL NOTES.

[April,

who tries to comprehend the lines on which Irish public busi¬
ness is conducted. People seem to have adopted the odd plan
of addressing the meeting either by letter or by speech on all
sorts of topics, whether such were exactly on the programme
or not, or whether the persons who spoke or wrote had or had
not any accurate information. There did not appear to be
perfect unanimity of feeling as to the present management of
Poor Law business. One member stated that he believed the
Irish Poor Law Guardians to be actuated by a high sense of
duty. On the other hand, an eminent physician stated that
not politics nor religion (which are commonly said to rule
everything in Ireland), but contracts governed the workhouses ;
and nobody contradicted him. Perhaps the two statements are
reconcilable, high sense of duty meaning duty to one’s favourite
contractors. It is comforting to think from the speech of the
Chairman of the Society that that body seems to think work-
houses (even conducted under a high sense of duty ?) are not
suitable places for the insane. On the other hand, an eminent
ecclesiastic, whose views were made familiar to us through a
paper read at the Cork meeting in 1901, wrote triumphantly of
the success which he foresees for his efforts towards the establish¬
ment for the chronic and harmless insane of auxiliary asylums
not under medical control. Those who have any knowledge of
the condition of the insane in the Irish workhouses at present
will hesitate before they endorse this scheme, since it seems to
offer no guarantee that the supervision in the new auxiliary
will not be less than in the old workhouse. However, merely
from the point of view of the workhouse reformer, it would no
doubt be a “ reform ” to get rid of the insane.

Some loose talk was indulged in as to the cost of asylums.
It is a favourite device to contrast the charges now made by
the asylum committees with those made a few years ago. At
that time the rate in aid was paid direct to the asylums, and
the cost of repayment of loans for building, etc., was met in
such a way that a claim on foot of this did not appear in the
demand made by the asylums on the counties. Now the
demand includes money for repayment of loans and does not
credit the asylums with the rate in aid, which is paid by
Government direct to the county councils. It is consequently
easy to show that the present gross cost is very much greater
than the former net cost, though it is not easy to see what is

Digitized by

Google

1903.]

OCCASIONAL NOTES.

321

gained by representations of this kind, nor by reckless state¬
ments as to increase in the rates. But asylums in Ireland are
very unpopular institutions, and any stone will do to throw at
a dog. It is curious, by the way, to observe that the notion of
boarding out the insane never seems to occur to the reformers
and economists in Ireland. Is this due to the ancient dread of
lunacy still existing there, or to mere ignorance of such a
method, or to “a high sense of duty” lest the insane might be
neglected, or have “contracts” anything to do with it? We are
left in a distressing state of uncertainty on these and many
other interesting points.

Clinical Cases .

The cases of clinical interest in our asylums must be very
numerous, and there can be no doubt that much valuable
information is buried in asylum case-books with little hope of
ever reaching the notice either of the specialty or the profession.

Striking pathological and symptomatological variations are
the most attractive for reporting, but new departures in general
treatment and special drug therapeutics are also of great im¬
portance. The negative results of the latter are even of more
value than the positive. If a drug produces favourable effects
these are almost certain to be published at once, whilst the
failures only reach publicity much later. Hence arise mislead¬
ing first impressions of the nature of a drug, which are long in
being corrected. In this direction, therefore, there is a valuable
opening for clinical effort.

The number of clinical cases recorded in this JOURNAL can be
but a fractional proportion of what might be with advantage
supplied from the vast material of our asylums. Medical
superintendents, and especially the secretaries of divisions,
would be doing good work in urging the junior members of
the Association to undertake clinical reporting. Careful work
of this kind is the very best foundation of medical character,
and this has never been more thoroughly demonstrated than
in the career of that eminent clinician, Dr. Hughlings Jackson.

The value of this JOURNAL would certainly be greatly
increased by a very considerable extension of the number of
carefully reported clinical cases, while many junior physicians

Digitized by v^.ooQLe

OCCASIONAL NOTES.

322

[April,

in making such contributions would be laying the foundations
of future literary and scientific reputation

Report of the Tuberculosis Committee .

The Derby meeting of the Association did not pass without
reference to the unfortunate report of the Tuberculosis Com¬
mittee. The President explained that the whole matter had
been considered by the Council, that they had obtained the
opinion of an expert of the highest eminence, and that it was
desirable to proceed further in order to have the statistics
corrected and published in this JOURNAL. As we have pre¬
viously indicated, the errors in these statistics do not vitiate
the important conclusions set forth by the Committee. Of
that the Council has been definitely assured ; and, as Dr.
Yellowlees remarked, it is the duty of the Council to protect
the honour and dignity of the Association. . The whole of the
materials accumulated and dealt with by the Tuberculosis
Committee in the production of their Report will be submitted
to a searching expert inquiry, and the results will be made
known. Nothing less could be regarded as satisfactory in the
circumstances; the members of the Committee are just as
desirous of having mistakes corrected as the Council or the
Association at large. The Chairman of the Committee has
taken a course which is absolutely unassailable; having con¬
sulted with the members of his Committee, he laid the matter
before the Council and gave every possible assistance towards
the amendment of the errors into which the Committee fell.
We may therefore await with confidence the result of these
deliberations.

The resolution proposed at the meeting, if successful,
would have had the effect of a finding of no confidence in the
Council, and it was consequently very properly, promptly, and
decisively rejected.

The Colney Hatch Fire .

The suffocation of fifty insane persons, as the result of a
fire in an English asylum, constitutes a tragedy that might

Digitized by v^.ooQLe

1 9°3*]

OCCASIONAL NOTES.

323

have been hoped to be impossible. Yet, despite the magnitude
of the loss of life, there is much reason to be thankful that
it was not greater.

The Commissioners in Lunacy for many years past have
exerted themselves strenuously and with unceasing vigilance
to render all buildings receiving the insane as nearly fireproof
as possible. They have most rigorously insisted on structural
means of escape, and on most elaborate provisions of all means
and appliances for the extinction of fire. The result of this
long-continued care is that asylums are probably better pro¬
tected against fire than any other public institutions.

The inflammable character of the buildings in which the
disaster occurred is therefore in direct antagonism to the prin¬
ciples of construction which the Commissioners have habitually
demanded.

The explanation of this exception is not far to seek. At
the time of the construction of these buildings the London
County Council were greatly pressed for accommodation for
their patients, and in their efforts to provide it there is every
probability that the principles of the Lunacy Commission were
overridden. This, however, could not have been accom¬
plished without the aid of the Home Secretary of that period.

The finding of the jury blamed the disastrous construction
equally on the London County Council, the Home Secretary,
and the Lunacy Commission.

The above considerations, however, lead to the conviction
that the latter body is not culpable, and that the blame really
attaches to the Home Secretary and the London County
Council. This latter body has done such good service in the
care of the insane that, their share of the blame should speedily
be forgotten, especially in face of the strenuous efforts that are
being made to render the recurrence of such a calamity im¬
possible.

The silver lining of this dark cloud is furnished by the
splendid behaviour of the asylum staff, from highest to lowest.
The searching inquiry of the jury failed to elicit the smallest
failure on the part of the staff, but proved, on the contrary,
that all concerned had, with self-sacrificing courage and devo¬
tion, efficiently performed their duty.

Digitized by v^.ooQLe

324

OCCASIONAL NOTES.

[April,

The After-care Association.

The Annual Meeting of this Association was held at the
house of Sir William Church, the President of the College of
Physicians, who presided.

The report shows a steady annual increase in the number
of cases assisted, but the increase in the subscription list is less
satisfactory.

The speakers, among whom were Drs. Claye Shaw and
Robert Jones, bore testimony to the valuable work of the
Association in the prevention of relapse in recovered patients,
and the suggestion was made by Dr. Rayner, in view of the
good results of the work, that it might well be called the
Association for the “ Prevention of Insanity by Relapse. ,,

The statistics as yet are not of sufficiently long standing, or
of sufficient extent to yield any definite results, but there can
be little doubt that, as time passes, the asylums which most
largely avail themselves of this aid for their recovered patients
will have the satisfaction of recording a considerable reduction
in the number of their relapsed cases.

Tent-life for the Insane. Q)

The tent-cure of the tuberculous insane, inaugurated in
June, 1901, by Dr. A. G. MacDonald at Manhattan, was
found so successful that in July of the same year it was tried
for filthy and demented patients, also with most strikingly
satisfactory results.

Increased appetite and assimilation were universal in the
dements, who in many cases improved in their habits, and the
tuberculous showed marked improvement. This mode of
treatment is also to be tried on convalescent patients.

The tent-life in New York State is apparently carried on for
only three or four months, but in our more favourable climate
it might probably be continued throughout the summer.
When St. Thomas’s Hospital was at the Surrey Gardens some
of the patients were accommodated in tent wards during the
larger part of the summer. It is to be hoped that this new
departure in treatment will be tried on this side the Atlantic.

Digitized by

Google

i9°3-]

OCCASIONAL NOTES.

325

Until other accommodation can be made for the tuberculous
insane it would be a great advantage to these patients, and
would for several months of the year relieve the non-tuberculous
patients from the danger of infection to which they are now
unavoidably exposed.

The treatment of the demented in this way during the
summer months might also avoid and mitigate some of the
special intestinal disorders to which they are prone.

The greatest advantage, however, would probably accrue in
the treatment of convalescent cases.

(*) American Journal of Insanity.

Reception-house and General Hospital.

A reception pavilion in connection with the General Hospital
has been established at Albany (N.Y.), and appears to be doing
very satisfactory work.

The Edinburgh Infirmary Reception Ward is not yet con¬
structed, but the rumour has reached us that patients are
being received in the existing wards.

The Sligo District Lunatic Asylum .

At the monthly meeting of the Committee of Manage¬
ment of this asylum, as reported in the Sligo Independent of
February 21st, we find the opinion expressed by one of the
members of that body that “the attendants were perfectly
right to use a certain amount of violence in order to keep
proper discipline amongst the inmates.” This expression
of opinion arose on a discussion on a sworn inquiry, held by
a Lunacy Inspector, as to the alleged ill-treatment of an
inmate by two attendants. The Inspector stated that the
patients “ gave evidence under evident fear of the con¬
sequences their action might entail.” A letter was read
from a number of attendants denying any terrorism, and
this was apparently accepted as disproving the Inspector’s
statement. The Inspector having admitted that the two
accused attendants could not, on the evidence obtained, be

Digitized by v^.ooQLe

326

OCCASIONAL NOTES.

[April,

convicted in a court of law, the Committee, after declining
the invitation of their chairman to ask the opinion of the
Medical Superintendent, exonerated the two attendants from
all blame.

If the facts are correctly reported there can be little doubt
that the maintenance of discipline in the Sligo Asylum is
an impossible matter, and that sooner or later “ regrettable
incidents” will occur in that institution. Ill-treatment of
inmates must inevitably occur in an institution in which the
attendants are encouraged to use “ a certain amount of
violence,” in which charges of terrorism by an independent
official are held to be refuted by the simple denial of some
of the accused parties, and attendants are entirely exonerated
under conditions of the very gravest suspicion,—where, in fact,
a majority of the governing body shows a marked bias in
favour of the attendants, rather than a desire to protect the
patients.

In 1901 an attendant of this asylum, who had assaulted a
patient, was recommended for dismissal bythe Lunacy Inspectors,
but the ’Committee decided only to caution him. This man
was, however, prosecuted before the magistrates for assault, and
imprisoned for two months.

Irishmen are so universally recognised as siding with the
weak and suffering that this perversion of the national
characteristic must have an explanation, and this is to be
found in “ politics.” In spite of St. Patrick the trail of the
political serpent is over it all. Committees are only anxious
to exercise to the full their unlimited power and patronage, and
have not grasped the duties and responsibilities devolving upon
the managers of asylums ; nor do they appear to have fully
realised the object with which those institutions have been
founded.

The Spirit World.

The pages of a spiritualistic contemporary afford a great
amount of seriously stated information in regard to existence
in the spirit world, which is almost as interesting as that which
we are accustomed to receive from our patients.

Digitized by v^.ooQLe

I 9°3-]

OCCASIONAL NOTES.

327

There appear to be a number of bad spirits who often use
bad language and give misleading information (through the
usual planchette and other channels), and even personate other
spirits, with intent to deceivfe. It is interesting to learn that
one such bad spirit, by communication with a spiritualistic
lady, had become quite a reformed character. This is most
satisfactory, since from the police and law reports many have
formed the opinion that the spirits had rather a pernicious
effect on the characters of those who were in frequent com¬
munication with them, and were not generally likely to benefit
by their friends in the flesh.

This reformed spirit, as a reward, asked the lady to bestow
on him a “ spirit dog,” one of several of whose existence she
had been unaware. Of course, if there are spirit dogs there
must be spirit cats; and if they are not reformed ! And if spirit
dogs and cats, why not pigs and sheep ? Imagine the spiritual
property of a Chicago pork-butcher, or an Australian mutton
millionaire!

This amusing publication has yet its pathetic side, when we
deduce from its considerable circulation the large amount of
potential lunacy that it connotes.

Licensing ( Scotland) Acts Amendment Bill .

This Bill, now before Parliament, is practically a repetition
of the last English Act. In approaching the subject, how¬
ever, the authors of the Bill have had to make certain altera¬
tions to bring it into conformity with the law of Scotland as
already existing. The clauses relative to separation of married
people who have become habitual drunkards have been omitted
in the Scottish Bill; but the constitution of licensing courts
and of licensing law is generally amended. Additional
penalties are imposed for offences involving drunkenness, and
the black list will be extended north of the Tweed. Much-
needed reforms in regard to the registration of clubs are
introduced, and it is to be hoped that these will pass into law
without delay. There are other matters to which we have
repeatedly referred as requiring amendment in connection with
drunkards and their doings ; and it is to be hoped that amend-

Digitized by ^.ooQle

REVIEWS.

328

[April,

ments will be made in the course of the Parliamentary
discussions to render this Act still more effective.

The Derby Dinner .

The dinner held after the quarterly meeting was well
attended, and a very happy evening was passed. Colonel
Gascoyne’s speech was duly appreciated after the visit to the
County Asylum. He said that the Committee had great con¬
fidence in Dr. Legge, who had done so much to bring the old
institution up to date ; but their unhappy experience was that
the County Council were always backward in granting large
sums of money. Still, they had to consider that they were
providing for a small town—a town which brought nothing
back to the ratepayers in hard cash. No doubt that is the
average unenlightened view of the County Councillor who
does not serve on the Asylum Committee, but our recollection
of Mickleover is that much money has been judiciously spent,
and that, irrespective of humanitarian considerations, there is a
recovery rate which shows that many patients are annually
restored to usefulness and thereby rendered self-supporting.

The hospitality extended to the Association by Dr. Legge
and his Committee was very pleasing to those interested in the
welfare of the Association and desirous of promoting its aims.

Part II—Reviews.

Sintusgenusse und Kunstgenuss [ The Pleasures of the Senses and of Art],
By Carl Lange. Wiesbaden: Bergmann, 1903. Pp. 100,
large 8vo.

Professor Lange has left a reputation that will not soon be for¬
gotten, not only in the medical annals of Denmark, but as one of the
founders of the much-discussed James-Lange theory of the emotions.
The possibility of applying such a theory to the explanation of the
aesthetic emotions was fairly obvious, and in 1894 Professor Sergi, in

Digitized by v^.ooQLe

KEVIEWS.

329

I903-]

his subtle and suggestive book, Dolore e Piacere (translated into French
as Les Emotions and reviewed in the Journal last year), tried to show
how aesthetic emotions may be regarded as having a physical basis of
muscular, vaso-motor, and visceral character. We are told that Lange
himself had long taken great interest in art (and it may be added that
his brother is a well-known historian of art), but it was not until the last
few years of his life that he undertook to write the present book, which
he left incomplete at his death from angina pectoris in 1900. In its
present translated form it has been edited, revised, and abbreviated by
Dr. Hans Kurella, who had long known Lange, and it appears in the
excellent series of Grenzfragen des Nervenund Seelenlebens.

While all that Lange wrote is deserving of study, it can scarcely be
said that the present book can be placed on the same level as his earlier
book on the emotions, and we miss the detailed analysis of emotional
states in which Lange showed so much skill. The first part, which
deals with the general physiology of enjoyment, is decidedly better than
the second part, which is concerned with various arts. From the
psycho-physiological standpoint Lange divides the methods of enjoyment
into three groups—(1) those which work along nervous channels, such
as the pleasure of sight and sound, and only influence the vascular
system secondarily; (2) those which chemically affect the blood, like
tea and alcohol; (3) those which mechanically influence the circulation,
like dancing. Joy he defines as “ the perception of a general vascular
dilatation in association with a heightened motor innervation and a
resultant feeling of greater strength and facility/* No reference is made
to the experimental investigations which have tended to throw doubt on
the constancy of the association between pleasure and vascular dilata¬
tion. There are some very interesting pages on ecstasy, which Lange
regards as the purest and most uncomplicated condition of enjoyment,
and on its physiological mechanism.

Lange’s theory of art is embodied in a very simple formula; the two
great tasks of art, and its two factors, are change, and sympathetic
emotional excitement. The second part of the book is concerned with
the application of the formula to decoration, painting, poetry, and the
stage. One cannot help feeling, however, that this formula is somewhat
bald and general, and that it leaves very much in the sphere of art
unaccounted for. It is not even new; so early a philosopher as
Aristotle recognised the aesthetic importance of perpetual slight
novelty, while the physiological excitement to which Lange attaches so
much importance is submitted to no detailed analysis. Moreover
other workers in the same field are entirely ignored; there is no
reference even to Sergi, and the psychologists in Germany, such as
Lipps and Groos, who are doing so much to elucidate these complex
problems, do not exist for Lange. While definite applications of the
theory are rarely introduced, when they do appear the facts are not
always exact; thus it is a mistake to speak of the Mas-d’Azil epoch
as contemporary with the reindeer, which had then retreated to the
north, and it is of course wildly incorrect to say that “the earliest
generations of men ” were acquainted with the potter’s art.

Criticism is, however, disarmed by the pathetic reference in the last
sentence to the author’s failing strength, and it may truthfully be said that,

Digitized by v^.ooQLe

330

REVIEWS.

[April,

though the problems of aesthetics have not here been placed on a new
level, or even been enriched by a really novel contribution of importance,
Lange's firm grip of the psycho-physiological basis of art renders this little
book very suggestive and illuminative to the large number of people who
are interested in these questions. Dr. Kurella has been well inspired in
bringing it before a wider audience than it could possibly reach in its
original Danish form. Havelock Ellis.

La Volonte. By F. Paulhan. Paris : Doin, 1903. Pp. 323, 8vo.

Price 4 frs.

The author of this new volume in Dr. Toulouse’s International
Library of Experimental Psychology is well known as an able repre¬
sentative of that typically French group of psychologists of whom
Professor Ribot is the best known and probably the most accomplished
member, if, indeed, he may not be regarded as the master of the
school. This group stands equally aloof from the old metaphysical
schools of psychology, which sought to force abstract systematic explana¬
tions on the complexity of psychic events, and from the very modern
schools, which apply the strict methods of physical science to psychology.
While in sympathy with the methods of science, and comprehensive in
their collection of data, they rely mainly on description, introspection,
and analysis. In many fields, not yet ripe for more precise investiga¬
tion, such a method yields the best results we can hope for, and it is a
method in which the special qualities of the French mind—its lucidity
and critical discrimination—appear to good advantage.

Such a subject as the will easily lends itself to this treatment, and the
author of this book, who has published previous books on closely allied
subjects, more especially on mental invention and on character and its
varieties, here finds himself at home. He discusses the various stages
in the evolution of the will from automatic acts, writes suggestively on
caprice as a preliminary unformed stage of will, studies its relationship
to other psychic conditions, and its physiological and social connections.
“ It is essentially,” he concludes, “a new and active synthesis. But it
is always mixed with automatism, and also with suggested activity, just
as invention is always mixed with routine and with imitation. Its part
in mental life seems at once much larger and much smaller than has
generally been believed.” The function of the will is to remedy the
insufficiency and the conflicting tendencies of automatism, and at the
same time to prepare a higher automatism.

It is characteristic of the author’s treatment, and also of the tendency
of psychological thought, that nothing is said in the body of the book
concerning the question of free will. A brief appendix is, however,
devoted to this subject. The author here observes that this question
had not appeared to present itself at any point in the course of his study
of the will. He has certainly postulated determinism, but a partisan of
indeterminism may easily accommodate himself to all that he has said.
Everyone is responsible, he argues, up to a certain point; no one is

Digitized by v^.ooQLe

REVIEWS.

331

I903-]

responsible in any absolute sense. “ Freedom is a relationship between
the different elements of the self,” and the difference between an act that
is free and one that is not free is not the difference between an act that
is indetermined and an act that is determined, but the difference
between an act that is the result of an unsystematised determinism
and one that is the result of systematised determinism. The theory
of indeterminism, he concludes, has little bearing on the theory of
the will, the connection being merely due to an ancient confusion
between indeterminism and freedom, so that in psychological as in
physical science it is reasonable to accept determinism.

The subject of the will no longer possesses the acute importance which
it had for all in the days when psychology was ruled by metaphysico-
theological conceptions. But it still has its interest, and not least to
the alienist, who from time to time finds the ancient metaphysico-
theological conceptions flaunted before his eyes. The present volume
will be found helpful and suggestive by those who wish to attain a clear
view of the present attitude of thinkers towards the subject—all the
more so, perhaps, because it is written without thought of medico-legal
applications. The style is throughout simple and pleasant.

Havelock Ellis.

Manuel de Psychialrie . By J. Rogues de Fursac. Paris: Alcan,
1903. Pp. 314, 8vo.

To write a handbook of psychiatry nowadays is a very much more
serious task than it was thirty years ago. The wide extension of the
outlying provinces of morbid psychology, the need of taking into
account the methods of normal psychology, and the growing tendency
to regard abnormal mental conditions as the outcome of general somatic
conditions, alone combine to render a brief magisterial discussion of
the vast field so complex a task that even the youngest and most
omniscient alienist may well feel appalled. There are, however, still
two ways in which even a man who is not endowed with a special
genius for this task may yet hope to accomplish it with fairly interesting
results. That is, he may either after long experience summarise the
results of his own personal observation and knowledge in such shape as
may seem best to him; or else, at an earlier stage in his career, he may
seek out the best that is known and thought in his time, and rely on the
masters he has chosen to follow rather than on his own experience.
The first method has the disadvantage that it may tell us nothing about
the general tendency of contemporary psychiatry, but on the other
hand it cannot fail to contribute instructive and useful observations;
the second method has the disadvantage that it may yield nothing of
original value, but on the other hand it may furnish a valuable indica¬
tion of the contemporary trend of psychiatry.

The present volume evidently belongs to the second class mentioned.
The name of Dr. Rogues de Fursac seems unfamiliar, but he easily
allows us to place him. He is a pupil of Joffroy (to whom the book is
XLIX. 23

Digitized by v^.ooQLe

332

REVIEWS.

[April,

dedicated), and he adopts almost without modification the classification
of Kraepelin, to whom he frequently refers with admiration. Throughout
he presents us with the combined teaching of these two masters.

The book is divided into a shorter part dealing with general
psychiatry, and a longer part devoted to special psychiatry. The first
part discusses etiology, general symptomatology, and general methods
of treatment. In the second part the various forms of insanity are
discussed, Kraepelin being followed in all main outlines. The
chapter on general paralysis may be referred to as showing the author
at his best; the present position of knowledge and opinion in regard to
this subject is set forth in a comprehensive, methodical, and precise
manner, and a judicious attitude is taken on the much-debated question
of etiology; with Joffroy, Nacke, etc., the author emphasises the
importance of neuropathic (not psychopathic) heredity as a predisposing
cause of the disease, and among the exciting causes syphilis is regarded
as “the most important and perhaps as essential.” While thus admitting
the great importance of syphilis in the etiology, the author concludes
that we are not entitled to affirm (with Fournier and others) that general
paralysis is a syphilitic disease. He suggests that it may perhaps con¬
stitute a syndroma which various causes may suffice to evoke, and that
possibly we ought to speak of general paralyses rather than of a single
general paralysis. As might be anticipated, dementia praecox is dealt
with fully, under three forms : simple, katatonic, with delirium. Two
chapters are devoted to alcoholism and two to the auto-intoxications,
including myxeedema and cretinism. There is a (somewhat perfunc¬
tory) discussion of sexual perversions, in which inversion is regarded as
always congenital, and also of obsessions, both under the head of
constitutional psychopathies; while chapters are devoted to epilepsy and
hysteria.

It will be seen that the author covers his large field in a fairly
comprehensive manner, though at places the treatment is thin. He
shows a fairly wide acquaintance with German literature, but, while
anxious to do justice all round, his direct knowledge of English,
American, and Italian authors is evidently very small; Darwin’s name
is Gallicised into “ Darvin.” Havelock Ellis.

Prison Hospital Nursing: a Manual of First Aid and Nursing for the
Prison Hospital Staff. By Herbert Smalley, M.D., Medical
Inspector of Prisons. Published by authority. London, 1902.
8vo, pp. 365.

This is a notable book, marking as it does a new era in prison
management. The frank recognition of scientific principles in the
treatment of criminals reassures us. It is well known that there does
exist a band of able workers in this department of State administration,
of whom Dr. David Nicolson has long been a pioneer; but the service
has been benumbed by obsolete ideas in high places, and it is only of
late years that reformation of methods has been in the air. We

Digitized by v^.ooQLe

I 9°3-]

REVIEWS.

333

welcome this volume as an earnest of what is to come, and congratulate
Dr. Smalley upon having produced a work of enlightenment and
practical value. The prison service owes a deep debt of gratitude to
him in this matter. We can well imagine the difficulties which had to
be overcome in organising a prison hospital staff, and in setting about
training that staff in accordance with modern methods.

Dr. Smalley, among other acknowledgments, expresses his thanks to
the compilers of the Handbook for Attendants on the Insane , and to our
colleague, Dr. John Baker, for his assistance. We have been well satisfied
with the success of the handbook, and take it as a great compliment
that it should have been found useful in opening new ground.

The work under review begins with an introductory chapter on the
general principles of nursing, and is continued, through anatomical and
physiological teaching, to the special work of observing the sick and
administering medical remedies and using surgical appliances. Emer¬
gencies are fully described, and appropriate methods of dealing with
these are also described. For our readers the most interesting part of the
book is the division which deals with crime and criminals, their classifi¬
cation, mental characteristics, etc. Dr. Smalley points out how prisoners
resemble their fellows outside prison walls, and then goes on to show
that there are certain peculiarities of mind and body among them. A
brief consideration of the facts of heredity and environment cannot
fail to arouse the interest of the nursing staff and aid them to under¬
stand the position where, on the one hand, discipline and kindness
work wonders on unfavourable specimens of humanity, and yet, on the
other hand, every moral influence is rendered of no avail by others
similarly conditioned. While the author is fully conversant with the
opinions of the severe school of criminologists, he accepts their opinions
with large reservations, acknowledging that their work has been useful,
but warning officials not to entertain “a morbid sympathy, seeing with
too lenient eyes the misdeeds of the majority of prisoners.” He is
hopeful that further study will throw more light upon the complex
problems involved.

The classification of criminals proceeds on the usual lines, and the
various groups are described tersely and clearly. Beginning with a
brief discussion of sound mind, Dr. Smalley proceeds to discuss the
insane criminal, and thereafter devotes a chapter to the prisoner under
mental observation, with remarks on feigned insanity. The importance
of obtaining accurate skilled information as to the conduct and condi¬
tion of those supposed to be insane cannot be over-estimated, and we
congratulate Dr. Smalley on having introduced a system of attendance
upon criminals which must be productive of a higher standard of
efficiency where that is greatly to be desired. We hope that the begin¬
ning thus made will produce results which will amply justify the labours
bestowed upon this manual, and that it will really be used for the pur¬
pose intended.

The later chapters deal with disinfection, preparation of food, etc.,
and the whole is supplemented by questions on the various chapters, a
glossary, and an ample index.

Digitized by v^.ooQLe

334 REVIEWS. [April,

Review of Neurology and Psychiatry . Edited by Alexander Bruce,
M.D., with the assistance of Edwin Bramwell, M.B. 8vo,
vol. i, Nos. i et seq. Edinburgh : Otto Schutze & Co., publishers,
1903. Price 20 s. per annum, post free.

This important venture will assuredly justify itself in these later days,
when neurology has been specialised into a great and important subject.
It could not have been started more opportunely or under better
auspices. The preliminary statement shows that this new journal is to
provide in English such a periodical as we are already familiar with in
other countries. It is, in fact, an adaptation of foreign ideas, and will
be of similar value to those who are urgent to know what is being done
at home and abroad in the shortest space of time. We have long
recognised the value of this kind of work, and have endeavoured in this
Journal to present current information on psychiatry in such a manner as
to indicate where further information is to be found. Dr. Bruce has laid
us under an obligation in carrying out this plan on a wider basis, and
especially in bringing important abstracts into notice. The Review is
designed to extend over forty-eight or sixty-four pages, made up of short
original articles, preliminary communications, abstracts, reviews, and
bibliographies, as well as digests of recent progress on special subjects.

We note that Sir William Gowers, Sir John Sibbald, Dr. Byrom
Bramwell, Dr. John Macpherson, Dr. Ashby Mackintosh, and other
prominent physicians have contributed articles ; and that the abstracts
are particularly well prepared for the purpose in view. This gives us
occasion for recommending the Review of Neurology and Psychiatry
to our readers with every confidence, and we trust that it will have a
brilliant future in the interests of the profession.

General Paresis , Practical and Clinical. By R. H. Chase, A.M., M.D.
(Philadelphia). London: Rebman, 1902. 8vo, pp. 291, 18
illustrations, 4 figures. Price 8 s. net.

This monograph, from the pen of the Physician-in-Chief of the
Friends' Asylum for the Insane, is especially directed to the attention of
general practitioners.

In a monograph having this object an exhaustive scientific treatment
of the subject is not expected, but rather such a description as will give
a clear view of the subject. This book, it is to be feared, falls short of
its objective by giving an amount of detail and division, with a deficiency
of emphasis of important points. This is evidenced by the numerous
illustrations, many of which are by no means strikingly characteristic of
general paralysis. Similarly the numerous cases quoted are interesting
rather than diagnostically instructive.

The facts collected in the book are numerous, but there is practically
nothing that is new or that demands criticism from the point of view of
the specialist. They are well up to date, and mention is made of the
most recent pathological views of Forbes Robertson, Mott, etc. The
type is excellent, and the book is well produced.

Digitized by v^.ooQLe

1 9°3»]

PROGRESS OF PSYCHIATRY.

335

Part III.—Epitome.

Progress of Psychiatry in 1903.

BELGIUM.

By Dr. Jules Morel .( l )

The year 1902 was distinguished in Belgium by the meeting of the
International Congress for the Care of the Insane—a meeting remarkable
not alone for the importance of the subjects that were dealt with, but also
for the number of distinguished foreign alienists who attended from all
parts of Europe. Dr. Peeters, Physician and Director of the Colony of
Gheel, served as President of the meeting, and conducted the proceedings
with the greatest kindness and tact, displaying at the same time his thorough
familiarity with all questions connected with the care of the insane on
the most advanced lines. The Congress concluded by the adoption of
certain resolutions which will entitle the proceedings of this assembly
at Antwerp to rank among the most important works that have been
done in connection with the organisation of asylums and of colonies for
the insane.

The great number of papers presented to the Congress obliges us to
be briefi and merely to indicate the general scope of the leading contri¬
butions. The reader who is anxious for further detail will need to refer
to the printed ‘ Proceedings * of the Congress, which will constitute a
very large volume. We could only glance at the discussions which
arose on the papers. It would scarcely interest our readers to treat
these discussions exhaustively, because on the one hand they were often
of such a character as to have chiefly a local interest (an interest only
for Belgians), and again because the resolutions, which were all finally
adopted by overwhelming majorities, satisfactorily epitomise the delibera¬
tions which took place.

Dr. Keraval, of Armentieres (France), opened the discussions by
dealing ably with the question of Patients , Public and Private , treated
outside Asylums . The subjects which he discussed are the following:

1. Can the establishments in which, by virtue of special enactments,
persons attacked with mental unsoundness are placed, attain to the most
free arrangements as to treatment ?

2. Do forms of insanity exist in which either from the beginning or
after a certain period of treatment in a closed asylum a certain amount
of liberty can be given, specially measured according to the case ?

3. What is this amount, and what modifications of liberty are most
suitable to the patients in question ?

These are the three great points which have constituted the guiding
ideas in the changes which the care of the insane has undergone.

Dr. Keraval gave a history of insane settlements, beginning with
Gheel and going on to those of Scotland, Germany, France, and Russia.
He came to the conclusion that the closed asylum must be the method
to be chosen for the greater part of acute cases. Perfected according

Digitized by

Google

EPITOME.

336

[April,

to the latest claims of psychiatric science, the closed asylum affords the
means of examining and treating all those acute cases which are most
susceptible of cure. The agricultural colony (/. e ., detached residential
farm buildings), or pavilions with open doors within the asylum estate,
have the advantage of introducing a comparative freedom, and begin¬
ning, as it were, to graduate the amount of liberty allowed; they have
also the advantage of facilitating further study of the state of the
patient’s mind and disposition; but they are still part and parcel of the
asylum. The domestic colony (settlement) is near the institution
indeed, but is absolutely outside it, and the social life which it presents,
being that of the hamlet or town, is entirely independent of the asylum.
In one or other of these forms of colonies patients who are convalescent,
or chronic cases who have become harmless, may be placed.

Dr. Van Deventer, of Meerenberg (Holland), dealt with the question
of The Organisation of Employment in the Settlements of the Insane
around a Central Asylum . In Germany, in Holland, and in some
other countries the principle of the connection of a settlement with
every asylum has already found a large application. Dr. Van Deventer
stated that a patient committed to family care should be considered as
a member of the family of the host, who ought to endeavour to make
him a useful being by employing him at labour, especially at agricul¬
tural labour. But the attendants ought to be selected from among
candidates acquainted with a trade, so as to be able to make use of
them eventually as hosts in case they desire to marry. The patients
can also be handed over to their own families if the latter come to live
in the settlement. In certain cases the insane who are under family
care may be employed in the workshops of the central asylum. The
attendant-hosts should receive a supplementary course of instruction in the
organisation of employment. Furthermore the settlement should possess
a particular place where the patients could assemble for the purpose of
recreation. Certain patients could be paid for their work with satis¬
faction to them and advantage to the institution which would profit by
their labours.

Dr. Meeus, of Gheel, who collaborated with his chief, Dr. Peeters,
in organising The Professional Instruction of Attendants in Settle¬
ments , treated of this subject, and insisted that it is as necessary in
settlements as in asylums that the care of the insane should be com¬
mitted to persons who have had special instruction, and have furnished
evidence of possessing all the requisite qualifications. He rightly prizes
the intellectual training of attendants and their primary education,
which facilitates the development of their moral sentiments and helps
to make them better understand the patience and even devotion that they
must possess in the art of caring for the insane. Dr. Meeus adhered to
the opinion of Dr. Van Deventer that it is right to furnish the host, who
ought to be a real nurse, with every modern advantage of knowledge,
instruction in the rules of their particular work, books, notions of
domestic economy, and so forth.

M. F. Gerenyi, Inspector of the Charitable Institutions of Lower
Austria, and delegate from Provincial Committee of Lower Austria,
announced that in his country, when a plan was recently on foot for
hospital provision, the question of reforming the care of the insane w*as

Digitized by v^.ooQLe

1903 .] PROGRESS OF PSYCHIATRY. 337

raised, and that the Landtag voted the following resolutions :—(1) Every
asylum in Lower Austria shall in future be established at the same
time for the treatment of the curable insane, for the care of the incur¬
able, and for the colonisation of patients who are not dangerous.
(2) The incurable patients who are able to work will go to the colony
(settlement); those who cannot work will remain in a division of the
asylum. Under the above conditions the Landtag sanctioned the
erection of the asylum of Mauer-Oehling for 1000 patients. Even
already the settlement comprises eight houses, used like those of
Dr. Alt at Uchtspringe.

Professor Bleuler, President of the Swiss Society of Psychiatry,
informed the Congress that the authorities of the asylums of Waldan
and Miinsingen have been authorised as an experiment to make terms
with private families to place with them certain insane patients at the
rate of one franc a day.

Dr. Vogt, of Christiania, stated that there are in Norway some
colonies of five, ten, or twenty patients, but that the organisation is far
from perfect. The condition of affairs is the same in Sweden, while in
Denmark almost all the insane are cared for in asylums.

A communication was read from Mr. J. W. L. Spence, Secretary to
the Scotch Lunacy Commission, with reference to the insane under
private care in Scotland. The English readers of this Journal are
sufficiently familiar with this aspect of the question to render it
unnecessary for us to enter here into details with regard to it. The
same may be said of the important speech of Dr. MacPherson, Lunacy
Commissioner in Scotland, on the present operation of family care in
his country.

Dr. Marie, of Villejuif, formerly Director of the Settlement at
Dun-sur-Auron, laid down the indications for The Care of the Insane in
Families in Relation to the Relief of Overcrowding in Asylums. It is
requisite always to have plenty of vacancies in the divisions for acute
patients, in order to facilitate the early admission of recent cases and
the conversion of our asylums into hospitals for mental and nervous
diseases. Furthermore the divisions for acute cases ought to have as
annexes with open doors divisions for convalescent patients, and the
latter sections should be kept from overcrowding by frequent discharge
on trial of patients who, during the remaining period of their con¬
valescence, receive, when necessary, aid from “ after-care ” organisations
(patronage publique ). With regard to the chronic insane, they may
remain in asylums, or at least separate blocks of asylums should be
reserved for them. Another division of this class—and here is a point
deserving of special attention—should be confided to such relations or
friends as are willing to claim them, who would receive payment for
them, varying in amount, but never exceeding the cost of ordinary
family care among strangers. Ordinary family care as carried out at
Dun-sur-Auron was dealt with.

Chronic lunatics, who for any reason are outside the scope of family
care, were divided by Dr. Marie into (a) turbulent and dirty patients,
to be put into chronic blocks in proximity to the large asylums; and (< b)
the chronic adult insane who can still be employed at labour, whom
one would place, 100 or 200 together, in simple buildings with small

Digitized by v^.ooQLe

33«

EPITOME.

[April,

dormitories, and amidst surroundings approximating to family life. To
these open cottages there should be attached market gardens or
workshops for trades of a simple and easy character. By these
economic principles the total cost would be reduced by 25 per cent. The
maintenance at first and the initial organisation would no doubt in the
beginning entail a higher charge, by perhaps 25 per cent., but the profit
arising from work would recoup this at the other end. There might even
possibly remain a small surplus which would be applicable to purposes
of after-care.

Dr. Alt, of Uchtspringe, reminded his hearers that in 1880 there had
been but two settlements in Germany, those of Bremen and Hofheim.
The foundation of the settlement at Ilten has given a general impulse
to the extension of family care, and during the last two or three years
nineteen asylums in Prussia have begun the attempt to treat the insane
in family care.

Professor Tamburini, of Reggio-Emilia, in a paper of great brilliancy,
argued in favour of—

1. The placing of the insane in other special establishments as well
as asylums. Among such establishments are to be reckoned—(a)
Almshouses or hospitals for the aged who are unfit to labour, or for
chronic patients. In Italy hospitals of this kind contained 2573 chronic
incurable lunatics, (b) Medico-pedagogic institutions for congenital
cases of weak intellect. There are at present seven of these in Italy,
and their number as well as their individual size is constantly being
increased, (c) Establishments for the treatment of sufferers from
pellagra during the early stages of that affection. There are three of
these in Italy, with a population of 560 pellagrous patients, (d)
Agricultural colonies. Of these Italy possesses three, but all in connec¬
tion with asylums, of which in each case they constitute a division.
(e) Asylums for criminal lunatics. Three in number. They contain
nearly 700 patients (persons under sentence, or persons charged with
crime but found irresponsible owing to their mental state).

2. Family care. In 1898 there were 1416 lunatics treated in family
care—that is to say, 4 per cent. At present the number has reached
2000. This figure includes patients under two forms of family care:
(a) care in the patient's own family (homo-familial); (b) care in the
family of a strange host (hetero-familial).

The “ homo-familial ” system has not in Italy been attended by the
success that was hoped for, by reason of the difficulty which has been
experienced in exercising a thorough, constant, and efficient supervision
over the patients and their treatment. In some districts this system has
been given up.

On the other hand, family care in households other than the patient's
own home, especially where it has been adopted with all the constant
precautions that are requisite, has given most satisfactory results.
For the last four years Professor Tamburini has committed some of
his tranquil female patients (dements, certain epileptics, and sufferers
from hysterical insanity and paranoia) to family care in the house¬
holds of attendants or employes, past or present, of his asylum who live
in the neighbourhood of the institution. He has found among many of
these patients an improvement in the mental state and a bettering of

Digitized by

Google

1903]

PROGRESS OF PSYCHIATRY.

339

the general demeanour. They become attached to the families of
their hosts, employ themselves actively, and enter with much propriety
into the enjoyments of liberty and of social arid domestic life. The
dislike and suspicion entertained by the families in the neighbourhood
towards the patients has disappeared, and the number of those who
apply for patients constantly increases. Dr. Cristiani, Director of the
Asylum at Lucca, has followed Tamburini’s example, and with the
same success.

Dr. Van Dale, of Ermelo (Holland), propounded not only his own
opinion of family care, but that of the majority of his Dutch colleagues,
who at their meeting in last July were engaged for a long time on this
question. The Psychiatric Society of the Netherlands unanimously
accepted the principle of the necessity for family care. The colony of
Ermelo was established before 1890, and of late years beginnings at
family care have been inaugurated at Bloemendaal (Loosduinen), and
at Dennenoord (Zuidhoren). The author records with satisfaction
that he has found considerable support from the two medical inspectors
of the Dutch asylums, who have expressed their lively sympathy with
the movement. The Dutch Minister for Home Affairs, again, has
shown himself very favourable to the extension of family care. “Hol¬
land,” says the author, “will proceed rapidly along the path of this
humane and beneficent reform.”

Dr. Zakaroff (Russia) mentioned that, of 200,000 lunatics there, some
50,000 have been already committed to family care.

The above-mentioned contributions served as the basis for a general
discussion. An immense majority of the alienist physicians at the Con¬
gress were favourable to the multiplication of colonies and to the family
care of the insane, but with certain reservations. All this will be
demonstrated by the resolutions adopted by the Congress and reproduced
at the end of this article.

Dr. Swolfs, of Brussels, Physician to the Asylum of Dave, near
Namur, attacked the system of Gheel, which most of the preceding
speakers had eulogised. He declared that family care was losing credit
more and more with alienists and philanthropists, in spite of the state¬
ments to the contrary emanating from the majority of the members of
the Congress, and in spite of the evidence furnished by the resolutions
adopted. The reflections which he cast upon the colony of Gheel were
warmly disputed by Drs. Marie (of Paris), Alt (of Germany), and Peeters
(of Gheel), and these gentlemen proved that not one of the alleged facts
was true.

The Position of the Alienist Physician was the subject of a paper by
Dr. Van Deventer, of Meerenberg. The author declared against the
possibility of two administrative authorities (physician-in-chief and lay
director) on the same asylum, because this state of affairs must inevitably
lead to collision. The non-medical director is incapable of taking on
the duty of the physician, or even of fulfilling the administrative work
which the latter undertakes. Further, a medical superintendent should
not be appointed until he has passed through a preliminary training in
an asylum and shown that he possesses administrative capacities. In
almost every country the physician-in-chief to the asylum is at the same
time its director. The function of physician and director has become

Digitized by v^.ooQLe

340

EPITOME.

[April,

more important than ever since the introduction of the professional
teaching of attendants, since the progressive tendency has set in towards
the multiplication of wards with open doors, and since the adoption of
domestic colonies (settlements in family care). Moreover the physician
and director should retain in his own charge a certain number of
patients, should employ himself in scientific work in the laboratories,
and thus be able to introduce new methods of examination and treat¬
ment of patients. Special physicians should be attached to the staff of
all asylums for the pursuit of anatomo-pathological researches, psycho¬
physical investigations, etc. Finally, arrangements should be made to
encourage the taste for psychiatric studies, and asylums should contain
provision for “voluntary” physicians, quartered and fed as assistant
medical officers.

Dr. Van Deventer also discussed at length the question of The
Professional Education and Training of Attendants in Asylums for
the Insane . This question is so familiar, and its problems have been
so well solved in the United Kingdom, that we may be excused from
detailing the reasons for this instruction so ably set forth by our author,
who has initiated this movement in his asylum, and has found so many
followers among his Dutch colleagues that there are now more than
450 trained attendants who have obtained the^diploma.

On the Means of improving the Medical Organisation of the Belgian
Asylums was the title of a paper by Dr. Crocq. The author, having
given a description of the extreme insufficiency of the present
medical organisation of the Belgian asylums, gave an excellent account
of the medical organisation in the greater part of European asylums.
His conclusion therefrom is that he desires for Belgium that which is
already in existence in the great majority of asylums throughout the
whole world. From this point of view it is to be hoped that Dr. Crocq’s
work will be consulted with advantage by the Belgian legislators when
they shall take into consideration the revision of the present laconic
law dealing with the management of lunatics. The author would wish
that the pauper asylums should be administered by the public
authority; that every asylum should have its physician and director, to
whom is committed the medical and administrative charge; that the
appointment of the physician and director should be made by the
public authority ; that courses of clinical psychiatry should be delivered;
that a special diploma in psychiatry should be established; that only
physicians holding this diploma should be attached to asylums; that
such gentlemen should not be appointed physician-directors until they
have served at least four years as assistant physicians ; that their salary
should be fixed (in Belgium most of the physicians are paid per diem et
per caput , so that the more numerous the patients are the higher is the
pay!); that there should be one medical man for every hundred
patients; and that general practice should be prohibited to asylum
physicians.

Dr. Manheimer-Gom^s read a paper on The Family Care of Back¬
ward Children . The number of backward children which now over¬
crowd special asylums is so great that it behoves us to seek fresh means of
dealing with them. This can be found in domestic care. That method
enables us to treat patients who are only liable to rare attacks of excite-

Digitized by v^.ooQLe

1903-]

PROGRESS OF PSYCHIATRY.

341

ment, and who are otherwise docile, without condemning them to a
definite imprisonment. In the same way convalescents can be dealt
with. As to the class of idiots incapable of education, and dangerous,
domestic care of the “ homo-familiar’ type, as in Italy, has not been
successful in the Department of the Seine. “ Hetero-familiai ” care
allows us to select our hosts with a view to their special education and
aptitude, and to reward and punish them by giving and removing
patients and so forth. The best situation is in the country, and the
best occupation for the largest number is agriculture. For the merely
backward through degeneration or weakness the establishment of special
schools is to be advised.

Dr. Decroly, of Brussels, spoke on The Care of Abnormal Children .
The anomalies of childhood display themselves under very varied
aspects. According as one looks at them from the point of view of the
psychologist, alienist, schoolmaster, jurist, minister of religion, etc., they
will be called imbeciles, weak-minded, backward, lazy, wayward, vicious,
hysterical, etc. It is necessary to bring order into this chaos if we
are to be of practical service in the treatment of this class. The
author suggests as the best general designation that of abnormal
children —whether the abnormality be due to physical defect (troubles of
speech, tics, slight chorea, etc., the senses and intellectual powers being
intact), or to defect of the senses (blindness, deafness), or to defect of the
intellectual faculties (backward, imbeciles, idiots), or to defect of the
emotional and moral faculties (vicious, wayward, criminal, epileptic,
etc.), or, finally, whether it be due to the fact of absence or imperfection
of education (orphans, children morally neglected, spoilt and ill-brought-
up children). The author recognises that these groups are not abso¬
lutely differentiated. Society protects, relatively at least, the blind, the
deaf, the infirm, the idiots, the sufferers from the graver forms of
epilepsy; it mainly neglects those who are less completely in¬
capacitated, and who, while with care they might be useful to the
community, being neglected, are capable of being very dangerous.
The backward, the sufferers from the lighter forms of epilepsy and the
like, cannot be put into asylums, but should be treated in special schools,
as at Antwerp and Brussels. The vicious, wayward, rebellious, and
criminal should be placed either in special institutions or in institutions
specially adapted for them, like those used by the English Government,
viz., industrial schools, truant ships, and training ships. It is desirable
that the teachers should be associated with physicians in the task of
educating the abnormal, and that there should be established a means
of after-care to supplement the mere school or training course and to
support and start in life such as werefound capableof taking a place in the
common existence of society. The remaining cases should be placed
in a special settlement, under regulations, where they can be employed,
preferably at farm and garden work. Thus a quiet and regulated
life can be secured for them, and their mischievous tendencies are
diverted by regular work, while the value of their labour will go to pay
for their cost to the State ; and the State, following the example of those
countries which are at the head of civilisation , will hasten to adopt these
measures from the moment that those who hold in their hands the highest
moral and material responsibilities of the country come to understand that

Digitized by ^.ooQle

342

EPITOME.

[April,

this matter is not merely one of reasoning and sentiment, of humanity
and of charity, but that it has, viewed more widely, important economic
factors, and that it is intimately bound up with questions of socialprophylaxis .

Dr. Paul Masoin, of Gheel, spoke of The Domestic Care of
Epileptics . The author, for scientific reasons, is not one of those
who favour asylums for epileptics. He prefers to see them scat¬
tered about in a settlement if the latter is provided with sufficient
medical help to properly care for them. He considers that the mode
of life (diet, etc.) of a settlement is quite suited to epileptics, and that
when such patients are isolated with their hosts they are the objects
of an amount of care that they cannot receive in wards crammed with
patients of this class. The hosts get to know their patients intimately
in a very short time, and are very often able to anticipate their attack
and thereby to take the necessary measures.

Dr. Ley, of Antwerp, spoke on The Treatment of Idiot and Imbecile
Children in a Colony with an Asylum School. The advantage of the
system commended by the author would be the bringing up of the
child in that potent educative atmosphere, the family, with its constant
multiplicity of experiences and psychic reactions. The father of the
medico-pedagogic method, the distinguished Seguin, long since pro¬
tested against big asylums for children.

Dr. Vos, of Grave (Holland), read a paper on The Selection of
Localities for Family Care. He prefers the system of Gheel, Lierneux,
Dun-sur-Auron, Ainay-le-Ch&teau, and even the system adopted by Alt,
to the Scottish system. Besides fundamental hygienic conditions, it is
necessary to take into consideration the nature of the population
(alcoholism, political dissensions, etc.), and also the risk of accidents
(canals, rivers, railways, etc.). Vos gives the preference to sandy tracts
of country intersected with plantations of timber, where the work of the
hosts is very varied, and particularly where the work is mainly agricul¬
tural. Industrial localities are not suitable.

Dr. Claus, of Antwerp, read a paper on The Care of Epileptics.
Contrary to the opinion of Dr. Masoin, the author would wish that all
epileptic lunatics should be placed in closed asylums. He calls for the
establishment of special asylums, hospitals, and schools for epileptic
children.

Dr. Marie read a note on The Internal Organisation of Certain
Central Institutions . The author particularly condemns those private
asylums which undertake the treatment of the insane by contract, which
is a source of enormous incomes, because the proprietors do not use
their profits for the improvement of the medical and administrative
departments of the institutions. The proprietors appoint the physicians
of their own choice. Dr. Marie quoted in support of his contention,
first, his own personal observations ; then the statements of certain
alienist physicians of Belgium, Dr. Masoin, Professor in the University
of Louvain, Dr. Lentz, and Dr. Morel; and finally, the excellent report
of the position of the insane in Belgium, printed in 1895, in which the
Minister of Justice himself sharply criticises the existing organisation of
the Belgian asylums, and particularly the organisation of those given up
into private hands, the appointment of the physicians by the proprietors,
the insufficiency of the medical staff, and the absence of medical work

Digitized by v^.ooQLe

PROGRESS OF PSYCHIATRY.

343

1903 -]

in the majority of the asylums. A similar state of affairs exists in the
private asylums in France, and Dr. Marie, like all true alienists of every
country, condemns the contract system for the treatment of pauper
lunatics.

Dr. Medici presented a paper on The Family Care of the Insane in
the Settlement of Levet (Department of Cher). This colony, being a
small one, serves as a good model. Every department could start a
colony, no matter how small, for chronic and harmless cases. In
family care the latter will augment directly the small resources of the
poor population, who, while doing a good work for the insane, make
a little profit for themselves, and also benefit by escaping the increased
taxation required for building and working a central institution.
Thus the plan is at once democratic, economic, and liberal, placing
the patient in his natural surroundings, saving the cost to the depart¬
ment, and giving care to the greatest number at the lowest rate.
The author gives a pretty long history of settlements for the insane,
particularly those instituted by the Department of the Seine, and
arrives at this conclusion—that asylums ought to be establishments
for treatment; existing asylums ought to be relieved of overcrowd¬
ing by carrying out a system of family care for the chronic and
harmless. At the same time the number of their physicians should be
increased, to enable the latter to have an individual knowlege of their
patients and to separate the acute and dangerous cases. It is only
when the patient has been studied and classed that he will be either
kept on in the central asylum or placed in one of the open divisions,
where he continues to be treated. If he appears curable after a varying
lapse of time, he should be committed to domestic care, which need
only be brief if he is already convalescent. Dr. Medici gives a detailed
description of the settlement of Levet, of its cost of maintenance, and
of the class of patients who have been sent there. He gives also
extremely interesting clinical outlines of a number of individual cases,
important as showing how many varieties of insanity can, under proper
care, be treated by the domestic method.

Dr. Havet,( 2 ) of Gheel, dealt with The Importance of Scientific
Laboratories in Asylums for the Insane . The author states that the
importance of such laboratories is recognised all over the world, and
that in this respect Belgium is in a backward position. Laboratories
may be of great use from various points of view. They should include—

(1) arrangements for chemical and microscopical analyses with the
object of establishing diagnoses and for aid in hygiene (analyses of
blood, sputa, urine, etc.), bacteriological research (tubercle, diphtheria),
so necessary for the protection and treatment of patients and staff;

(2) arrangements for systematic autopsies (cause of death, instruction
both of physicians and attendants); (3) means of promoting the advance
of mental medicine (normal and pathological psychology, clinic in
nervous and mental diseases, cellular and pathological biology). All
this work requires the activity of many workers, and the principle of
the division of labour can well be applied to researches of this sort.

Dr. Picqu£, Surgeon to the Asylums for the Department of the Seine,
under the head of Surgery in Lunatic Asylums , dealt at much length
with the necessity for a surgical service in asylums, particularly in

Digitized by v^.ooQLe

344

EPITOME.

[April,

those of a large centre. He described several cases in which patients
who were operated upon have recovered mental health at the same
time with physical health.

A communication was submitted from Prof. Pick, of Prague, on
The Registration of the Insane who are not confined in Asylums.
The following are his conclusions :—(i) In order that the law may be
able to protect all the insane, it is indispensable that it should be
obligatory to report all the insane who are treated outside asylums.

(2) Though it may not be possible to classify the mental ailment, the
duty of reporting the patient depends upon the new situation which is
produced, and which is judicially definable—the diminution of liberty
or of personal responsibility, the limitation of civil capacity, personal
insecurity, and the necessity for treatment. (3) While signalising the
necessity for registering the insane, this notification should be carried
out in such a manner as not to excite the prejudices of the public.
(4) With regard to the insane in their own home living with their
parents or children, notice should be sent when an internment of three
months’ duration has been made; but when a patient is supported at
the public cost notice should be sent at o'nce. (5) Notification should
be made by whomsoever has the care of the patient. It does not seem
practicable to demand it from the physician. (6) When a patient is
located in the house of a strange host notification should be sent
immediately by the host. (7) The physician should have the right to
make a confidential report in any of the preceding or following cases.
(8) With regard to asylums not known as lunatic asylums, we have—
(a) “ Maisons de sante,” hydropathic establishments, “ hospices,” con¬
vents, etc. The duty of notification begins here as soon as the patient’s
personal liberty or civil capacity is interfered with. Notification should
be made by the physician of the establishment. ( b ) Hospitals which
only receive the insane temporarily. Notification should be made
when their stay exceeds fifteen days. Psychiatric cliniques attached to
hospitals may be subjected to special regulations, and these regulations
should resemble those framed for patients who are taken care of in
their own families. ( c) Establishments for idiots, which with regard to
notification should stand in the same rank as asylums, (d) The same
may be said of asylums for epileptics. In both of these latter cases
notification should originate with the physician or the superintendent of
the institution.

Dr. Olah, of Buda-Pesth, read a paper on The Best Means for deal -
ing with the Psychoses at their Beginning. This author concludes with
these proposals :—(1) That we should suppress everything which inter¬
feres with the full utilisation of asylums as prophylactic and therapeutic
institutions. Thereby we also combat the notions which are popularly
current on the nature of mental disease. (2) That we should endeavour
to make asylums more popular with the general public, and by the close
supervision of cases in family care try to establish a social prophylaxis.

(3) That we should give our public asylums the title of “State Institu¬
tions for Nervous and Mental Diseases.” (4) That we should eschew
all unmeaning denominations as not suitable to the end in view (5) That
we should minimise as much as possible the formalities preceding the
admission of patients. (6) That the placing of a patient in an asylum

Digitized by v^.ooQLe

I9°3-] PROGRESS OF PSYCHIATRY. 345

should not always necessarily require a declaration of his legal in¬
capacity. (7) That every effort should be made by the denomination,
the organisation, the character, etc., of our asylums to make the public
understand that mental disease is a bodily affection closely allied to the
other diseases of the nervous system.

Dr. Marie spoke on Domestic After-care of the Convalescent Insane .
In this work the author truly and feelingly complains that more
trouble is bestowed on the after-care of criminals who have been
discharged from prison than upon recovered lunatics, who are often
turned loose upon society without a refuge and without occupation. He
reviewed what had been done abroad with this object, and came to
the following conclusions :—After-care organisations for the insane who
are recoverable should look after the families of the patients while the
latter are confined in asylums, so as to secure a home for them on dis¬
charge and to re-establish the relations between the patients and this
home in case of recovery. Placing convalescents in family care permits
of early discharge, and constitutes the best prophylaxis against relapses.
It should be encouraged by the public authorities, who, by arranging
funds for this purpose, would avoid having to pay for detentions in the
asylum, prolonged and repeated. Domestic after-care, in case of
relapse, should supply first aid at home and should simplify the
formalities for sending back the patient to the asylum, cases in which
return is delayed being, as we know, the least curable. After-care
should be made use of to instruct the public about the insane, and
to destroy those prejudices which lead people to regard the lunatic as
different from all other classes of patients, and as always dangerous.
The preaching of these doctrines, and active moral support for dis¬
charged patients and for their families, are as necessary as aid in
money or material support. The task of after-care is to secure both.

Dr. Terwagne, of Antwerp, contributed a paper on Tuberculosis
among the Insane , in which he declared himself entirely opposed to
placing tuberculous patients on settlements. Dr. Peeters, on the con¬
trary, recommends settlements, because in them the patients live
comparatively apart, whereas in asylums the life in crowded wards
constitutes the great source of propagation.

The courteous, learned, and able Secretary to the Congress, Dr. F.
Sano, of Antwerp, contributed a communication on the subject of
City Asylums . The author shows the need in every large town of a
reception asylum, where the insane could be received on the first
appearance of their illness. Cases for which only a brief period of
treatment was considered necessary could be retained there; other
cases would be sent either to the ordinary asylum or to the settlement.

The Congress concluded its labour by the adoption of the following
resolutions, which were carried by an immense majority:

1. Family care ought to be made use of in all the forms of insanity
and in a great number of individual cases. (Tamburini.)

2. For a large portion of the insane who require care and who can
be submitted to this form of treatment, the family colony represents
that form of treatment which is the most natural, the most free, the
best, and the least expensive . It forms, besides, an important thera-

Digitized by v^.ooQLe

346

EPITOME.

[April

peutic agent for a great number of patients. Family care can be
adopted as an adjunct to any asylum which is directed by a psychiatric
physician, and can be instituted according to the exigencies of time
and place, particularly when the attendants are placed in the enjoyment
of comfortable dwelling-houses—a thing which is besides indispensable
if we are to obtain first-class attendants. But in the majority of large
institutions family care can only be adopted on a very limited scale.
The general use of the method cannot be obtained except by the
erection on suitable country properties of central institutions, reproducing,
but on a small scale, the well-known special arrangements (of an
asylum), and serving as points around which the domestic colonies can
be founded. Domestic colonies do not do away with the necessity for
existing institutions, as they by no means constitute the most suitable
abode for every case of insanity; but they can check the constant
increase of the number of establishments in a very ready, practical, and
cheap way. (Alt.)

3. It is essential that the labour of the insane shall be carried out
under the direction of the medical staff of the asylum, who shall direct
its nature and duration. (Van Deventer.)

4. It is essential that those to whose charge the insane are committed
should receive professional instruction, theoretical and practical. The
communication of this instruction should belong to the medical staff of
the asylum, on whom is also incumbent the duty of controlling the
results. (Van Deventer.)

5. The direction of an asylum for the insane must belong to the
physician, both with regard to medical and administrative charge. (Van
Deventer.)

6. In accordance with the opinion of Guislain, every asylum ought to
contain one physician for every 100 patients. Every asylum physician,
in the interests of the patients committed to his care, should be housed
in the establishment. General practice should be prohibited. (Van
Deventer.)

7. It is desirable that every asylum for the insane should have such
laboratories as are necessary for the study of everything that can con¬
tribute to the diagnosis of disease or the progress of mental medicine.
(Van Deventer.)

8. Considering that a ready access and an early admission to hospital
treatment form the most sure guarantee for recovery from insanity, all
facilities should be given to treatment outside asylums, and also to
speedy admission for treatment on the appearance of the earliest signs
of disease, and without preliminary certification being always necessary.
(Voison, Alt, Leroux, Marie, Francotte.)

9. The progress of contemporary psychiatric science condemns the
employment of means of restraint. (Alt, Marie, Van Deventer.)

10. Considering the great advantage of medico-pedagogic institutions
for backward children, it is desirable that these institutions should be
developed and increased everywhere. In these institutions education
should be systematically given, at once moral and intellectual, technical
and manual, and should be directed to preparing the pupils for a useful
calling. The scientific direction of all these medico-pedagogic institu¬
tions should be medical. It is desirable that committees of after-care

Digitized by v^.ooQLe

PROGRESS OF PSYCHIATRY.

347

1903 ]

should be established to watch over the subsequent lives of patients of
the phrenasthenic class* discharged from these institutions. It is
important that special courses of instruction in the education of the
backward should be instituted in normal schools. (Tamburini, Ferrari,
Decroly, and Ley.)

11. Considering that among the causes of the great number of back¬
ward children the science of to-day recognises maternal affections
during gestation and delivery, and the diseases that occur in early infancy,
and considering that these causes are connected with conditions of social
life, it is requisite to inquire how far it is possible to contend against
them. In the hope of effecting an improvement in these conditions, the
Congress will proceed to nominate two commissions—one of specialists
to study the relative importance of the diverse causes of phrenasthenia
of that order which may be called social; the other to investigate the
best practical means to remedy the conditions in question. (Madame
Marie, Dr. Ferrari.)

12. It is desirable to establish in domestic settlements an asylum
school, where the children, under competent medical direction, could
receive complete medico-pedagogic treatment. The children would
have, before this, been subjected to a sufficient period of observation in
the special schools or medico-pedagogic institutes. (Ley, Ferrari.)

13. It is desirable to solve by the experimental method the question
of the influence of the insane in settlements on the children and the
normal adults who are around them. (Dr. Schuyten.)

14. All closed institutions for the insane ought to be provided with
resident physicians in sufficient number, and should have buildings
annexed permitting of the application of the family system under
effective medical supervision, as a curative means during convalescence
and as a provision for such chronic and harmless cases as are suitable
for liberty under control. (Marie and Buffet.)

Note. —Our valued correspondent desires us to add to the above
report that it must not be supposed, because almost all the proposals
made at the termination of the Antwerp Congress emanated from
foreign physicians, that therefore the alienists of Belgium are indifferent
to the progress of psychiatry or to the need for reform in the care of the
insane—outside the question of family care, so specially discussed in
connection with the Belgian settlements. To us it would seem that the
organisation of the closed asylums of Belgium, which, though dealing
with public patients, are in private hands, would not commend itself in
countries where the principle of “ no taxation without representation 99
has been so entirely accepted that the public could not be asked to pay
for any institutions which they do not rule, either directly through their
representatives or indirectly through the State. The visiting physicians
of institutions such as those to which we refer may be excellent men, but
they can hardly see as clearly as we probably do the insufficiency of the
arrangements under which they themselves hold office. Dr. Morel
points out that all Belgian alienists, however, are not without a
distinct enough perception of the need of certain reforms [though
the peculiar position of affairs in that country may often hinder

XLIX. 24

Digitized by v^.ooQLe

34»

EPITOME.

[April,

the freest expression of opinion]. Dr. Crocq, as will be seen above, spoke
strongly at the Antwerp meeting on the question of the pay and position
of the medical officers of asylums. So long ago as 1895, ^ r * Masoin,
Professor in the University of Louvain, expressed himself even more
strongly at a meeting of the Societk de Mldecine Mentale de Belgique ,
saying that “ the remuneration of the physicians to asylums ought to be
fixed on a uniform scale, and not on a pro rata scale according to the
number of patients ” {per diem et per caput , as above). “You see the
reason for this demand : In the present situation of affairs the physicians
have an interest in retaining in the asylums certain patients who are in a
condition to be restored to liberty . Now we always do ill when we put a
man between his interests and his conscience.” [Where the poor,
whose relatives have little power or opportunity to protect them, are
treated at so much a head, and where there is no effective central
supervision, the physician is placed in a most painful position, and can
hardly expect not to have the worst construction put upon his action.]
Dr. Masoin asks whether there is not a danger that “ the insane may
become the victims of avaricious management.”

Dr. Lentz, medical superintendent of the State Asylum at Tournai,
at a meeting of the same society in the same year, said : “Yhe future of
the care of the insane seems thus to lie in the reform of the asylums
managed under contract. The central point of this reform is the pre¬
ponderance of the medical authority, and therewith the* increase of the
special staff. The means to be adopted are, wherever it is possible, to
place those establishments which perform the office of public asylums
under the control of the public authorities, who will be guided only by
medical opinion and will act solely for the good of the patients.”

A year earlier, Dr. Morel, Medical Superintendent of the State
Asylum at Mons, in his presidential address to the Society, declared that
“ scientific life has not yet sufficiently penetrated into our asylums.
The cause is to be sought in the relative state of inferiority in which
our alienist physicians find themselves, and in the ignorance or
indifference which we meet among the majority of the proprietors of our
asylums. The numerical insufficiency of the medical staff, the insuffi¬
ciency of their pay, the absence of medical libraries and of all other
scientific resources, cannot fail to cast our colleagues into a state of dis¬
couragement which too often degenerates into a state of indifference as

to science.No one in Belgium seems to take an active

interest in improving the scientific position of our alienists. We must
protest that in the year 1850 (that is, at the time when Belgium adopted
its first law as to the management of the insane) the science of mental
medicine was very far from being what it is in our days. From that date
in most European and North American countries the attention given to
the endeavour to secure the best men for the specialty has been ceaseless

and increasing.Can the alienists of our country sit with their

arms crossed in face of the progress realised among our neighbours ? ”

Monsieur Lejeune, Minister of State, formerly Minister of Justice,
declared at the International Congress of Criminal Anthropology held
at Amsterdam in 1901 : “In Belgium the regulations are defective. The
asylums are in the hands of private individuals . I would wish all that
altered.”

Digitized by

Google

I903-]

ANTHROPOLOGY.

349

The resolutions adopted at Antwerp with regard to asylum manage¬
ment were not by any means new. Many of them have already found
practical application in most asylums in Europe and the United States.
Attempts to realise them in Belgium, however, have so far proved
fruitless. ( 3 )

(*) The Editors regret that the publication of this important contribution had
to be postponed until the present number of the Journal. —( 2 ) Now Professor at
the University of Louvain.—( 3 ) We cannot believe that they will continue without
fruit when made by such bold and earnest advocates. Those readers who may
wish for further information on certain of these questions would do well to consult
Dr. Morel’s many papers thereon, among which we may mention— Venseignement
professional des gardiens dans les asiles d'aliinis (Bulletin de la Sociiti de Mide -
cine Mentale de Belgique , 1894-95); Le r 6 le du patronage h Vigard des alUnes ,
avant, pendant et a pres V internemente (Congrfc international des Patronage ,
1898); Valitement dans le traitement des formes aigues de la folie et des modi¬
fications qu’il pourrait entrainer dans Vorganisation des itablissements consacris
aux aliinis (XIII Congres International de Mide cine, Section de Psychiatric,
Paris, 1900); La prophylaxie et le traitement du Criminel Recidiviste (Congres
d‘ dnthropologie criminelle tenu a Amsterdam , 1901).

[Note. —The word “colony” is often used in Continental countries
in two senses—one meaning an asylum farmstead with residence for
patients, the other a township where patients are maintained in private
houses. Where the word is used in the latter sense in our esteemed
colleague and correspondent’s communication we have sometimes sub¬
stituted the word “ settlement,” so as to avoid the danger of confusion.]

Epitome of Current Literature.

i. Anthropology.

The Proportions of the Adult [Die Profiortionen des erwachsenen Men-
schen\ (Zeit.f. Morph. u. A nth., H. 2, 1902.) Pfitzncr, IV.

This valuable and elaborate paper is one of the series of socio-
anthropological studies to which attention has been called from time
to time in the Journal. It is the last we may hope to receive, for
Prof. Pfitzner died at Strassburg on New Year’s Day at the age of 49.
He was a worker whom we can ill afford to lose, and his patient and
thorough investigations of many difficult and obscure questions have
done much to illuminate the social and psychological bearings of
anatomical and anthropological data. (An authoritative sketch of
Pfitzner and of his twenty years’ activity at Strassburg, from the hand
of Prof. Schwalbe, will be found in the Atiatomischer Attzeiger, 1903,
No. 22.)

The present “ socio-anthropological study ” embodies a vast amount
of labour, largely of a mathematical character, compressed into 113
pages. It would be impossible to summarise it within a reasonable

Digitized by

Google

350

EPITOME.

[April,

space. One result of Pfitzner’s work is to rehabilitate the value and
significance of averages which, provided we are dealing with sufficiently
large and sufficiently homogeneous data, he found to correspond almost
invariably with the plurimum, so that the most frequent dimension is
also the average dimension. Reason is also found for questioning the
current view that the infants head is relatively large as compared with
the adult’s in order to favour the early development of a highly
important organ. This question, as Pfitzner viewed it, may be
generalised, and is really one of proportion; with the increase of every
dimension corresponds, but in decreased degree, the increase of other
dimensions ; “ there is no difference between children and adults, and
every individual has the head that corresponds to his stature.” The
adult standard of proportions would thus not be fixed and preordained,
but merely the accident of a stage of growth which has stopped, but
would lead to a new scheme of proportions if it could continue. It is
evident that Pfitzner was here entering on a new but somewhat difficult
field of speculation. Havelock Ellis.

a. Neurology.

Old and New Researches on the Brain [Alie und neue Untersuchungen
ueber das Gehirn\ (Arch, fur Psychiat. % B. xxxvi, H. i.) Hitzig.

In this continuation of his inquiry Dr. Hitzig treats of the relations
of the cortex cerebri and of the subcortical ganglia to the function of
vision in the dog, and prosecutes his old polemic against Munk. The
disputes of these two distinguished physiologists are so far useful
that they constitute some safeguard against one being misled, as each
is ready as well as able to correct any oversight or error in his
opponent’s statements. In the present paper Dr. Hitzig gives the
details of ninety experiments at considerable length, and illustrates his
text with engravings. To give a r'esum'e is impossible, and to criticise
the interpretation which the professor gives of his experiments would
be presumptuous. Those who are engaged in original research will go
to Hitzig’s paper for themselves. It will be sufficient here to present
his conclusions. He found that injuries to the sigmoid gyrus were
almost constantly followed by disorders of vision. To produce this
result it was sufficient to lay bare the convolution. Injuries to the
orbicular centre were followed by disorders of the optic reflexes, and
often, too, by a wider opening of the eyelids. If the lesion be made
somewhat anteriorly and laterally, approaching the centre for the facialis,
it leads to impairment of the nasal reflexes. The anterior limb of the
II—IV primitive convolutions, as well as the anterior part of the
descending nerve-bundles and the inner capsule, may be injured
without any direct disturbance of vision following. It will be remem¬
bered that Munk holds that the mental or cortical blindness of certain
parts of the retina only results from injuries of the posterior region of
the brain. Hitzig promises in a further contribution to consider the
effects of lesions to the posterior portions of the hemispheres.

William W. Ireland.

Digitized by v^.ooQLe

! 9°3-]

NEUROLOGY.

35 1

Functions and Diseases of the Frontal Lobe in Man [Leistung und
Erkrankung des menschlichen Stirnhims , i Theil, Graz , 1902].

(Reported in Neurol, Cbl ., Oct. 16th, 1902.) Anton and Zingerle.

There are still many unsolved questions about the functions of the
frontal lobe; most investigators think that it contains centres for the
muscles of the head and trunk, while Munk places them on the
convexity of the hemispheres, and Horsley on the median plane of the
marginal gyrus. It seems certain that in front of the sulcus praecen-
tralis there are centres for the movements of the eye. The frontal
lobe has an influence on the maintenance of the bodily equilibrium.

In their laborious study of the histology of this lobe the authors
have found that the structure of the frontal lobe is not different from
that of the other lobes. The great mass of the association fibres lies
laterally to the ventricles ; the projection and commissural fibres nearer
to the middle line. There are regions in the frontal lobe in which the
fibres of the corona radiata are scanty. Hence impairment of associa¬
tions may be explained. The authors point out that injuries to the
frontal lobe are frequently followed by atrophy of the opposite side of
the cerebellum. William W. Ireland.

On the Localisation of Cerebral Hemiancesthesia [Zur Localisation
der cerebralen Hemiandsthesie\ {Neurol. Cbl., No. 21, 1902.)
Schaffer.

Dr. Schaffer observes that there are centripetal nerve-tracts which
end in the optic thalamus, from which another neuron issues which
passes to the cerebral cortex. From case of haemorrhage of the
thalamus studied by Probst, it appears that the thalamo-cortical neuron
passes through the lamina medullaris externa to the side of the inner
capsule, and, lying close to the ganglion lenticularis, reaches the median
convolutions, the parietal lobes, and the gyrus fomicatus. Those fibres
which go to the occipital lobe spring from the pulvinar and disperse in
the stratum sagittale externum. Probst’s results agree with those
of Flechsig. According to Dejerine and Long, there is no distinct
sensory system in the posterior limb of the inner capsule; the fibres
which go to the cortex, as well as those going to the thalamus, mingle
with the fibres of the pyramidal tract, which, beginning in the knee,
spread to the retro-lenticular segment of the inner capsule. Hemianaes-
thesia occurs under two conditions—(1) a lesion of the thalamus
opticus which may affect the ganglion in the passage of the fibres either
on the bulbar or cortical side; (2) when the conducting tract between
the thalamus and the cortex is affected, the thalamus remaining intact.
In this case the lesion is of an extensive character.

Observations made both by the clinical and experimental methods
prove that the motor functions, the cutaneous sensibility, and the
muscular sense are localised in the same parts of the cortex—that is, in
the motor zone, which ought to be called the sensori-motor zone.

Dr. Schaffer then gives a description of a case of hemianaesthesia, a
labourer, aet. 18 years, who suffered for above a year from complete
motor and sensory paralysis of the left half of the body. The loss of
sensation, which approached the middle line, was complete. The sense

Digitized by v^.ooQLe

352

EPITOME.

[April,

of position was wanting in the whole left side. The special senses were
unaffected, but the intelligence was diminished, the patient answering
questions sluggishly and in short phrases.

On examining the brain there was found softening of the right
hemisphere extending from the posterior limb of the Sylvian fissure
over the lower part of both median gyri to the first temporal. This
softening dipped inwards to the head and body of the nucleus caudatus
and the anterior limb and knee of the inner capsule. This had
brought about atrophy of the thalamus opticus, which was not
directly affected by the softening. There was also a descending
degeneration of the pyramids implicating the pons, medulla, and lateral
columns of the cord.

The degeneration was most marked in the dorso-lateral nucleus of
the thalamus, showing that the cortico-thalamal neuron was affected.
The professor observes that the lesion was confined to the motor
portion of the inner capsule, while the back part of the posterior limb
was free, although this tract, according to Charcot, conducted sensory
nerve-fibres. In this case, while only the motor portion of the inner
capsule was destroyed, there was hemiplegia with decided hemianaes-
thesia. William W. Ireland.

Hypertrophy of the Brain with Alterations in the Thymus and
Supra-renal Capsules [ Wahre Hypertrophie des Gehirnes mit
Befunden an Thymus und Nebensnieren\. (Neurol. Cbl., Oct. 16 th,
1902.) At the Meeting at Karlsbad in Sept., 1902. Anton,
Obersteiner, Stekel.

Dr. Anton, of Graz, described a patient who was of a neurotic
heredity, had severe attacks of epilepsy, but no symptoms of
cerebritis, although there was a certain slowness in spontaneous
movements. The intelligence was always good. He died at the age
of twenty years in the status epilepticus. The outer vault of the
skull was found to be as thin as paper, and even the bones of the
base of the cranium were wasted. The occipital curve was flattened.
The brain was of strikingly large size, and weighed not less than
2°ss grammes. It Was thus one of the heaviest on record. The
hypertrophy was general, the proportions of the parts being preserved.
For example, the cerebellum was n per cent., as in the normal
brains. The fissures were very deep, but the proportion of the
grey and white substance was normal. There was some hydrocephalus
internus, though not considerable. The thymus gland was larger
than usual ; its blood-supply came directly from the innominate
artery. The muscular tissue of the heart was degenerated. Anton
thinks that this might be the sequel of immoderate dosing with
bromides. The supra-renal capsules were invaded by cysts so that the
central substance was quite destroyed ; the cortical substance remained,
though pathologically altered.

Dr. Anton observed that persistent maintenance of the thymus gland
and degeneration of the supra-renal capsules are frequently observed
along with abnormal brains. In these cases, the cerebral functions are
generally impaired. We do not know what relations these alterations

Digitized by v^.ooQLe

PHYSIOLOGICAL PSYCHOLOGY.

353

1903 -]

nave to one another. We shotild bear in mind the powerful con¬
stricting capacity of the supra-renal capsules, which might become the
cause, not only of monstrosities, but also of other brain diseases, such as
congenital hydrocephalus.

Dr. Obersteiner observed that hypertrophy of the brain is a very rare
disease. He had a case of it in a boy set. 8 years. There was no great
impairment in intelligence. The brain, without the fluid of the
ventricles, weighed 1920 grammes.

Dr. Stekel stated that he had observed in migraine a lowering of
temperature to occur with some regularity. The same declension was
observed in a case of sarcoma affecting the supra-renal capsules. He
holds that the condition of the supra-renal capsules had a significance
in migraine. William W. Ireland.

3. Physiological Psychology.

A Criticism of the Applicability of Plethysmographic Curves in Psycho¬
logical Questions \Zur Kritik der Verwendbarkeit der plethysmo -
graphischen Curve fur psychologische Fragen ]. (Zeit. f PsychoL u.

Phys . d. Sinnesorgane , H. 5 and 6, 1902.) Muller , R.

This lengthy and able paper presents an interesting study of the
historical evolution of the plethysmograph, and then discusses the
interpretation of its results. Lehmann’s plethysmograph was used.
Muller is not, however, like Lehmann, prepared to admit a psychological
interpretation of plethysmographic curves, but considers that at present
such interpretations are in a high degree confused and uncertain.
However simply the plethysmogram may be obtained, its interpreta¬
tion presents complex possibilities of error which involve some of the
most debated points in the mechanism of the pulse. We are therefore
yet far removed from the time when w*e shall be able to give a settled
representation of the relations between psychic and circulatory
processes. The schemes of C. Lange, Lehmann, and others are, Muller
believes, without justification. Before we can take psychic elements
into consideration we have, he argues, three different orders of physio¬
logical waves to allow for in interpreting the curve of the volume of the
pulse: (1) the pulse-wave proper; (2) respiratory waves, and also
waves which correspond to, and perhaps are, Traube-Hering waves;
(3) S. Mayer’s waves, which are of longer periodicity than the Traube-
Hering waves. These waves are discussed at some length, and Muller
severely criticises the statement of Lehmann that “ those oscillations of
the pulse which do not depend on the breathing or on muscular move¬
ment are of psychic origin.” The paper deserves careful study by all
who are interested in the psychological applications of the plethysmo¬
graph. It by no means follows, however, that the necessity of recog¬
nising waves of infra-cortical origin in the plethysmographic curve
altogether invalidates psychological interpretations.

Havelock Ellis.

Digitized by v^.ooQLe

354

EPITOME.

[April,

4 . Clinical Psychiatry.

Psychoses among Tramps [Die Psychosen der Landstreicher\ ( Cb/.

f Nervenheilk. u. Psych., Dec., 1902.) Wilmanns, Karl.

This study is founded on the examination of 120 tramps who reached
the asylum from the workhouse of Kislau. Most of them had been on
the road for many years; only twelve were women. All but twenty-
two had at some time found themselves in prison, and in some cases
there had been over one hundred convictions. Considerable stress is
placed on the influence of alcohol in moulding the lives of tramps. It
usually acts slowly, with increasing dislike of w f ork, loss of will-power, and
moral depravity, together with stupid well-being; the irritability and
tendency to criminality which have often been marked in adolescence
give place to resignation and habits of begging; these alcoholic tramps
easily adapt themselves to the routine of the workhouse, and delirium
is rare; only when alcohol has produced chronic mental weakness or
prolonged insanity do these cases reach the asylum; this occurred in
seven cases.

Cases of uncomplicated imbecility were only found three times ; but
imbecility, the author remarks, is the chief recruiting ground for
tramps ; he finds two classes of imbeciles among tramps—the erethic
group, who have much mental restlessness and moral incapacity, with
criminal tendencies which render them an anti-social element; and
the anergethic or torpid group, who are marked by a slow, good-natured
indifference, not usually leading to active criminality. The erethic
imbeciles somewhat resemble the hysterical group also found, often
with severe syndromas—paralyses, convulsions, etc.—and a tendency to
commit minor offences. The tendency to enter on a life of vagabondage
not infrequently accompanies the first appearance of maniacal condi¬
tions ; this was found in four cases. There were also four similar cases
of general paralysis. Epilepsy appears in a still higher degree to con¬
stitute a predisposing cause of vagabondage, and this group includes
nineteen cases, only one being a prostitute, epilepsy, it is remarked, not
leading to prostitution so often as do hysteria and dementia praecox;
the epileptics also constitute the group of tramps most willing to work,
with intervals of restlessness. The largest number of his cases—as
many as sixty-six—Wilmanns places under the head of dementia
praecox, and here distinguishes three groups—individuals who were
mentally sound until between the ages of twenty and thirty, when they
suffered from acute symptoms of insanity, which has left permanent
mental weakness or delusions ; a second group in which there was no
acute outbreak of insanity, but a sudden disturbance of conduct slowly
leading up to mental defects or delusions, including characteristic cases
of hebephrenia; a third group, definitely pathological from the first,
and including the cases of katatonia. The author does not believe
that the remarkably large proportion of hebephrenic and katatonic cases
which he has found among tramps can be solely accounted for by
their mode of life or by the influence of imprisonment, but considers
that the congenital mental condition in such cases directly predisposes
to an anti-social and unsettled life. The author admits that many of

Digitized by v^.ooQLe

I 9°3-]

CLINICAL PSYCHIATRY.

355

these cases would by others be regarded as coming under the head of
imbecility, but points out that we are not entitled to regard imbecility
as a progressive condition; we can at most regard such cases as im¬
becility on which hebephrenia or katatonia has been grafted. There
were numerous miscellaneous cases: a syphilitic cerebral case, a case
of prison psychosis complicated with imbecility, a weak-minded cretin,
a typical sane congenital criminal, and five in which the diagnosis
remained very obscure.

The author concludes that insane tramps present “a variegated
mixture of all possible states of mental weakness.” Unlike ordinary
habitual criminals, who are more active, they usually show passive
weakness of intelligence and will. Havelock Ellis.

Plethysmographic Investigations in the Insane \Plethysmographische

Untersuchungen bei Geisteskrankheiten\. ( Cbl. f Netvenheilk. u.

Psyche Nov.) 1902.) Vogt) Ragner.

For some years past, the author has interested himself in the study of
the pulse among the patients under his care at the asylum of St. Hans,
in Denmark. It is a point to which he does not think that alienists
pay sufficient attention, since the variations of pulse frequency are
extremely great in many cases, especially when associated with states of
fear and anxiety, and valuable indications of the mental condition may
thus be obtained. Vogt carried on a preliminary series of observations
to test objectively the susceptibility to fright of patients by noting the
increase of pulse frequency on hearing a sudden noise ^hand clapping),
and found that in states of anxiety it was sometimes raised from 70 or
80 to 120 or 126. He has also studied the mental conditions associated
with abnormally high pulse frequency. In the case of one very irritable
female patient the pulse rose to 216; at this pulse-rate the patient’s
language was always threatening and obscene. It is remarked that
coarse and abusive language tends to be associated with a pulse-rate
over 150. There is generally motor unrest, but this is not an invariable
accompaniment of high pulse-rate. In a paranoid dement lying peace¬
fully in bed, the pulse would be between 80 and no, and when attention
was drawn to his morbid ideas, although he continued to lie quietly,
amusing himself by making a few contemptuous remarks, it rose to
180.

The plethysmographic investigations were made with Lehmann’s
apparatus, a useful modification of Mosso’s. The results, duly illus¬
trated by curves, on the whole show similar results to those obtained by
Mosso, Lehmann, and others in normal subjects. Slightly imbecile
individuals seemed to show great susceptibility to the reactions of fear,
which in stuporose cases could not usually be obtained at all. A con¬
dition which seems to the author rather frequent in his cases, and even
in the sane, is one in which the reactions begin normally and then shew
a progressively increasing vascular dilatation associated with a con¬
dition of shame and confusion at having perhaps given a wrong answer
to the questions involving mental calculation put to him ; if the subject
continued calculating, the vascular dilatation was accompanied by
increased pulse frequency. A very marked change in the plethysmo-

Digitized by v^.ooQLe

356

EPITOME.

[April,

gram of a paranoiac patient was observed on the appearance of an
attendant by whom he believed he was persecuted. Vogt remarks that
the plethysmograph may be useful when there is a suspicion of the
simulation or the dissimulation of insanity. Havelock Ellis.

Dementia Prcecox [La d'emence pricoce\ {Rev. de Psychiat ., No. 6,
June , 1902.) SerieuXy P.

This is a very valuable summary of our knowledge concerning
Kraepelin’s interesting conception of the dementia of adolescence.
The history of this disease recalls that of general paralysis, under which
were at one time grouped quite a number of different conditions, and
conversely to which we now refer a number of cases at one time con¬
sidered quite unlike in their pathology. For we see that subjects
formerly labelled as suffering from various psychoses—maniacal excite¬
ment, melancholia, stupor, katatonia, delusional state in the degenerate,
primary or secondary mental weakness, primary dementia, etc.—in
reality exhibit but various manifestations of a distinct disease, dementia
prcecox , characterised by certain special symptoms and by its evolution.
Moreover it is often possible, as in the case of general paralysis, to
diagnose the affection in its first stage. Let us therefore give up the
idea that dementia praecox is a complication of various insanities
(secondary dementia, etc.), but endeavour to diagnose the disease in its
early stage and thus obtain valuable data for prognosis.

Reviewing the history of the disease, Serieux finds that the first
author who carefully studied it was Morel (1857—1860); in more
recent times he draws attention especially to the memorable researches
of Hecker, Kahlbaum, and Kraepelin, and to important contributions
by Christian and S^glas.

Definition .—Dementia praecox is a psychosis essentially characterised
by a special and progressive psychical enfeeblement, supervening usually
during adolescence, and culminating as a rule in the disappearance of
all manifestation of mental activity, without ever compromising the life
of the subject. As in general paralysis, we may distinguish in dementia
praecox essential symptoms—those pertaining to the psychical enfeeble¬
ment ; and accessory symptoms—the delusional disorders. The latter
may assume all forms.

In asylums the proportion of these cases to the total number of
patients probably varies from 5 per cent. (Christian) to 15 per cent.
(Kraepelin).

Symptomatology. —To facilitate description, four varieties may be
considered— (a) simple dementia; {b) the delusional form; (c) the
katatonic form ; (d) the paranoid form.

{a) Simple Dementia (mitigated or slight hebephrenia of Christian) is
not very often seen in asylums, and is characterised by a progressive
enfeeblement of the psychical faculties, usually beginning at the age of
sixteen to eighteen years ; attention diminishes ; comprehension is slow ;
apathy is* a dominant feature. Cephalalgia, changes in temper, vague

Digitized by v^.ooQLe

1903-] CLINICAL PSYCHIATRY. 357

fears, hypochrondriacal preoccupations may denote the onset. Vaga¬
bondage and prostitution are frequently observed.

(b) Delusional Form (hebephrenia).—The distinctive characters are
delusions, usually polymorphous, the absence of definite katatonic
symptoms, and of delusional conceptions tending to become sys¬
tematised. A prodromal period, frequently unrecognised, often precedes
it. There is a mobility, an absurdity about the delusions, a want of
precision about the conceptions, a marked variability in disposition,
which are striking in these cases. The written and spoken language is
markedly incoherent, although different from that of mania, of epilepsy, or
hysteria; the grammatical construction is there, but there is a plethora
of pretentious, foreign words, of neologisms and senseless expressions.
This disorder of speech is found also manifested in the appearance and
acts of the patients; their gait is odd, bizarre. Certain physical signs
which we find accentuated in the third form may be present in this
form. In time these cases settle down into a condition of apathetic
dementia.

( c) Katatonic Form. —This is the form well described by Kahlbaum,
and characterised by peculiar states of stupor or excitement, culminating
as a rule in dementia and accompanied with negativism, stereotypy, and
suggestibility in the movements of expression and in the acts
(Kraepelin). This negativism is manifested by resistance to all foreign
interference, to displacement of the limbs, and movements of muscles
generally : by refusal of food, retention of urine, etc. Suggestibility is
characterised by the katatonic attitudes — “ flexibilitas cerea” of
muscles, catalepsy, echolalia, echropaxia. Negativism and suggestibility
may be observed together, and are the dominant feature of katatonic
stupor. Frequently we may observe sudden impulses and outbursts of
laughter in the course of an access of stupor. Katatonic excitement
differs from ordinary maniacal conditions by the tendency to stereotypy
in the language and acts, this “ stereotypy ” (Kraepelin) being character¬
ised by the abnormal duration of motor impulses ; hence the persistent
curious gaits, repeated similar movements of the hands, etc., which
these patients exhibit. Stereotypy is very frequent in speech (verbigera¬
tion) and in writing.

( d) Paranoid Dementia. —In this form we get a rapid development of
intellectual enfeeblement, with complete preservation of lucidity, accom¬
panied with delusional conceptions, and commonly, too, with sensorial
disorders, which are the predominant symptoms for some years.
Kraepelin includes in this variety cases with systematised delusions
( Phantastiche Verriicktheit ), which most authors look upon as a separate
clinical entity ( e.g., Magnan’s class, etc.). In paranoid dementia, we find
ideas of grandeur or of persecution, hypochondriacal delusions, little or
non-systematiscd, more or less tenacious, with slight excitement and
auditory sensorial disorders. The delusions may in their extravagance,
their mobility, their inanity, equal or even exceed those of general
paralysis. The verbigeration, stereotypy, or “ jargonapha^ ia ” of the
katatonic forms—more or less accentuated—may be observed.

Physical Signs .—In the various forms of dementia praecox may be
noted the following physical signs :—Exaggeration (even marked) of knee-
jerks ; increase in the mechanical excitability of nerves and muscles ;

Digitized by v^.ooQLe

3S»

EPITOME.

[April,

dilatation of pupils ; inconstant pupillary inequality; vaso-motor dis¬
orders (cyanosis, oedema, etc.); modifications of cardiac rhythm;
diminution of temperature; menstrual disorders; enlarged thyroid ;
exophthalmos; tremors; anaemia, etc. In a certain proportion, we find
vertigo, convulsive seizures, hysterical attacks, temporary aphasias,
tetany, etc.—more commonly in women. Increased knee-jerks, pupil¬
lary abnormalities, and altered cutaneous reflexes have been especially
frequently observed by S^rieux and Masselon in their researches.
Muscular symptoms are, of course, well exemplified in the katatonic
forms.

Termination, —The psychical enfeeblement which supervenes after a
few months, or even several years, possesses certain characteristics.
Delusions gradually disappear, but traces may remain, stereotyped in
form: hypochondriacal ideas, ideas of persecution or grandeur, ill-
defined and often very puerile, etc. This weak-mindedness is occasionally
only slight, but undoubted when a careful examination is made. In
more marked cases it presents itself in one of two forms— apathetic
dementia and restless or agitated dementia . In the latter the salient
features are the signs of automatic purposeless agitation—suppressed
muttering, declamation of the same senseless phrases, stereotyped
questioning, curious, unseemly gait, tics of various kinds, etc. In
apathetic dementia may be seen a tendency to stereotypy, but the
characteristic feature is the emotional indifference of the patient, an
extraordinary apathy, the ruin of all affective, altruistic, or ethical feelings,
with a more or less profound torpor and loss of psychical activity (loss
of attention, of judgment, etc.). Patients seek solitude, become mute
and immobile—the outer world ceases to exist for them. One does not
find in cases of dementia pnecox the “ euphoria ” or sentimentality of
general paralytics and of organic or senile dements, nor the morbid
emotionalism of the degenerate. In a few, rudiments of psychical
activity subsist which bear the stamp of automatism, stereotypy, and
puerility; the appetites are gross; patients are vulgar, dirty; many
assume stereotyped attitudes (will not sit down, carry their head con¬
stantly bent, etc.).

Psychologically , that which differentiates dementia praecox is the
weakness of mental images. Hence absence of emotional tone, of
tendency to act; the impossibility of fixing the attention; the difficulty
of associating ideas or recalling impressions. Masselon sees in dementia
pnecox a primary affection of the active faculties of the mind ; apathy,
abulia, loss of intellectual activity—these are the three fundamental
symptoms. Disorders of speech , so frequent in dementia praecox, are
of much interest; verbigeration we have noted especially under the
heading of katatonic excitement, and mutism in katatonic stupor; but
one also finds stereotypy (the same questions put to all sorts of people,
the same exclamations uttered, etc.); “ nigger” talk ; voluntary stutter¬
ing ; babbling and prattling, occasionally unintelligible ; neologisms ; and
in some cases a true “ jargonaphasia.”

Course of Disease. —One may describe three stages—the onset, the
development, and the termination. The onset is often mistaken for
neurasthenia, hysteria, hypochondriasis, etc., and is vague. The duration
of the disease may be ten, twenty, thirty, or even forty years.

Digitized by v^.ooQLe

I903-]

CLINICAL PSYCHIATRY.

359

Remissions .—These may be observed in the second stage, and
especially with katatonic excitement. They generally come on in the
first few months, but occasionally even after three years or more. In
20 per cent of the cases the remission is prolonged, and may be put down
as a cure, in spite of the persistence of a few signs. Relapses generally
supervene within five years of the onset of the remission—occasionally
later.

Prognosis .—While dementia praecox is not as fatal as general paralysis,
and does not cause death, its prognosis is grave; mental recovery is rare.

Diagnosis .—Although the physical signs of dementia praecox are not
pathognomonic in comparison with those of general paralysis, they are
often characteristic enough to enable a careful observer to suspect the
onset of a serious disease, and to give a very guarded prognosis in certain
cases which appear slight on superficial examination. The signs to be
especially noted are: psychical enfeeblement with relative integrity of
memory; disappearance of affective feelings, of emotional tone; apathy;
puerility; feeble judgment; marked disorder of personality not related to
the activity of delusions; the peculiar characters of katatonic excitement
and stupor; flexibilitas cerea or rigidity of muscles ; suggestibility or nega¬
tivism; confusion of written or spoken language (verbigeration, echolalia,
“ jargonaphasia ”); the various forms of stereotypy ; and the association
of such physical signs as pupillary abnormalities, altered superficial and
deep reflexes, etc. Simple dementia praecox must be specially differen¬
tiated from hysteria, neurasthenia, degeneracy. The delusional form
is often mistaken for the insanity of degenerates, or recurrent insanity,
or the mania or melancholia of badly developed individuals. The kata¬
tonic form must be distinguished from ordinary stupor and cataleptic
states in the one variety; from ordinary maniacal excitement, mental
confusion, general paralysis, and various toxic and infectious states, in
the other. Paranoid dementia is often confounded with Magnan’s
systematised delusional insanity in the early stages.

In the final stage dementia praecox is to be differentiated from
imbecility, presenile dementia, epilepsy, general paralysis.

Pathological Anatomy. —Macroscopically, there is a notable atrophy in
the anterior region of the hemispheres ; histologically, grave affection of
the cortical cells, especially in the deeper layers ; destruction of nuclei,
increase of large neuroglia cells have been described.

Etiology .—Adolescence is the great factor. Kraepelin found that
out of 296 cases, 60per cent, began before the age of 25 years. Heredity
is important A large proportion of the cases ( e.g. , 60 per cent) appear
to enjoy good mental health before the onset of dementia praecox.
Morel considered that alcoholism in the parents is a powerful factor.
Among the determining causes the puerperal state and imprisonment are
especially mentioned, more particularly in the katatonic form. Over¬
pressure has been mentioned by some observers (Christian, Marro).

Pathogeny .—Kraepelin attributes dementia praecox to lesions of the
cerebral cortex dependent upon auto-intoxication, probably of sexual
origin; this is practically also Regis’s view. But other auto-intoxications
than those dependent upon disorders of the organs of reproduction
may no doubt determine it. Christian classifies it with the group of
psychoses due to exhaustion. There is an interesting contrast between

Digitized by v^.ooQLe

36 o

EPITOME.

[April,

dementia praecox and general paralysis, that whereas the toxin in the
latter affects not only the brain, but also the cerebellum, the pons, the
medulla, etc., and is fatal to life; in the former the poison seems to
exercise some selective action on the most vulnerable elements of the
nervous system—the neurons of the centres of association;—/. e ., the
poison is apparently selective and specific in its action on certain
neurons.

Medico-legal Aspects. —As is the case with general paralytics, the
subjects of dementia praecox, especially those suffering from a typical
and simple dementia, are often prosecuted for various offences. One
must bear this affection in mind, especially in the case of young
soldiers ; and one must not forget that, as various extravagances are
characteristic of the condition, it is important to exclude it before
dubbing suspicious cases “ malingerers ” or simulators.

Treatment. —Organotherapy has given no good results. Re-educa¬
tion of suitable cases seems to be indicated. H. J. Macevoy.

On the Question of Dementia Prcecox. (Joum. of Ment. Path ., vol. * 7 ,
No. 4.) Serb ski , Vladimir.

This is an abstract by the author of a paper published in the Journal
S. S. Korsakora , Nos. 1, 2, 1902, and read at the second Congress of
Russian Psychiatrists, January, 1902. It is especially concerned in
refuting Kraepelin’s conception of dementia praecox. To begin with,
as one and the same disease may lead to various and different termina¬
tions, Serbski considers it impracticable to base any classification on
the factor termination—that is (here), on dementia,—for, according to
Kraepelin, this issue is not invariable—some cases recover. The
general characteristics of the disease, as they are given, impress one as
being markedly vague; such qualifying adjectives (which occur often
in the description)as “generally,” “often,” “not infrequently,” “some¬
times,” lead him to infer that the signs to which they are applied are
inconstant, not essential. Even signs relating to disturbance of atten¬
tion and impairment of judgment are said not to be invariable, but
conditional, in dementia praecox. While there is a close connection
between katatonia and hebephrenia, and some cases of katatonia should
be classed with dementia praecox, this does not apply to all cases. Kata¬
tonia as a syndroma may be met with in the course of various mental
disorders. Such objective signs, again, as automatism, negativism,
stereotypy, are not pathognomonic of dementia praecox or any given
disease; they may be observed in many diseases. Serbski would
restrict the name dementia praecox to those forms of mental disorder
the fundamental traits of which are : (1) the onset of the disease takes
place not later than the adolescent age; and (2) the development into
a condition of mental enfeeblement of varying degree takes place
rapidly or definitely.

Certain varieties may be distinguished: (a) a slow and progressive
psychical disintegration occurs without any acute stage; (b) acute
symptoms occur followed by dementia; sub-varieties may be differen¬
tiated—Hecker’s hebephrenia, the katatonic form, the paranoidal form,—
but these often merge one into the other; (c) dementia praecox may be

Digitized by

Google

I9°3-] CLINICAL PSYCHIATRY. 361

a secondary manifestation, /. e ., secondary to some acute, defined,
psychical disease. He does not believe that we can rely on the
physical signs described in dementia praecox. The diagnosis of
dementia praecox is sometimes very difficult, even when the definition
of the disease is restricted as above, and can be made only after a long
period of observation; at present, for example, we cannot differentiate
between secondary dementia of adolescence and dementia praecox.
The theory of auto-intoxication as a cause of the disease is quite
alluring, but it cannot be substantiated. The theory of infection with
the products of the sexual, organs is altogether unfounded. Kraepelin’s
views on this aspect of the question are refutable. H. J. Macevoy.

Dementia Praecox and Katatonia \Dhnence Precoce ei Catatonie\

(Nouvelle Iconographie de la Salpitriere, 1902, No. 4.) Seglas,J.

Reviewing briefly the work of Kahlbaum, of Hecker, of Finch,
Kraepelin, etc., on the subject of katatonia, S^glas insists on the
importance of differentiating the affection katatonia proper from the
katatonic state, the neglect of which accounts for a good deal of
difference of opinion on the question. The conclusions of Finzi and
Vedrani, in the present state of our knowledge, appeal to him most:
(1) The syndroma katatonia is observed more or less pronounced in
many mental diseases. (2) It never constitutes alone the clinical
picture; it is not the whole of the disease, but only occupies certain
phases of the morbid process. (3) It is most complete and most lasting
in cases of juvenile dementia which have a good deal of analogy with
hebephrenia. But it is most important to be clear and precise as
regards the essential features of katatonia. According to some authors
it is synonymous with tonic spasm of certain groups of muscles; the
general opinion among French alienists is that katatonia denotes the
cataleptiform states in the insane. These views are not comprehensive
enough.

The principal phenomena of katatonia are stereotypy of attitude,
speech, acts; tendency to cataleptic immobility—culminating in tension
of muscles and almost tetanic rigidity—more or less permanent and
pronounced. Resistance of the patient, refusal of food, mutism,
Kahlbaum’s negativism, are also included under this heading of tension,
and rigidity or spasm. Certain other phenomena, which at first sight
seem to be the opposite of negativism, belong to katatonia ; such are
catalepsy, echolalia, echopraxia. This second group of symptoms is
not so important as negativism, but their affinity is well shown by their
co-existence or succession in the same individual. Another important
symptom—for, according to some authors (Soffiner), it constitutes the
fundamental tendency, whence proceed all the other katatonic
phenomena, from catalepsy to negativism—is stereotypy.

Katatonia may be present, as is well recognised in such varying
mental affections as melancholia, circular insanity, amentia, toxaemic
states, senile dementia, general paralysis, hysteria, etc., but it is generally
partial and only transitory. It is in certain forms of dementia praecox
that we observe it in its full development and with a marked character
of persistence. The full notes of three interesting and typical cases of

Digitized by v^.ooQLe

EPITOME.

362

[April,

the katatonic form of dementia praecox, with illustrative plates, are given,
and bring out these points very well.

S^glas shares Kraepelin’s view that the symptoms of katatonia are
psychical in origin, as opposed to Kahlbaum, who looked upon
them as simple muscular spasms. An important characteristic is that
they are automatic, independent of the consciousness of the patient,
unrelated to delusional ideas or hallucinations ; but, adds S£glas, such
phenomena of automatism can only be corollaries. The primary con¬
dition, which constitutes the substratum, is the permanent or temporary
(and partial or generalised) insufficiency of cohesion between the various
elements which constitute the aggregate personality; it is the defect of
unity, of synthesis, of voluntary activity; it is abulia . In conclusion
he shows that negativism and stereotypy, etc., are quite compatible with
the existence of abulia, and refers briefly to the psychopathology of
dementia praecox—a subject carefully treated by Masselon ( Thbse de
Paris, 1902). H. J. Macevoy.

On the Fundamental Nature of the Delusional Ideas of the Insane .

( Joum. of Ment. Path., vol. ii. No . 3, April, 1902.) Ferrari .

The author holds that a sharp distinction is to be drawn between
“ delirious ideas of the insane proper and those caused by intoxications
or infections.” In the latter the impure blood circulating in the brain
“gives rise to a number of mental images and ideas which, while
spurring on one another, are unsystematised,” while “ in the insane the
ideas always have an intimate bearing on the personality itself.” A
short summary of the psychic symptoms in a number of the commoner
drug-intoxications is given in support of this view. The argument
appears to imply, though this is not made quite clear in the translation,
a rather arbitrary denial of the influence of the organic personality in
the toxic deliria. W. C. Sullivan.

5* Sociology.

Medico-legal Report on Vidal, the Murderer [Vidal, le Tueur de
Femmes: Rapport\ (Arch, dAnthropol. crim., Nov. 15 th, 1902.)
Lacassagne, Royer, Rebatel.

Nearly the whole of this number of the Archives is occupied with
an elaborate report on Vidal, the result of observations carried on in
the prison at Lyons during six months. So careful and scientific a
report must lead every English reader to view with regret the casual and
summary methods, carried on with mediaeval secrecy, which alone are
permitted in our own country.

Vidal was born at Vais in 1867, the only survivor of four children.
His father died young, apparently of tuberculosis, of which also many
of his family died. His mother, though herself healthy, was the
daughter of an epileptic, whose sisters were also epileptic. An elder
brother of Vidal, who died before him, was of unbalanced temperament,

Digitized by v^.ooQLe

r 9°3-]

SOCIOLOGY.

363

a fine talker, but without doubt a rascal. Vidal was a posthumous
child, and his mother had been worn out during the pregnancy by
sick-nursing and sleepless nights. He had convulsions during dentition,
and nocturnal incontinence of urine until puberty. At fifteen he had
a severe attack of typhoid, from which convalescence was very slow.
He had always been of only very moderate intelligence, was sulky and
of a capricious temper, but the fever left him partially deaf and deprived
him of memory; he became “ almost an idiot.” The significance of
this illness was undoubtedly grave. At the age of twenty, without any
serious motive, he suddenly ran away from home to Paris, where,
having no money, he went to a restaurant, ordered an expensive dinner,
and was in consequence sent to prison. On liberation, he returned
home, but this was only the first of a succession of similar flights. It
is clear, Lacassagne remarks, that on the basis of a defective hereditary
constitution, the attack of typhoid, occurring at puberty, had profoundly
disturbed the nutrition of the nervous system and set up a condition
of psychic degenerescence. At the age of twenty-one, we find him
engaged in his period of military service,* which he seems to have
carried out in a satisfactory manner. Having been treated, it would
appear, with some severity at home, he showed no inclination to rebel
against military discipline. On leaving his regiment, he had a severe
bicycle accident, resulting in an injury to the head which left him
unconscious for some hours ; this traumatic incident seems to have been
of some significance. At the age of twenty-four, he began, on the one
hand, to make various attempts at suicide by poison, and on the other, to
commit thefts, mostly of a trifling character. At this time, however, he
received an appointment in the Sudan as overseer of negroes; the
blacks under his charge complained of his brutality, and said he was
mad, while his white comrades spoke of him as taciturn, sulky, unsoci¬
able, and ferociously selfish ; “ weak-minded, timid, uncommunicative,”
was the colonial agent’s report. Vidal himself complained of various
symptoms: frequent bleeding of nose, habitual constipation, trembling
of hands and legs, violent nocturnal headaches, noises in the ears.
From childhood, he had always shown great nervous sensibility, and
was always very easily moved to tears. He presented, it is said,
the emotional type of the weak-minded degenerate. His love of
animals was extreme; as a boy he could never hurt a fly, and he would
not join in catching rats, which he regarded as a barbarous occupation.
Moreover this man, who himself committed numerous murders, had
an extreme horror of dead bodies, and could never go near a room
which contained a corpse. With regard to sexual impulsions, no
true perversions existed; as a boy he had practised masturbation
to excess; then he became sexually frigid. In character he was very
weak, always changing his opinion, and almost without will-power. It
may be added that, during the two years he spent in the Sudan, he
suffered from malaria, and indulged in alcoholic excesses to the verge
of dipsomania.

In 1901, he was at Beaulieu, having failed in every attempt to earn his
living, and being no longer able to extract money from his mother. He
resolved to obtain money at all costs, took train to Nice, accosted a
young prostitute who was unknown to him, accompanied her to her

XLIX. 2 5

Digitized by v^.ooQLe

364

EPITOME.

[April,

home, with many precautions to avoid being seen, and at the moment
when the girl was lighting the lamp drew from his pocket a knife he had
brought with him for the purpose, and stabbed her in the back. She
screamed and he fled, without committing the robbery he had planned,
overcome by the dread of discovery. The crime was committed with
extreme deliberation and caution; there was no hesitation, no mental
struggle, no obsession of anxiety, no sudden impulsive explosion, and
his memory of the event remained perfectly clear. He returned to
Beaulieu, resumed his usual habits, and continued his attempts to earn
a living with the same nonchalance as usual and the same lack of
success. Ten days later, he committed a second cridie, this time at
Marseilles, accosting a girl who wore much jewellery, and observing
at every point exactly the same precautions as on the previous occasion;
he struck the girl at the same moment as before, but she turned, kicked
him vigorously, and he again fled. The third crime occurred three
days later, at Toulon. This time, instructed by his failures, he adopted
a somewhat different method; he spent the night with a prostitute and
made an appointment with her for the following day, led her to a
deserted spot, struck her a fatal blow in the back, removed her jewellery,
took her keys, and (it is believed) returned to her rooms and searched
her drawers. A few days later, at the Nice railway station, he watched
a shop girl; getting into the compartment in which she sat alone as the
train moved out, he killed her with a long knife, threw her body out of
the carriage and himself after, dragging the corpse some distance, and
returned to Nice, where he slept peacefully. This time, however, he
committed an act of imprudence ; he hung up in his room his mackin¬
tosh, still showing signs of blood, intending to wash it later. This led to
his arrest.

Vidal was rather above average height, normally built, without mal¬
formation, lean, not muscular, of distinctly unattractive appearance.
His head was narrow and decidedly dolichocephalic; the face showed
much lack of symmetry. The sense organs were normal, but there was
convergent strabismus. The skin sensibility was normal, but there
were distinct dermographic manifestations, the stroke of a pencil leaving
an accentuated red line. On the whole the physical signs were unim¬
portant separately, but significant when taken together.

Mentally, he was not highly intelligent, but laziness seemed the chief
feature in his character. There were no hallucinations, no delusions,
not the least indication of epilepsy,—nothing but mental apathy, the
absence of initiative and will. The experts conclude that Vidal was
sane, but that there were certain signs of degenerescence, that his crimes
were deliberate, and that he must be declared “ responsible with a
slight attenuation.”

We have to admit, there can be no doubt, that the man whose
history has here been very briefly summarised must be regarded as
absolutely normal, “sane,” and “responsible,” in accordance with
standards which even yet largely rule. One could not desire better
evidence than is furnished by this case of the inadequate nature of the
conceptions of “ sanity ” and “ responsibility ” which are still widely
accepted by those who are unfamiliar with the exact study of criminality,

Havelock Ellis.

Digitized by

Google

1903]

SOCIOLOGY.

365

The Hereditary Nature of the Occurrence of Twins [Die Geminitdt in
ihren erblichen Beziehutigen\. ( Virchow's Arch, f patholog. Anat.
u. Physiol ., B. clxx , 1902.) Naegeli , Aekerblom.

In a paper filling 210 pages the author, a Swiss physician, now in
Geneva, conducts a most laborious review of the inquiries already made
by Speyr, Goehlert, and Hellin as to whether the production of twins
follows certain families. This can in human beings only be done by
studying the records of royal and princely families, which can be traced
back for many generations. In following out this method of inquiry it
appears that these learned Germans, through imperfect study or want of
due attention, have made a number of mistakes which their Swiss critic
exposes with unrelenting diligence. He shows that no trustworthy con¬
clusion can be built upon the data which they present. Unhappily,
Naegeli’s own results are but negative. We are still, he tells us,
arranging and classifying our facts. Farther, that we still know nothing
about the causes of twins, and will scarcely learn anything in future
save by collective investigations through generations.

One difficulty often faces the inquiry about the introduction of a
special proclivity into such families—the frequency of intermarriages.
This is well shown in considering the family of the Prince of Hesse—
Philippsruhe and the Princess Margaret of Prussia. Dr. Naegeli shows
in detail that going back six generations the princess has only twelve
ancestors out of sixty-four different from those of her husband. In
1896 Margaret, who is the sister of the German Emperor, gave birth to
male twins who are still living. Wolfgang von Barby, wffio died in
1565, appears ten times in the ascending pedigree of the Emperor
William, and John George von Solms-Laubach (a twin) perhaps twenty
times. Facts collected by medical men show that the tendency to
produce twins descends both through the males and through the
females of the family.

Dr. Naegeli engages in a detailed work to show the fallaciousness of
the genealogies which are used to prove the heredity of insanity.
But, though he may assert that there is no greater number of twins
or any larger mortality in the princely families which he has investi¬
gated, he can scarcely assert that insanity and idiocy are not rife
amongst them. The learned critic censures Dejerine, who, in his
Heredite dans les Maladies du Systbne nerveux , presented a table in which
he has grouped together all the stigmata and weak traits of the Emperor
Charles V, which Naegeli observes is a mere caricature.

Dejerine might, however, reply that he did not design to give a
complete portrait of the Emperor, but to call attention to certain
neurotic traits, and that his great qualities were known to all readers
of history. Naegeli confirms the occurrence of the prominent chin in
the house of Austria, which he traces down to Charles VI, the last of
the male Hapsburgs.

In conclusion we venture to entertain the hope that with such
great diligence and so much learning Dr. Naegeli will yet be able to
work out some positive rather than negative results.

William W. Ireland.

Digitized by v^.ooQLe

366

EPITOME.

[April,

Sex and Degeneration [Gesehlecht und Entartung ]. (. Halle, publ. by

Carl Mar ho Id, 1903.) Mobius .

This is the second of the series of essays which Dr. Mobius is pub¬
lishing under the general title of Beitrage zur Lehre von den Geschlechts -
Unterschieden . The work, being mainly one of vulgarisation, claims
notice not so much for any new observations which it embodies as for
the fresh and original manner in which the author states his views on
various questions of the physiology and pathology of sex. As readers
of Dr. Mobius are aware, his qualities of clear and forcible exposition
do not go without their defects; his work is essentially “ temperament-
voll,” and his most positive conclusions are only to be accepted with full
allowance for the personal equation. This is particularly needful when,
as in the present case, he has to deal with matters relating to the
intellectual and social position of women, on which questions his
orthodoxy verges on the fanatical.

The leading idea of the essay is that all disorders of the sexual
personality (Geschlechtswesen) are stigmata of degeneracy, sexual inver¬
sion, taking the term in the widest sense, being one of the most impor¬
tant of such stigmata. By disorders of the sexual personality the author
understands partly deviations from the normal in the primary or
secondary sexual characters, and partly deviations of the sexual impulse,
such deviations being, of course, in both cases congenital and not
acquired.

In the normal, according to the author’s ideal, the essential point is
the opposition of the sexual characters ; the man is soundest when he
is most male, the woman when she is most female. And every departure
from this standard of extremest difference is to be taken as a condition
of degeneracy, a link in the chain which reaches down to the her¬
maphrodite monster. Obviously the number of such deviations will be
pretty considerable; from cigarette smoking to inability or unwillingness
to suckle, all sorts of tendencies which Dr. Mdbius does not like are
thus classed as stigmata of degeneracy. However, doubtless from the
nature of the question, which is after all mainly one of taste, the author
fails to support his thesis by any definite evidence; he shows no reason
why a tendency to decreased sexual differentiation should be regarded
as the way of decay rather than the way of progress. And so, when all
is said, “ stigma of degeneracy ” with Dr. Mobius, as with a good many
others who employ that overworked phrase, is very often not much more
than a mere term of abuse.

Having given us his standard of the ideal human being, the author
shortly describes the various forms of somatic sexual abnormality,
pseudo-hermaphroditism, hypospadias, cryptorchidism, gynaecomastia,
feminism, infantilism, etc. He then touches briefly on the anomalies
of the sexual instinct.

Regarding treatment, the view maintained is practically that the
sexual degenerate, or rather the degenerate of any sort, is to be accepted
as a hopeless incorrigible, and that the proper direction of humanitarian
effort should be to prevent his production. Hereditary taint and
parental alcoholism, being the two great sources of degeneracy, are,
accordingly, the evils to be attacked; and under present circumstances

Digitized by CjOOQle

1903-]

SOCIOLOGY.

367

there is most prospect of good results from a crusade against alcoholism.
Fortunately one can agree in this practical conclusion without accepting
what would appear to be the author's ideal of a humanity physically and
mentally stereotyped, exchanging platitudes in Esperanto, and rigidly
suppressing every departure from its commonplace standard as a
“ stigma of degeneracy.” W. C. Sullivan.

Is Alcohol a Food? [L’Alcool est-il un Aliment ?] (Gaz. des Hop., Jan.

13 th, 1903.) Triboulet .

M. Duclaux, in a note recently published in the Annales of the
Institut Pasteur (November 25th, 1902), discussed a series of experi¬
ments made in America by Attwater and Benedict on the nutritive
value of alcohol, and expressed his concurrence in the conclusion
arrived at by these authors that the saccharine or farinaceous elements
in a normal diet could be replaced by an isodynamic weight of alcohol
without perceptible effect. In the French scientific world, where extreme
anti-alcoholic view's have been dominant, M. Duclaux's paper appears to
have caused something of a sensation, and his conclusions have been
attacked energetically in the medical and even in the lay Press. In the
present article M. Triboulet criticises them in vigorous terms, pointing
out that they are in contradiction to the results of the large majority
of other observers, notably w'ith the recent researches of Chauveau
(C. R. dc VAcad. des Sciences , January 21st, 1901), as regards the effect
of an alcoholic diet on the quality and quantity of muscular work; and
further that even those who, like Gley (C. R. du Vile Congr. Intemat .
Antialcoolique , 1899, tome ii), admit that alcohol is a food, are agreed
that the organism only tolerates it in very feeble doses. Moreover the
American experiments did not last over more than three or four days,
which would be far too short a time to allow conclusions to be drawn
as to the ultimate effect of the diet. Finally, Triboulet urges that in
such a question it is impossible to separate the abstractly scientific
aspect from the practical aspect with which the physician has to do;
and that the last word should rest not with the chemist who finds
alcohol to be a food, but with the clinical observer who can show that
it is also a poison. Even, however, from the purely medical side there
appears to be some divergence of opinion, for Boix, in a paper published
in the Arch. gen. de mldicine (January 6th, 1903), endorses Duclaux’s
views from clinical experience. W. C. Sullivan.

Insanity and Marriage . (Westminster Review , August, 1902.)

Wilcox, A, W.

In this extremely interesting article Dr. Wilcox has brought together
a number of the most striking facts regarding the influence of hereditary
taint in the causation of mental disease, pointing out the measures of
social hygiene which ought to be the practical corollaries of such facts.
Having shown by clinical and statistical evidence that heredity and
drink are the two overwhelmingly important causes of insanity, the
author advocates as preventive measures “ the prohibition of the
marriage of persons with a distinct family history of insanity or
alcoholism, the permanent detention of persons after a third admission

Digitized by v^.ooQLe

368

EPITOME.

[April,

to an asylum, and the granting of divorce from the unfortunate victims
of incurable insanity or continued drunkenness.” The last-named
suggestion in particular should be well within the sphere of practical
politics, and Dr. Wilcox is able to point to a precedent in the United
States, in some of which, e.g., Florida, insanity—“continuous, of at least
four years* duration, and pronounced incurable by experts”—constitutes
a ground for divorce.

Articles of this kind, where accurate information is given without
technical pedantry, should be among the surest methods of educating
the public mind as to the prevention of insanity, and it is to be regretted
that they are not more frequent in the lay Press. W. C. Sullivan.

Political Assassins: arc they all Insane ? {Journ. of Ment. Path.,
vol. ii, Nos. 2 and 3, March and April, 1902.) Spitzka, E. C.

The author, who has recently published {Philadelphia Med. Journal,
February, 1902) a protest against what he terms the “degeneracy
chimera,” renews his attack in the present paper, dealing with the
special point of the supposed abnormality of political assassins.

He takes as his text Rdgis’s definition of regicides in his well-known
monograph, “ Degenerates of a mystic temperament, who, misguided by
a political or religious delirium, complicated sometimes by hallucina¬
tions, think themselves called on to act the double role of judiciary and
martyr, who, under the influence of an obsession that is irresistible,
kill some great personage, in the name of God, the country, liberty, or
anarchy.” The terms of this definition are then criticised in detail. It
is pointed out that regicide is an act which arises under extremely
different social and political conditions, which has very diverse motives,
and is effected in very varied ways. It is quite inadmissible to treat it
as a phenomenon of constant character, and to regard political assassins
as a uniform group whose mental state can be defined by any single
formula. Moreover Spitzka holds that the grounds on which insanity
has been attributed to many regicides in history are absurdly inadequate,
especially when due account is taken of the moral and intellectual
atmosphere of their times, and that in the case of more recent assassins
the proof of “ degeneracy,” “ hereditary taint,” and so forth has been
equally flimsy. At the same time it is admitted that the present
tendency is to a predominance of insane over sane regicides.

From the facts ascertainable regarding 277 political assassins, the
author has drawn up a number of interesting tables showing the pro¬
portion of insane and suicidal assassins, the weapons selected by the
sane and the insane, the proportion of successes and failures in the two
groups, the fate of the murderers, etc. The ratio of aggregate suicides
and insane in the series comes to 19*13 per cent., the insane alone
amounting to 13*71 per cent, and suicides alone to 6*13 per cent.
Insane regicides have been relatively much less successful than the sane,
particularly with weapons which demand courage and determination;
thus they have almost always failed with the dagger, which in the hands
of the sane assassin has proved a good deal surer than firearms. The
value of the paper is not increased by the political rhetoric with which
it is freely diluted. W. C. Sullivan.

Digitized by v^.ooQLe

1903 .]

ASYLUM REPORTS.

369

6. Asylum Reports, 1901.

Some English County and Borough Asylums.

Derby County .—Dr. Legge notes a curious point in lunacy regulation:

Seclusion was employed in the case of one female patient for two hours.
According to a recent definition by the Lunacy Commissioners, seclusion consists
in the solitary confinement of a patient before 7 p.m. Owing to a failure of gas in
November it became necessary to put a large number of the more dangerous
patients to bed at six o’clock. Sixty of them were in consequence technically in
" seclusion ” for an hour on that occasion.

He took in a patient aet. 93.

Gloucestershire. —The admission of patients from this asylum’s
gathering ground seems to show a tendency to decrease rather than the
reverse, though the accumulated residue increases in consequence of
depreciating recovery and death rates.

The Brentry Inebriate Home being situated in the county, a practice
grew up of sending those of its inmates who became insane to Barnwood.
The inequity of this procedure being represented to the Home Secretary,
he took steps immediately to put the matter right. The Local Govern¬
ment auditor took exception to the payment by the Committee of the
funeral expenses of attendants dying in the service. In consequence
the Committee put themselves within the provision of the Lunacy Law,
1890, Sec. 258, by which a committee is allowed to bury an attendant
in ground covered by a contract.

Lancashire (Prestwich).—The subjoined appreciations of Mr. Ley’s
services, gratifying as they must be to him, will also form pleasant
reading to all of our Association, who know how true they are.

By the Committee: 4

Your Committee cannot speak in too high terms of Dr. Ley, nor can they
adequately express their sense of the loss they are about to sustain by his resigna¬
tion. They, however, know that Dr. Ley’s renown is not confined to themselves,
but is well known to and appreciated by the whole of your Board, and by a world¬
wide circle of those interested in matters relating to the care and treatment of the
insane. They must content themselves by recording that he is second to none, and
they confidently trust that, in the matter of a superannuation allowance, he will
receive at your hands the most generous treatment, as an officer of exceptional
ability who has served the country most emphatically well.

By the Commissioners :

Mr. Ley’s incumbency of the office of Superintendent had extended over many
years, and his management of the asylum had always been most able and success¬
ful; and we desire on this occasion to give expression to our entire appreciation
of the Value of his services, in which appreciation we know that all of our colleagues,
past and present, who have known Mr. Ley have fully shared. We are glad to
learn that the Asylums Board have recognised Mr. Ley’s services by a liberal pen¬
sion, which we trust he may long enjoy.

This huge lunacy machine, with the largest population in the country,
continues to exhibit the proofs of its drawing its inmates from an area
where turmoil, restless activity, disease, and vice flourish to an extent
unsurpassed elsewhere. Alcohol, in one relation or another, was

Digitized by v^.ooQLe

37°

EPITOME.

[April,

assigned as a contributing cause of insanity in one third of the admis¬
sions, and 50 out of the 112 of this class admitted were females!
Thirty-six male and nine female cases of general paralysis came in,
while of the total admissions, 104 suffered from acute mania and 132
from acute melancholia, 44 from recurrent mania, 21 from mania a potu ,
24 from recurrent melancholia, and 14 from puerperal melancholia.
The anxiety naturally attached to so many active cases was diluted
apparently by the admission of five chronic maniacs and two secondary
dements.

A recovery rate of 50*97 is a not unexpected compensation for this
anxiety, but a death-rate so low as 6*57 on average residence, under the
circumstances, is proof of high medical skill and nursing.

Middlesbrough Borough. —Dr. Pope gives in his report details about
the patients’ employment, tendencies, etc., such as are usually asked for
by Commissioners on their visit. This practice, while it keeps the
staff up to the point of showing satisfactory returns under the various
headings, also serves to demonstrate the responsibilities connected with
the carrying on of an asylum.

He notes two curious admissions :

One woman was admitted for the eleventh time into a fresh asylum. She is an
alcoholic. Her daughter being a circus rider, she apparently travels in her train,
and when she breaks down is removed to the nearest asylum. Her knowledge of
asylums and asylum physicians is extensive and peculiar. A man was admitted
with a history of dog-bite, and all the distressing symptoms which we associate
with hydrophobia. For a considerable number of days he was a source of appre¬
hension, but proved to be a case of mania in which a curious condition of hyste¬
rical terror was set up. Appropriate treatment has brought about his convalescence.

Suffolk County. —Dr. Whitwell continues to show the movements of
the year, admissions, removals, and residue on a single chart in a form
that seems to us to be the best for ready conveyance of the various
elements. We should think that the chart would be perfect if only it
could give for comparison the estimated yearly population of the area
served by the asylum.

The benefits of boarding out suitable patients (which he considers
could be selected from the present asylum population to the extent of
20 per cent.) are much pressed on the attention of the Guardians for
economic purposes.

An autopsy was performed in each of the sixty-nine deaths, with the
exception of one which occurred outside the asylum.

Hertfordshire .—We are glad to see that this county has arranged with
Middlesex to exchange ten of its improvable idiots for ten patients of
any class from the latter county. We again wish to draw attention
to the benefits of such a system, and to repeat that Middlesex has
done good service in starting an educational establishment for these
cases. It seems difficult to understand why the rating authorities
should propose to rate farm buildings and an isolation hospital at a
proportion higher than that of the asylum itself. But they attempted
this and were defeated on appeal. It is worth noting for use by other
new asylums that the final assessment represented a sum equal to
3 per cent, on capital cost. The “ letting value ” of an asylum is

Digitized by v^.ooQLe

ASYLUM REPORTS.

1903]

371

obviously a matter which cannot be fixed by ordinary local experience,
so the above adjustment may be kept in mind in other localities.

The Visiting Commissioners congratulate Dr. Boycott on the success
attending his arduous work in organising the asylum.

West Riding of Yorkshire (Wakefield). —Dr. Bevan Lewis’s report
always contains information worthy of note. The most interesting
points are the installation of a thoroughly equipped plant for treatment
by electricity, and the work of the Stanbury Hall branch for improving
the condition of idiots and imbeciles.

With regard to the former Dr. Lewis speaks highly of the use of the
sinusoidal current. Twenty-six females of various types (acute mania
not being represented) were submitted to daily treatment. Of these,
seven, including five chronic melancholics, were in no way benefited.
The rest were more or less improved, and 50 per cent . recovered under
treatment.

So with the electrostatic bath; by the agency of the Wimshurst static
machine, of the 6 females and 33 males, together 39 cases, 17 recovered,
14 much improved, and 8 were unimproved.

A Finsen lamp and other improved electrical apparatus were in process
of installation at time of the report. Dr. Lewis hopes to give next year
an account of substantial results from their use.

With regard to the school, Dr. Lewis reports that not only has the
discipline much improved the pupils directly and others indirectly, but
that there is ample evidence of the increase in individual intelligence
which can be brought about in apparently hopeless cases. He gives
details of some of these.

A marked fall in the death-rate from tuberculosis and pulmonary
phthisis is reported : from 27*69 per cent, of resident population in
1897, to 10 40 in 1900, and 12*58 in 1901. It is mentioned that the
death-rate from the same disease is found in Wakefield Prison and in
the county generally to be decreasing.

London County Asylum .—We can but renew our former appreciation
of the vast amount of work done in and about the care of the insane
belonging to the vast population of this area. Whether we turn to the
central organisation of the system or to the periphery of asylums, we
find evidence of the same determination to carry on the work in a
thorough and liberal manner. The system grows, and each new asylum
brings some innovation, the results of which will no doubt be added to
the general stock of information which is to be found in the voluminous
report which we now propose to review. This report is a careful,
methodical record which does every justice to those responsible for its
compilation, whether in bulk or in detail. The Committee itself shows
a bright example of whole-heartedness. When we read of 178 attend¬
ances on the part of its Chairman out of a possible total of 208, and
of 175 to 205, 174 to 184, 96 to 117, 58 to 60, and so on on the part
of other members, some at least of whom have other business demands
on their time, we can have no fear of the present high standard of aims
and performances being let down in the least. The central staff is
responsible for some highly interesting and graphic diagrams, showing

Digitized by v^.ooQLe

372

EPITOME.

[April,

year by year, since the County Council assumed the direction of asylum
affairs, the relations of the insane, both residential and incoming,
to total general population, to general pauperism, and to accommoda¬
tion provided. In this connection we get included not only the County
Council’s own patients, but those belonging to the Metropolitan Asylums
Board. Thus we get some comparison between the two classes of
patients themselves, and also between the two combined and the
general population of the area. This latter most important effect is not
obtained in other County Reports, though for each year the calculations
can be found in the Commissioners’ Reports.

The trend of total chargeability, which had been reduced by a few in
the previous year, has resumed its march upwards, the difference for the
year being 786 in excess. This is partly explainable by increase of area.
The increase is almost entirely in regard to asylum patients, who
number 776 more than in 1900. From the figures of this and previous
years the Committee consider their anticipation of a yearly increase of
500 to be quite justified, in spite of the temporary check in 1900. The
gradual “ set ” of insane population from workhouse, etc., to asylum,
has produced a redistribution in twelve years of 10*71 of the total
insane. In other words, a very considerable number of the insane
have been deliberately sent to asylums in preference to Caterham,
Leavesden, and Darenth, where “ rent ” and maintenance are consider¬
ably cheaper. As far as the extra financial burden thus cast on the
ratepayers of London, that is their own concern ; but the important
lesson here taught should not be lost by those who are eager to reduce
the cost of lunacy throughout the country by differentiating habitation
and treatment in respect of acute and active insanity on the one hand,
and of mental wreckage on the other. If there is any point to be gained
by the legislation called for, why should London, with the best-equipped
institutions of each class, and with the best means of ensuring proper
selection of patients for them, thus deliberately turn its face towards
the more expensive form of treatment ?

However this may be, the County Council is advised by the Com¬
mittee to contemplate the provision of a ninth asylum—in addition, we
suppose, to the proposed reception-houses which have not as yet been
sanctioned by legislation.

They recommend that the new asylum shall be of a modified form of
villa type, with central administration buildings, etc. This form seems
to be generally adopted now, and we think with justice.

The Committee evidently place great store on teaching of the staff,
and set out fully the work done in each asylum towards gaining the
certificates of our own or the St. John’s Association. We regret to note
that at Banstead and Colney Hatch no classes were held during the
year under report.

Commutation of emoluments in the case of present officers who have
separate residences at asylums has been established, and will be the
rule in future.

The weekly maintenance charge to Guardians has risen from 9*4 in
1891 to 11*8 in 1902, being in each case a trifle over actual cost.

The Council continues to bestow superannuations consistently and
liberally.

Digitized by ^.ooQle

ASYLUM REPORTS.

373

1903 .]

Still dealing with central information, we turn next to the patho¬
logist’s report, wherein Dr. Mott enumerates the various items of highly
important work carried out in the laboratory. Dr. Mott further gives
statistics showing that at Claybury the cases of colitis are considerably
lessened. A systematic record of dysentery and diarrhoea at the various
asylums has shown that when either was prevalent a great many cases
would come from one ward. He thinks that too much care cannot be
taken to impress upon the attendants the infective nature of the disease
in order to arrest its spread, and thereby prevent its occurring in an
epidemic form.

Dr. Mott found, post mortem , signs of syphilis in 50 per cent . of the
deaths from general paralysis at Claybury.

Taking the individual asylums, we note the following :

Banstead. —Several changes in the medical and general staff are
recorded, and the Commissioners on their visit made a handsome
reference to the retirement of Dr. Claye Shaw. His successor, Dr.
Johnston Jones, notes the admission of a large number of “ drink ”
cases, who came in almost convalescent, and would apparently have done
as well if they had been left in the Union Infirmary. The death-rate
was 7*41 per cent. t being the lowest on record since the opening year.
Colitis seems to have been absent altogether.

Cane Hill —Only eight cases of colitis are mentioned by the
Commissioners in their report as occurring in fourteen months, of which
two were fatal. Mention is made of the serious attack on Dr. Moody by
a patient. Sad as such occurrences are, they serve to point out the
risks attaching to the management of asylums. We congratulate Dr.
Moody on his having recovered. Mr. Clifford Smith, the Asylums
Engineer, notes that the installing of a water-softening apparatus has
resulted in a saving of one tenth in the consumption of soap and soda
in the laundry. He further reports a reduction in the gas bill from
^1808 in 1895 to ^1040 in 1901. This he attributes in great
measure to the judicious use of incandescent burners.

Claybury .—The Committee, in adverting to the resignation of Dr.
Emily Dove, record their opinion that in an asylum for the insane
there are reasons why it is preferable to return to the old practice of
having only male medical officers. Asylum dysentery laid a heavy
hand on this asylum, causing twenty-one deaths in 121 persons attacked.
Dr. Robert Jones notes the reconstruction of the whole system of
drainage, the reduction in the number of beds, and the more stringent
isolation of all cases of diarrhoea.

Colney Hatch .—Colitis here also was a source of much trouble,
causing twenty-five deaths in sixty patients attacked by the disease.
General paralysis caused 34 per cent, of the total male deaths, while of
the deaths among Jewish male patients only it caused 53 per cent.
The terrible catastrophe which has so recently fallen on this institution
is dealt with in another part of the Journal, but it is right to record
here that both the Committee and the Engineer refer with satisfaction

Digitized by ^.ooQle

EPITOME.

374

[April,

to the installation of a new main and powerful pumps for protection
against fire.

Hanwell. —Dr. Alexander states that, as the result of careful inquiry
into causation in the admitted cases of general paralysis (fifty-seven male
and seven female), a causal relationship between that disease and
syphilis was established in about 80 per cent. He comments on the
continuing increase of cases of melancholia in relation to mania, no less
than 44 per cent, of the men and 57 per cent, of the women falling
under the former denomination. The statistics of causation by alcohol
which he gives are startling, the admissions having risen in almost equal
stages from 15 per cent, of males and 8 per cent. of females in 1898 to
32 per cent, and 16 per cent, respectively in 1901, and he thinks that
even these figures are far from representing the truth. Dysentery
caused 3 per cent, of the deaths in either sex, but in almost each
instance it occurred in cases broken down in health by age, etc. This
fell disease caused death in 40 per cent, of the thirty-seven males and
14 per cent, in the twenty-seven women attacked. The disease broke
out in two wards only, and was stamped out by isolation and disinfec¬
tion. Until 1895 it was very little known, the last entry in the death
register from it being in i860. From 1895 onwards it has never been
absent in any one year; the asylum being during that period in the
hands of the builders for improving its light and ventilation. In face
of the conclusion as to the potency of overcrowding as a cause, Dr.
Alexander notes as a curious fact that hardly a case occurred in an
overcrowded ward. He is disposed to believe that our dysentery of
recent years is of a different variety from the sporadic dysentery of
former days, and he is led to so think by the high infectivity, its
tenacious hold on a ward, its stubborn resistance to treatment, its heavy
mortality in the broken-down, and its marked tendency to recur
(often after a long interval) without any abatement of its original
infectivity.

Bexley. —Arrangements are being made for nursing some of the male
sick wards by female attendants. Dr. Stansfield, after a sufficient period
of experience, has no hesitation in pronouncing in the strongest terms
in favour of villas as against barracks for the housing of a large pro¬
portion of the insane. The acute hospital villa serves well for the
patients admitted. Those who are capable of recovery are retained
there until approaching convalescence. As they improve they live more
and more in the open air, weather permitting, the meals frequently being
served on the lawn. The villas are surrounded by gardens and lawns,
and have no retaining fence of any kind.

Of the general paralytics admitted, 74 per cent, of the 79 males and
55 per cen *' °f 20 females had undoubted evidences of syphilis.
Even these high proportions are lower than those in 1900. Dr. Stans¬
field is quite correct in stating, when dealing with alcoholic causation,
that it is not so much acute drinking that is to blame as prolonged and
secret “ nipping.” We feel sure that grocers’ licences have a good deal
to answer for in this relation.

Strict isolation of all cases of diarrhoea (203 slight and 82 severe)

Digitized by CjOOQle

ASYLUM REPORTS.

375

1903]

and of dysentery (47) was practised, and they are treated as if they
were typhoid, isolation being continued for fourteen days after dis¬
appearance of symptoms.

Dr. Stansfield adverts to the murderous, but happily unsuccessful,
attempt made on the life of Mr. Manson. The man who made it
had a strong criminal history, and had been in penal servitude often
and long,and was possessed of exceptional cunning. He had previously
laid up a murderous weapon for Dr. Stansfield himself, it being luckily
found tied by a shred of handkerchief to the scrotum and held in the
perineum. We quite concur in Dr. Stansfield’s protest against such
gaol-birds being retained in ordinary public asylums.

London (Metropolitan Asylums Board Asylums).—Though these
institutions do not technically come within this division of our review
it seems to be appropriate to consider their reports here, since they are
a very important complement of the lunacy service of the Metropolis.
As a matter of fact they contain more than a quarter of institution
patients chargeable to London, their population containing a large pro¬
portion of those who in other areas would find their home in the county
asylum.

The Asylums Committee starts its report with this opinion, which is
not only pious but practical:

The scope of our work during the year 1901 has, for the most part, been directed
to the proper maintenance of existing institutions and the carrying out of various
improvements calculated not only to promote the welfare of the patients, but to
produce a greater amount of contentment amongst the staff. This is one of the
most important factors in the satisfactory conduct of any asylum, as a contented
staff means not only a more permanent staff, but reacts beneficially on the
patients, and so conduces to the happiness of the whole establishment.

The improvements alluded to are extended accommodation and
homes for attendants, and cottages for those who are married. In
view of the epidemic of smallpox the Managers extracted the following
opinion from the Local Government Board as to their right to vaccinate
patients as a protection :—“ It would appear that the consent of the
patient may be regarded as implied in adult cases, in cases of the
kind in question,” but that, as regards children, any arrangements made
should not 44 extend, under ordinary circumstances, to the case of any
child as to whom the Managers may have sufficient grounds for suppos¬
ing that the parent would object.” The entire absence of smallpox
during the year in all the asylums may be attributed to the steps taken
under this wise dispensation.

The Managers speak warmly of Dr. Elliott’s services at Caterham,
and were allowed to add eight years to his twenty-five years’ service for
completing his pension, and this on the ground of 44 peculiar profes¬
sional qualifications ” and of 44 special circumstances.” This gratifying
instance of liberality is another evidence of the spirit which possesses
most of those who manage asylums, if only they are left to themselves.

Leavesden. —Here, while colitis was found post mortem to have existed
in seven instances of death, tuberculosis has been the prominent patho¬
logical trouble. The Committee, under Dr. Elkins’s skilled guidance,

Digitized by CjOOQle

376

EPITOME.

[April,

have gone deeply into the question, and have taken serious steps to
combat it. The neighbourhood itself is admittedly healthy, but
Dr. Elkins points out that his population is drawn from the broken-down
wreckage from the poorest homes in London, and is peculiarly liable to
infection. The first and most important step taken has been to reduce
the normal amount of beds (about 1990) by 220. The tubercular
patients have 346 beds allotted to them. For the advanced cases two
wards on each side are set apart, affording 100 square feet of floor space
to each. The incipient cases are allowed 60 square feet by night and
30 by day.

Rustic shelters have been erected in the airing courts, so that patients
may have as much air as possible, independently of the weather.
Tubercular patients are not allowed to go to the entertainment hall or
to chapel, but special arrangements are made for them in both directions.
The males are allowed to work in the garden, but not on the farm,
especially near the cows. The latter are naturally objects of the most
careful watching and testing. Dr. Elkins speaks hopefully of the results in
the future of the above precaution, and of careful medical treatment and
diet; and it is right to add that the visiting Commissioners accord credit
for the thorough manner in which the war is carried on against this
preventable disease, which caused 40 per cent, of the deaths in 1901.

Caterham .—Here the evidence of tuberculosis is but little felt, only
twelve out of 109 deaths being attributable to it. The general death-rate
is very low, being only 57 on the average population.

Darenth. —Dr. Taylor makes his last report of this asylum, having
been chosen as medical superintendent of the East Sussex Asylum, on
which appointment we congratulate him. Concerning juvenile general
paralysis he writes:

Six patients died from general paralysis, and of these, four, i. e., three females
and one male, were children. Judging from the number of deaths from juvenile
general paralysis which have occurred at this institution during the last three
years, this disease would appear to be by no means so rare as at one time it was
supposed to be, and the fact that the females were in a proportion of three to one,
both in the admissions and deaths, is noteworthy. I find, however, that, taking the
last three years, the proportion of deaths between the sexes from this disease is
more nearly equal, being five males to seven females, which approximately agrees
with the conclusion of Dr. Mott that the sexes are affected equally.

He suggests to the Managers the appointment of a pathologist in con¬
nection with their asylum. This would be a highly praiseworthy
procedure.

At the Commissioners’ visit only one bedsore existed in the nearly
2000 patients, many of whom are peculiarly feeble.

Rochester House .—This is a new departure. The house was pur¬
chased by the Managers for the accommodation of 150 improvable
imbecile children, and Dr. Shuttleworth was appointed Consulting
Medical Expert, and now makes his first report. The structural
arrangements bring the sexes so close that boys can only be retained
until puberty, while there is no such limit placed on the other sex.

Digitized by v^.ooQLe

ASYLUM REPORTS.

377

1903 ]

Though the existence of the school is too recent for any definite
opinion, the result of general observation is that the conduct of those
longest in residence shows ample justification of the experiment. Those
who show no improvement will be returned to Darenth. Industrial
training and horticultural pursuits are, of course, used as means of
occupation and learning. Dr. Shuttleworth thinks that when these
means have been fully established an industrial colony for those who
by age are passed out from Rochester House must come as a logical
sequence. He points out the necessity for continued segregation, even
of those who have been fully trained, since duty to succeeding genera¬
tions calls for prevention of all chance of the race being propagated
by such beings. Dr. Shuttleworth speaks of the benefit of moral
training and the appreciation of simple religious services by the inmates.

Some English Registered Hospitals.

Bamwood House .—We are glad to see that the Pension Fund now
tops ,£12,000, £2838 having been added in the past year out of current
revenue. The latter seems to have been considerably in excess of the
expenditure, the rates for patients being respectively £3 is. 3 d. and
£ 2 3 s. 2d. each week. The considerable surplus was devoted to the
above purpose and to new buildings, but was not thereby nearly
exhausted, £2400 still remaining.

Bethlem. —The capacity of this hospital is still lessened by the fact
of male wards being -closed for repairs, and consequently the admissions
were fewer in number. Including both voluntary and certified patients,
they were 263, being, so Dr. Hyslop reports, about one tenth of all
the applications. The voluntary boarders admitted were 33.

The recovery rates were for certified, 52 per cent. , and 47*5 percent, for
voluntary patients, while the death-rate, calculated on average residence,
was 4 58 in respect of the former, and zero for the latter. Of the fore¬
going total of 263 admissions, 53 paid for board, etc. Over one quarter
of the certified patients were admitted on urgency orders.

We note that Dr. Hyslop includes among the forms of mental disease
in table xi, delusional, impulsive, and alcoholic insanities, and folie
circulaire. Clerks and governesses were the classes which stood first
among the definite occupations prior to admission.

The Retreat ( York). —This report does not contain the usual financial
statements, but from Dr. Bedford Pierce’s nummary we find that, while
the average weekly income from each patient was £2 Ss. 10 d. y the
expenditure was £2 Ss. 4 d. The lowest rate for unassisted patients
had to be raised by six shillings to £2 Ss. per week on account of
increased cost of maintenance. Four deaths followed a residence of
over forty years in each case. Dr. Pierce has installed electrical treat¬
ment and also classes for Swedish gymnastics, and as far as matters
have gone as yet he is of decided opinion that the latter is a valuable
aid to treatment.

Extensive arrangements are made for training nurses, who now are
taken on a four years’ agreement. At the end of two years they are

Digitized by v^.ooQLe

3/8

EPITOME.

[April,

expected to enter for the Association certificate; at the end of the third
year they have to be examined again for the Special Retreat certificate
and “ William Tuke ” medal, which is bestowed after a fourth year of
private nursing. They are specially instructed in medical gymnastics,
massage, and invalid cooking.

Some Scottish District Asylums.

Fife and Kinross .—Dr. Turnbull presses the boarding-out system in
every possible way, and was enabled to plant out seventeen cases with
relatives and eleven with strangers. They are frequently sent out “ on
pass ” for twenty-eight days to see how the trial results. Experience
soon shows that the result of the trial depends not only on the mental
state of the patient, but largely on the capabilities of the receiver. In
spite of the vacancies thus created, it is found necessary to build accom¬
modation for ioo more patients, equally divided as to sex. The
estimated cost is ^135 per bed, which is most reasonable. Dr. Turn-
bull discusses in a thorough manner the question whether asylum farms
pay, and comes to the conclusion that they do, though not always to the
amount claimed. The raising of all butcher-meat in his case is a
material factor in the farm’s success.

Dr. Turnbull speaks in favour of the treatment of incipient cases in
mental wards of general hospitals.

In view of the increasing burden of lunacy throughout the country, a proposal
has recently been put forward, and has been much discussed, that in general hos¬
pitals, such as the Royal Infirmary of Edinburgh, there should be provided wards
for the treatment of mental cases. Two objects are aimed at. One is that
incipient and transient cases of insanity should be treated in these wards, without
requiring to go to the asylum proper, thus avoiding as far as possible the unfortu¬
nate prejudice which is still often shown against asylum care and against those
who have required it. It is of course evident that, in the absence of special
regulations, the cases received could only be those in which the patients submitted
readily to treatment, and did not need compulsory detention or restraint in other
ways. The other object is that treatment should be obtainable by the poorer
classes of the population for those forms of mental disturbance which lie on the
border-land between sanity and insanity. In these the patient’s condition is such
that he may not be properly certifiable for asylum care, and yet may require special
treatment; and if he does not get that treatment his illness may easily pass on to
active insanity. That the plan of having such wards is practicable is shown by the
fact that it is already in use in some parts of the Continent. In asylum work one
finds far too often that the best time for the treatment of the illness has been
allowed to slip past. Often the “ insanity ” is said in the admission papers to be
of only a few days’ or a few weeks’ duration ; but inquiry shows that the symptoms
indicating the commencement of mental disturbance have possibly been present
for many months, and have been gradually increasing, while the patient drifted on
at home without the means of getting the treatment he required. The step of
certifying cases for asylum care, involving as it frequently does their also coming
on the public rates for support, is so serious that naturally it is often deferred as
long as possible ; and so valuable time is lost. In giving the opportunity of
treatment for these cases the mental wards of a general hospital would meet a
much-felt want, and be productive of good ; and it is therefore very desirable that
they should be provided. If they receive also some of the transient forms of
active insanity, it should lessen pro tanto the admission rate of asylums; but as
these cases would have been discharged from the asylum on recovery, it is not
likely that from that side it would produce much effect in lessening the number of
chronic residents.

Digitized by v^.ooQLe

1903 ]

ASYLUM REPORTS.

379

Glasgmv, Gartloch. —Dr. Parker, who has recently assumed the
direction of this excellent asylum, holds opinions strongly opposed to
this same proposal of treating cases in general hospitals.

With such a large proportion (57*6 per cent.) in these classes, a recovery of
40 8 per cent . may be looked on as very satisfactory. Apparently this continued
large admission rate of those ill over a year is closely related to the increasing
tendency on the part of the public to trust their aged and helpless relatives to
asylum care. This tendency, though entailing a heavy burden on the asylum, is
welcome as a sign of public confidence, and it seems to me a pity that at such a
time a movement should be made that might be interpreted by the public as a
slur on asylum care and treatment, as though patients could not in asylum
hospitals get the same treatment and care as in a general hospital. To get at the
cases that are uncertifiable or difficult to certify, an increased use should be made
of the law which permits voluntary inmates in asylums under sanction from the
Commissioners in Lunacy, and people should be encouraged to come to asylums
for the help they feel they need. On the other hand, to keep certifiable cases in
wards not amenable to the regulations binding asylums is a course very likely to
lead to abuses; but there is nothing to prevent early and non-certifiable cases
from being treated in the wards of any general infirmary, as has for many years
been done by Dr. Alex. Robertson, of Glasgow, in the town’s hospital. This is
no new thing, and can be done now as in the past. To form wards for the special
treatment of the insane in general hospitals is to label the patients as insane just
as much as if they were sent to an asylum. The strongest argument (other than
the teaching one) in favour of treating insane folks in a general hospital is lost if
there are special wards for the purpose. There should, however, be dispensaries
for nervous and mental diseases attached to our general infirmaries, where the
mentally ill and their friends could easily and conveniently get the best advice. I
am sure that if this were done, and properly taken advantage of, it would assist in
keeping down the numbers of the insane, and so relieve the tension in our asylums.

Glasgow , Woodilee .—Dr. Blair has retired from the medical superin¬
tendency, and has been succeeded by Dr. Marr. We are glad to note
that the Managers, both in his case and in that of Dr. Oswald on
leaving Gartloch for Gartnavel, place on record their warm appreciation
of the eminent services rendered to their institutions by both gentlemen.

The whole of the male hospital is officered by women, and a “ nurse
with the advantages of a course of training in a general hospital has
been put in charge.” Dr. Marr states that the relegation of noisy, dirty,
destructive, and suicidal cases to a dormitory has been followed by
advantage to themselves and to the quieter patients, who have their
bedrooms instead.

Both here and at Gartloch extensive additions are being made in the
shape of iron and wood buildings for the treatment of tubercular cases.
We are afraid that the recent calamity at Colney Hatch may cause some
disquiet on the score of similarity in material.

Considering the gathering ground of these conjoined asylums, the
proportion of 7*5 per cent . of the admissions is not a high one to show
in respect of general paralysis. We are glad to see that Dr. Parker
furnishes a table of the probable cause in the general paralytics admitted.
Syphilis was established in nearly 50 per cent., hereditary predisposition
in nearly 50 per cent., while fourteen out of nineteen had been drinkers.
We wonder that other superintendents do not make a special inquiry
for instructive report in this direction.

Govan .—In this asylum general paralysis makes even a less mark in

XLIX. 20

Digitized by v^.ooQLe

380

NOTES AND NEWS.

[April,

the admissions, only thirteen cases occurring in 239 who entered; but no
case in all the latter was attributable to syphilis. A large number of
male alcoholics (38 out of 143) w f ere admitted and increased the turn¬
over of the asylum, which is a high one, the proportion of admissions
to average population being more than 50 per cent . The Commissioners
advise the authorities to consider whether a in some cases appropriate
medical treatment could not be given elsewhere than in the asylum for
the short time that is often all that is required to complete recovery of
these drinkers.”

Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The General Meeting was held at the Derbyshire County Asylum, Mickleover,
on Thursday, February 12th, 1903. Dr. J. Wiglesworth, the President, occupied
the chair.

The following members were present:—Drs. T. Stewart Adair, W. Lloyd
Andriezen, Henry T. S. Aveline, Horatio Barnett, Fletcher Beach, Harry
A. Benham, C. Hubert Bond, David Bower, A. N. Boycott, George Braine-
Hartnell, Robert H. Cole, F. K. Dickson, Charles C. Easterbrook, Francis
H. Edwards, G. Stanley Elliott, H. Gardiner Hill, Theo. B. Hyslop, Gerald
H. Johnston, J. Carlyle Johnstone, Robert Jones (Hon. Sec.), W. Ernest Jones,
Walter S. Kay, Richard Legge, Henry C. MacBryan, Henry J. Mackenzie,
S. Rutherford Macphail, W. F. Menzies, Alfred Miller, C. S. Morrison, Gilbert
E. Mould, H. Hayes Newington, Michael J. Nolan, Bedford Pierce, Evan Powell,
Daniel F. Rambaut, Robert L. Rutherford, J. Beveridge Spence, Bernard Stacey,
Rothsay C. Stewart, F. J. Stuart, T. Seymour Tuke, Alex. R. Urquhart, Lionel
A. Weatherly, Ernest W. White, J. Wiglesworth, T. Outterson Wood, and David
Yellowlees. Visitors: Colonel G. Gascoyne and Drs. E. Collier Green and
E. Vaudrey.

Apologies for non-attendance were received from Drs. C. Mercier, A. R.
Turnbull, R. Percy Smith, P. W. Macdonald, E. B. Whitcombe, J. F. Briscoe,
and H. Rayner.

In the morning the Educational and Parliamentary Committees met, and a
Council Meeting was held. The following were present at the Council:—Drs.
J. Wiglesworth, H. Gardiner Hill, T. Stewart Adair, Alfred Miller, Ernest W.
White, C. Hubert Bond, G. Braine-Hartnell, R. L. Rutherford, David Yellowlees,
H. Hayes Newington, J. Beveridge Spence, A. R. Urquhart, Theo. B. Hyslop,
Lionel A. Weatherly, Rothsay C. Stewart, and Robert Jones.

At half-past one Dr. R. Legge entertained the members to lunch, at the close
of which Dr. Wiglesworth proposed the health of their host, remarking upon the
evident popularity of the quarterly meetings of the Association held in the
provinces, as evinced by the numbers present.

Dr. Legge, in responding, paid a high tribute to his committee and expressed
much pleasure in being able to forward the interests of the Association.

Dr. T. Outterson Wood then proposed the health of Colonel G. Gascoyne,
Chairman of the Asylum Committee. This was heartily received, and Colonel
Gascoyne responded in cordial terms.

Dr. Wiglesworth presided at the afternoon session. He regretted to announce
that Dr. Clouston was absent through a serious and severe illness, that
Dr. Macdonald was unable to be present from a similar cause, and that Dr. Mercier

Digitized by ^.ooQle

NOTES AND NEWS.

3»I

1903]

was absent owing to domestic and family bereavement. The sympathy of members
was cordially expressed, and it was announced that the Council had requested the
Hon. Secretary to convey this to each of the members thus absent.

Tuberculosis Statistics.

The President said there was a resolution on the agenda in the name of
Dr. F. J. Stuart, concerning the work of the Tuberculosis Committee of this
Association. It would be within the recollection of all of them that that Com¬
mittee presented a report, which was adopted. The accuracy of the statistics
which the report contained was challenged, whereupon the Secretary of the Com¬
mittee wrote to the British Medical Journal and accepted personal responsibility
for them. He (the speaker) thought that was unfortunate, because every member
of that Committee was equally responsible for what the report contained.

Dr. Stuart here rose to a point of order. Could the President discuss the
question before the resolution had been proposed and seconded ?

The President stated that the question was not being discussed, but he had been
desired by the Council to make the following statement:—That morning the
Council had gone fully into the matter, and found that the expert who, at the
request of the Council, had the report and statistics under his consideration,
had arrived at certain conclusions, but had not sent in a detailed report. The
revised statistics, when obtained, would be presented to the Association and con¬
sidered in the fullest possible manner. That being the position of affairs at present,
it would be seen that the matter was, to some extent, sub judice ; he would there¬
fore ask whether Dr. Stuart wished to proceed with his resolution.

Dr. Stuart expressed his intention to proceed, and moved as follows:—“ That
a committee be appointed to reconsider and to report on the statistics obtained by
the late Tuberculosis Committee of this Association.” He said that it had been
suggested that whatever criticism was made on the work of this Committee should
have been made in the Journal of Mental Science. He wished to state that he
commented on those statistics in the British Medical Journal because that report
had been sent out, amongst others, to the Chairman of the Asylum Committee of
the staff of which he was a member. He referred at considerable length to the
errors in the report which the Tuberculosis Committee had drawn up, and he
regarded it as unsatisfactory that the Secretary had accepted full responsibility for
the errors. He asserted that each member of the late Committee should be held
responsible for the report, and he claimed that a new committee should be
appointed to deal with the matter.

Mr. W. Ernest Jones seconded the resolution.

The President stated he was a member of that Committee, but was only able
to attend one meeting. He accepted his share of the responsibility.

Dr. Hayes Newington moved, as an amendment, that the matter be, for the
present, left in the hands of the Council.

Dr. Yellowlebs seconded this. He thought they were indebted to Dr. Stuart
for pointing out the errors contained in the report; he considered, however, it
would be wisest to pass the amendment. Now that these mistakes had been
brought to light, the Council would take steps to rectify them. It was the duty of
the Council to protect the dignity of the Association in every possible manner, and
that duty was not going to be neglected.

Dr. Macphail thought that Dr. Stuart was right in bringing the matter forward.

Dr. Stuart said that if the Chairman of the Committee had accepted the
responsibility for the report instead of the Secretary doing so, he would not have
brought the matter up before the Association.

Dr. Yellowlees aid not think that the Chairman of the Committee would deny
responsibility; he believed that the Chairman deplored the errors as much as
anyone.

The President, in answer to Dr. Stuart, said that the whole matter had been
referred to a statistical expert, and that the corrections would be published in
the Journal of Mental Science.

After some further discussion the amendment was put and carried by an over¬
whelming majority. It was afterwards adopted as a substantive motion, no one
voting against it.

Digitized by v^.ooQLe

382

notes ANt> News.

[April,

The Stereoplasm of the Nerve-elements —A Study in Nerve Dynamics.

Dr. W. Lloyd Andriezen read a paper, with lantern demonstration, on the
“ Stereoplasm of the Nerve-elements—a Study in Nerve Dynamics.” After review¬
ing the older doctrine of the morphological unity of protoplasm, he pointed out that
this was succeeded by the modern view of its diversity of structure and function,
and exemplified it by lantern-slides of specimens of the central nervous system.
He emphasised the view that the neuron, or nerve-element in its entirety, was an
individual element embryologically (as shown by His), anatomically (as shown by
the work of Golgi, Ramon y Cajal, and others), and physiologically (as shown by
various experimental methods relating to velocity of nerve-impulse, reaction-time,
etc.). The Golgi method of staining revealed the neuron as an opaque body even
to its terminal fibrils and “gemmules.” He then showed that the cell-body, by
modern methods of staining, seemed to be composed of a reticulo-fibrillar element
or stereoplasm and a hyaline substance or hygroplasm. He pointed out analogies in
the case of epithelial cells, gland-cells, and muscle-cells in regard to this differen¬
tiation of structure, and illustrated the nature of the hygroplasm from observations
on the amoeba, on leucocytes, and on young cartilage cells. The stereoplasmic
network, with its prolongation into fibrils in the axis-cylinders of nerve-cells, seemed
to be present even in such lowly forms as the Crustacea, as shown by Retzius
with the intra vitam methylene-blue method, and it was more marked in the
higher vertebrata. His own studies on the brain and spinal cord of the cat, ox,
monkey, and man harmonised with this view. (Various slides were shown on the
screen illustrating the stereoplasmic structure of the nerve-cells in the spinal cord,
cerebrum, and cerebellum as shown by special methods of staining.) The large
motor-cells of the human spinal cord, the pyramid cells of the cortex, and the
Purkinje cells of the cerebellum showed the structure described. He also pointed
out that even in the spinal cord of the freshly killed ox the fibrillar prolongations
of the stereoplasm could be shown in cell-processes and within the cell-body. He
then discussed certain physico-chemical theories regarding the nature of this
structure as contrasted with the hygroplasm, and stated his view that the chief
metabolic changes (assimilation of food, the building up of the tigroid substance or
Nissl’s bodies, and probably also the maintaining of the intra-cellular stereoplasm
in a state of heightened functional excitability) were subserved by the hygroplasm.
Analogies from other tissues of the body and from unicellular organisms were
cited and shown to harmonise with this view. The stereoplasm was thus, both
from positive and negative evidence, believed to be the conducting element of the
nerve-cells, but it was also more than this, for its structure and its environment
were modified in the axis-cylinder as compared with the nerve cell-body itself. To
quote a simile from the body politic, he would look upon the hygroplasm as the
more mobile and “progressive” element, and the stereoplasm as the more “con¬
servative” element. He concluded by pointing out that Herbert Spencer in some
of his remarkable speculations (Data of Biology) had come very close to the
general view which the lecturer had just propounded, and urged that such a view
not only gave a philosophical interest to study, but enabled them to understand
some of the deeper problems of neurology and psychology. He also briefly
described observations in cases of insanity (chronic alcoholic insanity, epileptic
insanity, and general paralysis of the insane) in which he found marked and
extensive destruction of the stereoplasm within the cell-bodies of the cortex, and
hoped that alienists and other investigators would devote special attention to the
study of this most important constituent of the nerve-elements.

Dr. Ernest White read a paper entitled “The Care and Treatment of Persons
of Unsound Mind in Private Houses and Nursing Homes ” (see page 245).

Dr. Outterson Wood read a paper entitled “Lunacy and the Law ” (see page
260).

The discussion on these two papers was adjourned until the next General
Meeting.

The members dined together in the evening at the Midland Hotel, Derby.

Digitized by

Google

1903]

NOTES AND NEWS.

383

SCOTTISH DIVISION.

A meeting of the Scottish Division was held in the Hall of the Royal College .
of Physicians, Queen Street, Edinburgh, on Friday, December 5th, 1902. The
following members of the Association were present:—Drs. Clouston, Yellowlces,
W. W. Ireland, John G. Havelock, T. Carlyle Johnstone, George M. Robertson,
A. R. Turnbull, John Keay, R. B. Mitchell, E. R. Wilson, J. M. Rutherford, C. C.
Easterbrook, R. D. Hotchkis, J. H. Macdonald, J. Carswell, W. Ford Robertson,
and Lewis C. Bruce (Secretary).

A letter of apology was received from Dr. Watson.

Dr. Clouston was called to the chair.

Dr. Yellowlbes. —In proposing Dr. Clouston for the chair I have the very
pleasant duty of congratulating Dr. Clouston upon his appointment to the
Presidentship of the Royal College of Physicians, Edinburgh. I also take this
opportunity of thanking the College through their President for their kindness in
placing the Library of the College at the disposal of the Scottish Division of the
Medico-Psychological Association for the usual Autumn Divisional Meeting.
(Applause.)

Dr. Clouston. —I beg to thank you, gentlemen, for your congratulations, and,
as President of the Royal College of Physicians, I can say that we have always
been pleased to have the Scottish Division of the Medico-Psychological Association
as our guests whenever they desired to hold a meeting in Edinburgh.

The Secretary read the minute of the last meeting, which was approved of.

The Chairman. —The next business is to consider the amended and revised
rules of the Association as submitted to the Annual Meeting at Liverpool and by
resolution referred to the Divisions.

The following resolutions were carried :

1. Rule 28. —Each Division shall nominate annually to the Council, after taking
the vote of the Division, a member to act as Secretary to the Division, and also
one member as their representative on the Council, who shall remain on the
Council for three years; such nomination to be received by the Council and
presented to the Annual Meeting.

2. Rule 34.—To delete the words “ and two Auditors.”

3. Rule 46.—To delete the words “by the Auditor,” and to substitute the words
" by two Auditors appointed by the Council.”

4. Rule 35.—After “ the Educational Committee ” insert “ and the Divisional
Secretaries.”

5. Rule 51.—Between C and D add, as a fresh paragraph, “the names of the
Secretary and the Member of Division nominated for the Council.”

6. Rule 67.—To insert between the word “year” and the word “and,” the
following:—“ Unless he can satisfy the Council that his absence has been unavoid¬
able.”

7. Rule 77.—That it should read thus :—“ Except in the case of a Divisional
Representative, in which case the Council may elect a member on the nomination
of his Division.”

8. That in the opinion of this Division a Nomination Committee ought to be
appointed, consisting of the President, Treasurer, one of the Editors, the General
Secretary, and all the Divisional Secretaries, to whom it shall be remitted to
nominate persons for all the offices in the Association, except where the nomina¬
tions are made by the Divisions.

9. That the Ordinances of the Association should be divided into Articles and
Bye-laws.

10. That all the rules passed since the last revision should be submitted to the
next Annual Meeting.

A hearty vote of thanks was accorded to Dr. Carlyle Johnstone for his valuable
assistance in the discussion.

Communications.

. Dr. Bruce read a paper entitled “ Bacteriology and Clinical Investigations in
some Acute Cases of Mental Disease ” (see page 219).

Digitized by

Google

3»4

NOTES AND NEWS.

[April,

At the conclusion of this paper Dr. Ireland took the chair.

Dr. Urquhart read a paper on “ Nomenclature of Diseases ” (see page 236).
On the motion of Dr. Turnbull, a hearty vote of thanks was accorded Dr.
Ireland for presiding during the latter part of the meeting.

IRISH DIVISION.

A meeting was held, by the courtesy of the President and Fellows, at the Royal
College of Physicians of Ireland, Dublin, on January 28th, 1903. Present:—
Dr. Oscar Woods in the chair, also Drs. Drapes, Norman, Vletherington, Nolan,
O'Neill, Eustace, Leeper, Finegan, and Dawson (Hon. Sec.). Intimations of
regret at being unable to attend were notified from Drs. W. Graham, Oakshott,
Maloney, and Cooke.

The minutes of the previous meeting were taken as read, confirmed, and signed.

Dr. Conolly Norman asked permission to bring forward the following resolu¬
tion, not on the agenda paper, which he proposed in suitable terms :—“ The Irish
Division of the Medico-Psychological Association assembled at their stated meet¬
ing this day desire to convey to their esteemed colleague, Dr. Seward, of the
Colney Hatch Asylum, the expression of their warmest sympathy in the trouble
that has befallen him through the calamitous fire in his institution yesterday.
Such a calamity must touch every heart, but knowing how much distress it must
particularly cause to Dr. Seward, we desire to assure him of our sincere
sympathy.”

The Chairman, in seconding the motion, remarked that if this dreadful occur¬
rence were the means of stopping the erection of such dangerous structures as
that which had been destroyed—structures to which he believed all superintendents
were opposed—it would not be an unmixed evil. The resolution was passed
unanimously, and the Secretary was instructed to send a copy to Dr. Seward
forthwith.

Time and Place of Next Meeting.

It was decided not at present to fix the time or place of the next meeting of the
Division.

Divisional Officers.

It was unanimously decided that the following names should be recommended
to the Council as Divisional Officers for the ensuing vear, viz., Dr. W. R. Dawson
as Divisional Secretary, and Dr. T. Drapes as Junior Examiner; also that
Dr. M. J. Nolan should be recommended for a seat on the Council.

Election of Ordinary Member.

The following was unanimously elected by ballot:—Henry T. Bewley, M.D.
(Dublin), F.R.C.P.I., etc., Visiting Physician, Bloomfield Asylum ; Physician to
the Adelaide Hospital, Dublin, etc. (proposed by Drs. W. R. Dawson, C. Norman,
and H. M. Eustace).

Vote of Thanks.

It was proposed by the Secretary, seconded by Dr. Nolan, and carried unani¬
mously, ” That the best thanks of the Division be conveyed to the President and
Fellows of the Royal College of Physicians for kindly placing a room in the
College at their disposal for the meeting.”

Hour of Meeting.

The Secretary reported that only a few replies had been received to the inquiries
which, as directed, he had made of the members regarding the most convenient
hour for the Divisional Meetings. He was directed to write to the members again
on the matter, enclosing a reply postcard.

Digitized by v^.ooQLe

«903]

NOTES AND NEWS.

385

Communications.

Dr. Conolly Norman contributed a communication entitled “ Notes on
Hallucinations ” (see page 272).

Dr. Dawson read a paper entitled “ A Case of Hebephrenia ” (see page 303).

Dinner.

Some of the members dined together at the Jammet Hotel, Dublin, in the evening.

PARLIAMENTARY NOTES.

The K ing’s Speech in opening Parliament this year contained no mention of
lunacy legislation.

Thursday, February 26th.

Lunacy in Ireland.

Mr. Clancy asked the Chief Secretary to the Lord Lieutenant of Ireland whether,
in view of the increase in lunatic asylum charges in Ireland in recent years, he
would consider the expediency of appointing a select committee to inquire into the
cause or causes of the growth of local expenditure on lunatic asylums in that
country, and to consider whether any means could be found of limiting or reducing
the burden on Irish ratepayers which was involved.

Mr. Wyndham replied : The statistics of insanity do most unfortunately show
an increase in the numbers of the registered insane. This increase is not confined
to Ireland. There has necessarily been a corresponding expansion in the contribu¬
tions from local rates and from Parliamentary grants for the provision of accommo¬
dation for the insane and for their maintenance. The proposal in the question has
already been dealt with in the Reports of the Royal Commission on Local
Taxation, and I see no reason for further investigation.

Tuesday, March 3RD.

Mental Derangement.

Dr. Farquharson asked the Attorney-General whether the Government would
consider proposals to legalise in England a system similar to that which was in
operation in Scotland for the private care of persons showing symptoms of
incipient mental derangement who could not be certified as insane.

Sir Robert Finlay replied: The Government has already assented to the
principle of such legislation, and a clause dealing with the subject was contained
in the Lunacy Bill of 1900. That Bill was introduced by the Lord Chancellor into
the House of Lords at the beginning of the session and was passed ; it came down
to the House of Commons on March 8th, 1900, but had to be withdrawn on
July 16th.

Thursday, March 5TH.

Treatment of Harmless Lunatics.

Mr. Hammond asked the Chief Secretary to the Lord Lieutenant of Ireland,
having regard to the restrictions placed upon boards of guardians in Ireland in the
treatment of harmless lunatics, if he would favour the proposal for the assimilation
of the law in Ireland to that in Scotland, under which it is practicable to have
these persons boarded and cared for in the homes of the peasantry.

Mr. Wyndham replied : The question of making better provision for the treat¬
ment of harmless lunatics in Ireland is receiving consideration.

ABERDEEN ROYAL ASYLUM. DR. ALEXANDER ASSAULTED.

At a Sheriff and Jury Court lately, a patient in the Royal Asylum appeared on a
charge of having assaulted J. T—, at the farm of Knaven, New Deer, on August

Digitized by v^.ooQLe

386

NOTES AND NEWS.

[April,

15th, by compressing his throat, and throwing him to the ground, and also of
having assaulted John Mitchell. Prisoner was further charged with having
assaulted Dr. H. De Main Alexander after he had been placed in the asylum, and
further with having assaulted William Morrice, head attendant, and lacerated his
face. Mr. S. D. Fowler, solicitor, who appeared for accused, examined Dr.
Alexander; Dr. Reid, Superintendent, Aberdeen Royal Asylum; and Dr. Angus, of
the Royal Infirmary; and their evidence showed accused was of unsound mind and
dangerous. The Sheriff ordered him to be detained during His Majesty’s
pleasure.— Dundee Advertiser.

Criminals may be refused by Royal Asylums under Lunacy Acts, and this seems
to have been the best way of dealing with a highly dangerous patient.

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION.

The American Medico-Psychological Association having become affiliated with
the Congress of American Physicians and Surgeons, it is obligatory under the
constitution and bye-laws of the Congress that the Association hold its meeting
in 1903 and every third year in Washington. The Council has therefore
instructed the Secretary to issue this notice, changing the place of meeting from
Providence to Washington, and fixing the dates, May 12th, 13th, 14th, and 15th of
this year.

SOCIETE MEDICO-PSYCHOLOGIQUE DE PARIS.

We observe that Dr. Paul Tollin and Dr. Ren£ Semelaigne have retired from
the joint secretaryship in favour of Drs. Blin and Dupaix, of the Vancluse
Asylum.

OBITUARY.

Dr. T. Gin£ y Partag&s, the doyen of Catalonian alienists, ended on February
27th last his long and active career. Born in Barcelona in 1836, he com¬
pleted his studies at the Faculty of the same town about 1858, retiring after¬
wards to Calva, a hamlet in the vicinity of Tarragona, where he practised
physic for three years. Assisting in the practical classes of the Faculty in
1863, he obtained the Chair of Anatomy in Santiago and Galicia. At last he
won the Chair of Clinical Surgery in his native city, later on directing his attention
to mental science. With this object he founded the Phrenopathic Review (1880),
and established the New Belem Lunatic Asylum. It was at this time that he
made himself known as a mental pathologist. He strove for the improvement in
Spanish law regarding moral insanity, and in several causes cilbbre gave proofs of his
great ability. To these labours were united those of teaching psychiatry in his
asylum, and writing no inconsiderable works on his speciality. Only the infirmities
of age and the progress of a cruel disease could extinguish his vigour of mind.
Spanish mental science is now in mourning for this great and irreparable loss.

We mention a few of his more important works relating to psychiatry:

Theoretical and Practical Treatise of Phrenopathy, 1876; Phrenopathic Letters
about Moral Insanity, 1882 ; On the Necessity of Popularising Psychology, 1883 ;
Phreniatric Aphorisms, 1884; Clinical Hypnotism, 1888 ; A Journey to Cerebropolis
(a scientific novel), 1889; Mysteries of Insanity (another scientific and literary
work), translated into Italian, 1890; and numerous articles and observations in
the Phrenopathic Review, Medical Independence, and other scientific reviews
and publications.

Digitized by v^,ooQLe

1903]

NOTES AND NEWS.

387

NOTICES BY THE REGISTRAR.

The next examination for the Certificate in Mental Nursing will take place on
Monday, May 4th, 1903.

The next examination for the Certificate in Psychological Medicine will be held
in July, 1903.

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 information respecting the various examinations of the Association
apply to the Registrar, Dr. Alfred Miller, Warwick County Asylum, Hatton, near
Warwick.

NOTICES OF MEETINGS.

Medico-Psychological Association.

General Meeting. —The next General Meeting will be held at the Langham
Hotel, Portland Place, W., on May 15th, at 4 p.m., and will be devoted to the
adjourned discussion on the papers read by Drs. Ernest White and Outterson
Wood at the last General Meeting. *

Annual Meeting . ; —The Annual Meeting will be held, under the presidency of
Dr. Ernest White, at 11, Chandos Street, London, W., on July 23rd and 24th next.
The Association will be invited to visit the City of London Asylum on July 25th.

South-Eastern Division. —The Spring Meeting will be held, by the courtesy of
Dr. Harding, at Berrywood Asylum, Northampton, on Thursday, April 23rd, 1903.

South-Western Division. —The Spring Meeting will be held, by the courtesy of
Dr. Benham, at the City Asylum, Bristol, on Tuesday, April 28th, 1903.

Northern and Midland Division. —The Spring Meeting will be held, by the
courtesy of Dr. Menzies, at Cheddleton Asylum, Leek, on Thursday, April 30th,
1903 -

APPOINTMENTS.

Craig, Maurice, M.D.Camb., M.R.C.P.Lond., appointed Lecturer on Mental
Diseases at Guy's Hospital, and Professor of Psychological Medicine to the Royal
Army Medical Staff College.

Price, Arthur Thomas, M.B., Ch.B.Edin., appointed Assistant Medical Superin¬
tendent at the Hospital for Insane, Toowomba, Queensland.

Pring, H. Reginald, M.R.C.S., L.R.C.P., L.D.S.Eng., appointed Honorary
Dental Surgeon to the City of London Asylum.

Savage, S. H., M.D., F.R.C.P.Lond., appointed Consulting Physician in Mental
Diseases to Guy’s Hospital.

Tuke, Thomas Seymour, M.B., B.Ch.Oxon., M.R.C.S.Eng., appointed Lecturer
on Insanity at St. George’s Hospital, W.

XLIX.

Digitized by v^.ooQLe

THE

JOURNAL OF MENTAL SCIENCE

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

No. 206 [X.“T] JULY, 1903. Vol. XLIX.

Part I—Original Articles.

The Changes in the Nervous System in a Case of Poren¬
cephaly. By J. O. Wakelin Barratt, M.D., B.Sc.Lond.,
F.R.C.S.Eng.

ALTHOUGH much has been written upon porencephaly, yet
detailed descriptions of the resulting alterations in the con¬
stituent neurons of the cerebro-spinal axis are few in number.
As a further contribution in this direction the present case has
been studied, and the changes found have been recorded as far
as possible graphically. No attempt has been made to collect
together the literature, largely clinical, of porencephaly, as it
has been felt that this cannot be profitably done until the
minute anatomy of the central nervous system has been placed
on record in a much larger number of cases than is at present
available^ 1 )

Clinical Account .

Patient is described as being healthy-looking at birth, and
delivery is believed not to have been difficult. He remained
healthy up to the age of eleven or twelve months, when he had
fits, to which his present condition is attributed. Subsequently
to the onset of the fits patient's altered physical state mani-
XLIX. 28

Digitized by v^.ooQLe

390

CHANGES IN THE NERVOUS SYSTEM,

[July,

fested itself. No history of any injury at the time of com¬
mencement of the fits is obtainable. Patient is not known to
have had any illness at this time or subsequently. The fits
persisted, and he became an idiot.

When grown up his facial expression was indicative of
defective intelligence. He was unable to speak, though he
made inarticulate noises, nor could he walk. He was, however,
able to waddle about the floor with the aid of the left upper
limb. At thirty years of age patient was admitted to the
West Riding Asylum. He was then (Fig. i) of fair height
and general development, and moderately well nourished. The
head was asymmetrical, the skull being flattened on the right
side. The right upper limb was of defective development, the
muscles being wasted and the movements of the forearm, hand,
and fingers very limited in range ; the fingers of this hand
could be partly straightened voluntarily. The left upper limb
could be moved without difficulty, and appeared unaffected.
The lower limbs were both equally wasted, the legs being
slightly flexed at the knees, and the feet exhibiting talipes
valgus.

Patient had typical epileptic fits. The pupils reacted to
light. Internal strabismus was present. The movements of
the facial muscles were not defective. Further details respect¬
ing the condition of the nervous system are not obtainable.
By careful attention patient could be kept clean. The principal
visceral lesions were mitral and aortic disease, with left-sided
cardiac hypertrophy, and, at the time of death, thirty-two
months after admission, left pleuritis.

Patient’s father died at seventy-five years of age, and
patient’s mother at seventy, death in each case being attri¬
buted to old age. One brother died at forty-two, cause
unknown. A second brother, aged forty-three, is in an asylum
suffering from melancholia ; he has also mitral disease.
Another brother has oedema of the legs, recurring at intervals.
Yet another brother has swelling of the joints of the hands.
The remaining brother is in good health.

Condition of the Body at the Autopsy.

Body emaciated (Fig. i). The head was asymmetrical,
being flattened on the left side, and was small compared

Digitized by

Google

1903.] BY J. O. WAKELIN BARRATT, M.D. 391

with the face, which was also asymmetrical in correspondence
with the asymmetry of the head. The right eye was turned
inwards. On the left side of the neck near the angle of the
jaw were several old scars, apparently caused by strumous

lymphatic glands. There was disproportionate wasting of the
muscles of the right upper limb (including the scapular
muscles), which was flexed at the elbow, wrist, and finger-
joints. The lower limbs were equally wasted, the wasting
being especially conspicuous in the legs and feet; the knees

Digitized by v^.ooQLe

392 CHANGES IN THE NERVOUS SYSTEM, [Jilly,

were moderately flexed, and talipes valgus was present, more
marked on the right side than the left The limbs were
flaccid at the time of the autopsy, and exhibited only a limited
range of movement at the right elbow and wrist, and at the
knees and ankles. Rotatory lateral curvature was present, the
upper dorsal vertebrae forming a curve convex to the left. Old
scars were found over the back of the right elbow. With the
exception of the defective formation of the skull, the right
upper limb, and both lower limbs, the general bodily develop¬
ment was fairly good.

The skull was asymmetrical, corresponding in its left-sided
flattening to the contour of the head. The skull-cap was thick
but not dense, and exhibited no local thickening or thinning
opposite the area of defect about to be described. Basal fossae
unaltered in appearance. The dura mater, which was not
thickened or unduly adherent to the skull-cap, exhibited a very
thin blood-stained pellicle on its inner surface over the vertex
on the left side. The pia arachnoid was opaque and thickened
both at vertex and base, and was somewhat congested. The
subarachnoid space contained much clear fluid.

The brain (i ioo g.) exhibited a moderate degree of general
wasting of the cerebral convolutions, more marked at the
vertex than at the base, and attended with corresponding
widening of the sulci, not, however, extreme in degree. The
right hemisphere was larger than the left (Figs. 2, 3, 4 A, 4 B,
4 c, 4D). Nevertheless the convolutions generally were of
nearly equal size on the two sides, being somewhat smaller on
the under surface of the left temporal lobe, but elsewhere
exhibiting no very marked general diminution in size on the
left side. There was, however, on the left side a defect in the
brain mantle (Fig. 2) in the situation of the operculum, the
island of Reil, and the superior temporal convolution, which
latter was destroyed except at its anterior extremity, while a
relic of its white substance still remained visible (Fig. 4 B).
This area of defect was occupied by the loose tissue of the pia
arachnoid, the meshes of which were filled with fluid, so that
no depression was visible on the surface. Its floor was formed,
as Figs. 4 A, 4 B, 4 c, and 4 D show, chiefly by the remains of
the white matter, though at the edge grey matter is also
present. It is evident that the small size of the left hemisphere
is partly if not largely due to the rest of the nervous substance

Digitized by

Google

Digitized by

To illustrate Dr. Wakf.i.in Barratt’s paper.

Bale and Danidsson, LUi.

Digitized by

Google

1903-]

BY J. O. WAKELIN BARRATT, M.D.

393

of this hemisphere closing upon the area of cortical destruction
(cf. Fig. 4 D, in which the third right frontal gyrus is seen to be
extending much farther backwards than is usual in the normal
condition), the actual limits of which must have been greater
than was at first sight indicated by the brain at the time of the
autopsy.

An examination of the brain after hardening showed that

Fig. 2.

The brain seen from the left side. The left hemisphere is smaller than
the right, but its convolutions are in general of good size. In the situa¬
tion of the operculum and of the greater portion of the first temporal
convolution, Ti, is an area, indicated by shading, from which the cerebral
cortex has disappeared. This area is occupied by the very loose connec¬
tive tissue of the pia arachnoid, the meshes of which contain fluid.
There is no depression on the surface of the brain. The fissure of
Rolando and the intra-parietal fissure are represented by/. R. and f. p. /.
respectively. Fi, Fs, F3; first, second, ana third frontal convolutions.
T2, T3 ; second and third temporal convolutions. R.fr. /., right frontal
lobe. R. occ. right occipital lobe. A A, B B, and C C represent, in this
and the succeeding figure, the planes in which the sections shown in Figs.
4 a, 4 b, 4 c respectively lie. D D is the plane in which the section
exhibited in 4 d is made. One half the natural size.

the island of Reil had largely if not wholly disappeared on the
left side, and that the left claustrum and external capsule were
of diminished extent. The left lenticular nucleus was slightly
smaller than the right, but the difference was not striking.
The caudate nuclei were of equal size. The left optic thalamus

Digitized by v^.ooQLe

394 CHANGES IN THE NERVOUS SYSTEM, [July,

was, however, much smaller than its fellow. This is shown in
Figs. 4 B, 4 c ; to avoid, however, risk of error arising from
possible obliquity of the sections, a horizontal section was made
through the middle of the thalami (Fig. 4 D), and the atrophy

Fio. 3.

The brain seen from below. The smaller size of the left cerebral hemi¬
sphere, as compared with the right, is much more striking in this than in
the preceding figure. The right frontal lobe is slightly bent over to the
left. The optic chiasma is also markedly deflected to this side. Not¬
withstanding the small dimensions of the left hemisphere, its gyri gene¬
rally are of fair size. The lateral hemispheres of the cerebellum are equal
in size. Some asymmetry is, however, visible, the left tonsil projecting
to the right (cf. Fig. 5). T 4, T 5, fourth and fifth temporal convolutions.
The other letters are as in the preceding figure. Slightly more than
one half the natural size.

on the left side conclusively exhibited. The white matter
forming the floor of the area of defect on the left side was
mottled in aspect. Elsewhere, as the figures show, the white

Digitized by v^.ooQLe

JOURNAL OF MENTAL SCIENCE, JULY, 1003.

To illustrate Dr. Wakelin Barratt’s paper.

link and Danielsion, Ltd.

Digitized by

Google

Digitized by

1903.] by j. o. wakelin barratt, m.d. 395

was little altered on the two sides. The internal capsule
(Fig. 4 d) exhibited in its anterior limb no marked change on
the left side. The genu and anterior end of the posterior limb
were indistinct on the left side, and the rest of the left posterior
limb was much smaller than the corresponding portion of the
right internal capsule. The temporo-occipital and thalamo-
occipital relations taken together exhibit a diminution in size
on the left side (Figs. 4 B, 4 c).

The ventricular cavity of the cerebrum was moderately
dilated. Though some asymmetry was present, the lateral
ventricles were very nearly of the same size. The choroid
plexuses were large. The ependyma was everywhere smooth.

Viewed from below, the difference in size of the two hemi¬
spheres was striking. The optic chiasma was bent over to the
left. The cranial nerves were all of natural aspect, and equal
in size on the two sides. The strabismus from which the
patient suffered was not attributable to a lesion involving the
third, fourth, or sixth cranial nerves. The mesencephalon shows
an atrophy of the left crus. Otherwise the mid-brain is
unaffected in its naked-eye aspect.

The cerebellum was well developed. The middle lobe was
natural in aspect, and the hemispheres were symmetrical except
in respect of the tonsils, of which the left reaches farther
posteriorly than the right (Fig. 5). On exposing the tonsils
more fully it was readily seen that this asymmetry did not
indicate any defect in bulk of the right tonsil. Nor was any
one-sided atrophy recognisable in any of the lobes of the
cerebellum. The vermis was well developed. The peduncles on
the left side appeared of the same size as on the right side.

The pons exhibited some want of fulness on the left side as
compared with the right, but was otherwise unaltered in its
external characters.

Seen from before, the medulla oblongata exhibited a striking
atrophy of the left anterior pyramid, which is less than half as
broad as the right (Fig. 6). The olivary eminences are, how¬
ever, equally developed, as are also the posterior columns and
the restiform bodies. The anterior median fissure is displaced
to the left of the middle line, and the left olive approaches
nearer the median antero-posterior plane than the right.

The pia arachnoid covering the spinal cord was somewhat
opaque in aspect, and clear yellowish fluid was present in the

Digitized by v^.ooQLe

396

CHANGES IN THE NERVOUS SYSTEM,

[July,

subarachnoid space. Beyond this there were no other macro¬
scopic changes to be noted in the spinal cord and its membranes,
nerve-roots, and posterior root-ganglia.

The longitudinal, lateral, straight, and cavernous sinuses were
patent, the left lateral sinus being larger than the right. The
cerebral surface veins exhibited no defect, being equally devel¬
oped over the two hemispheres. On the left side the anastomotic
vein of Trolard was present, and of similar aspect to its fellow.

The left middle cerebral artery was smaller than the right.
It presented, however, no occlusion or narrowing, and its four
main branches were present and patent.

Fig. 5.

The cerebellum seen from below. The lateral hemispheres are everywhere
symmetrical except in the situation of the tonsils, T, the left descending
lower than the right. Nevertheless on exposing these structures com¬
pletely it was readily recognised that the right was quite as large as the
left. No other asymmetry is visible, and the lobes of the vermis are
natural in size and aspect. Q. L., quadrate lobe. Natural size.

The basal arteries of the brain were free from atheroma.

The right pleura was healthy ; the left was covered with
lymph 1 to 3 mm. thick, and contained 750 c.c. of blood¬
stained sero-pus. The right lung (555 grs.) was congested and
cedematous, behind and below ; the left lung was collapsed and
camified.

The pericardium was thickened ; there was about 5 5 c.c. of
clear fluid in the pericardial sac. The heart (365 grs.) exhibited
left-sided hypertrophy. The heart muscle was firm and of good
colour. The mitral valve was thickened considerably; the
aortic valve was also greatly thickened, and was incompetent.

Digitized by v^.ooQLe

I903-] BY J. O. WAKELIN BARRATT, M.D. 397

Commencing atheroma was present in the root of the aorta.
The coronary arteries were healthy.

The liver was healthy.

The kidneys (right 75 grs., left no grs.) were small, and
exhibited evidence of chronic interstitial nephritis, the cortex
being slightly wasted, and the capsule stripping with erosion of
the subjacent tissue.

No morbid changes calling for special note were found in the
remaining viscera.

Minute Anatomy of the Nervous System .

Spinal cord ,—All the segments of the spinal cord, hardened
in a nearly saturated solution of potassium bichromate, were
sectioned as far as the fifth sacral segment. The sections
were stained by Pal’s, Marchi’s, and von Gieson’s methods.

The right side of the cord was smaller than the left (Fig. 7),
the change affecting both white and grey matter in the cervical
region, but scarcely at all in the dorsal region below the second
segment. On the left side the mesial portion of the antero¬
lateral column was atrophied. The grey matter was diminished,
and the number of its cells diminished on the right side, chiefly
in the cervical region. Asymmetry affecting both white and
grey matter was present. These changes will now be described
in detail.

Commencing with the white matter, reference may first be
made to the posterior columns. These, as Fig. 7 shows, ex¬
hibited nowhere any change or defect on either side.

On the right side the antero-lateral column was defective,
not in its anterior portion, which was well developed, but in the
lateral part of its extent. In particular, as a reference to the
figure will show, there is on this side, as compared with the
left, a narrowing of the portion of white matter lying between
the base of the posterior horn and the lateral surface of the
spinal cord. This difference is noticeable in the whole length
of the cervical region. It is present in a slighter degree in the
dorsal and lumbar regions, but is not recognisable in the sacral
segments.

On the left side that portion of the white matter lying
between the anterior horn and the anterior median fissure was
defective. As Fig. 7 shows, this defect, which was striking in

Digitized by v^.ooQLe

398

CHANGES IN THE NERVOUS SYSTEM,

[July,

the cervical region, was continued in the dorsal and lumbar
segments, gradually lessening in degree until it became absent
in the sacral segments.

There was no sclerosis of the white matter of the spinal cord
in any of the white columns.

The right grey crescent was shortened from before backwards
in the second and third cervical segments, but there is widening
from side to side, and no defect was apparent. Below this
level there was, in addition to a shortening of the crescent
from before backwards, a defect of grey matter affecting chiefly
the anterior horn on the right side, very slight in the fourth and
fifth cervical segments, better seen in the sixth, seventh, and
eighth cervical and the first, second, and third dorsal segments,

Fig. 6.

The medulla oblongata seen from before. The left anterior pyramid is
conspicuously smaller than its fellow, and the anterior median fissure is
displaced a little to the left of the middle line. The olives are of fairly
equal size, and the medulla is otherwise free from asymmetry. Figs. 8
and 9 represent respectively the lower and upper surfaces of the medulla
as here shown, x i|.

becoming slight again in the fourth and fifth dorsal segments,
and disappearing or becoming too slight to recognise with
certainty in the rest of the cord. This diminution in size of
the grey matter was attended with a defect in the number of
large cells in the anterior cornua. The latter was not so exten¬
sive as the diminution in size of the grey matter, being notice¬
able only in the sixth, seventh, and eighth cervical and first
dorsal segments. The defect was noticed in the lateral cell
groups. In the adjoining, and also in the lumbar and sacral
segments, the examination of a large number of sections failed
to reveal any constant preponderance of cells on one side.
The meshes of the grey matter lying outside the base of the

Digitized by v^.ooQLe

1903.3

BY J. O. WAKELIN BARRATT, M.D.
Fig. 7.

399

L S2 R

Transverse sections of the second, fourth, sixth, and eighth cervical, the
third and ninth dorsal, the first and third lumbar, and the second sacral
segments of the spinal cord, all drawn to the same scale. Attention
should be directed to the diminished size of the left antero-internal
column in all the segments as far as the sacral, but chiefly in the cervical
and dorsal regions; and to the relatively smaller size of the right half of
the cord, the defect involving grey and white matter, the latter being
greatest in the situation of the crossed pyramidal tract. The defect of
grey matter is attended with diminution in the number of nerve-cells in
the lower cervical region. No sclerosis of the white matter is present.
Further details are given in the text. R, right; l, left. Stained by
van Gieson’s method, x 2.

Digitized by v^.ooQLe

400 CHANGES IN THE NERVOUS SYSTEM, [July,

posterior horn were finer in the second and third cervical
segments on the right side than on the left. Clarke's column
was well seen in the sections, and was of equal size on the
two sides.

The asymmetry of the spinal cord in transverse section was
caused by the above-described defect in white and grey matter.
In the dorsal region below the second segment the atrophy
on the one side compensated for that on the other, and there
was no inequality in area, though the defects in grey and white
matter were readily observed.

Staining by Marchi's method revealed no evidence of recent
tract-degeneration. There was much pigmentation of the
anterior horn-cells at all levels of the cord.

The pial sheath of the spinal cord remained fairly thin,
although opaque in naked-eye aspect, and the septa were not
markedly thickened. The anterior septum was distorted, being
convex to the left. The blood-vessels of the cord were
numerous, but did not show any marked change. At the
bottom of the anterior fissure a large vessel on each side,
running longitudinally, was frequently seen.

The nerve-roots of the spinal cord presented no marked
diminution in size in the cervical region or elsewhere.

The medulla oblongata .—The study of microscopic sections
of the medulla (Figs. 8 and 9) exhibited more in detail what
has already been described as the result of naked-eye examina¬
tion, furnishing at the same time further information as to the
condition of those parts of the medulla which were not repre¬
sented externally. The sections were asymmetrical, this being
due apparently entirely to the difference in size of the anterior
pyramids, the right being about twice the diameter, and there¬
fore about four times the sectional area, of the left. The con¬
sequence of this was that the anterior median fissure was
displaced to the left, particularly at the lower part of the
medulla just above the decussation of the pyramids (Fig. 8).
If, however, the pyramids were neglected it was seen that the
medulla was otherwise almost perfectly symmetrical, the most
marked difference being that the olive approached nearer to the
median septum on the left side (Fig. 9), while at the lower
part of the medulla there was also apparently some narrowing
of the commencing formatio reticularis on this side.

The olives appeared of fairly equal size on the two sides,

Digitized by ^.ooQle

1903.] BY J. O. WAKELIN BARRATT, M.D. 4OI

such differences as existed in individual sections (cf. Fig. 9, in
which more of the left olive was cut across than the right) not
being constant at all levels, and therefore attributable to
obliquity in the section. The formatio reticularis, the ascend¬
ing root of the fifth nerve, the posterior longitudinal bundles,
and the arciform fibres all appeared developed to the normal
extent, nor was any definite alteration to be noted in the size
or structure of the various collections of grey matter situated in
the medulla.

The anterior pyramids stained by Pal’s method exhibited a
darker staining on the right side than on the left (Figs. 8
and 9). The nerve-fibres on the latter side were not conspicu-

F ig. 8.

Transverse section of the medulla oblongata, three millimetres below the
olivary bodies, and just above the decussation of the pyramids. The
medulla is somewhat flattened in front on the left side. The same
marked disproportion between the anterior pyramids, a. p., is to be noted
as in Figs. 6 and 9, but no marked asymmetry is seen in the arrangement
of the rest of the nervous tissue. In the middle line, lying behind the
anterior pyramids, is the superior pyramidal decussation, and on each
side of this the formatio reticularis, between which and the pyramids lies
on each side the lower end of the corresponding accessory olivary
nucleus. In front of the superior pyramidal decussation is the grey
matter surrounding the central canal. Posteriorly are to be noted, pro¬
ceeding from within outwards, the gracile and cuneate nuclei and the
tubercle of Rolando, r., right; l., left. Stained by Pal’s method, x 2.

ously smaller than on the former, but were separated by a certain
amount of unstainable material. There was, therefore, in the
medulla, unlike the spinal cord, some degree of sclerosis of the
left pyramidal tract. No such difference in the colour of
analogous portions of the medulla, white or grey, was noted
elsewhere.

The cerebellum .—There is little further to be said of the
cerebellum. Microscopic sections in various parts, particularly
the uvula, pyramid, tonsils, and the cuneate and central lobes,
were in every respect natural. Sections of the ganglia of the

Digitized by v^.ooQLe

402 CHANGES IN THE NERVOUS SYSTEM, [July,

medullary centre also failed to exhibit any marked change.
The restiform bodies and superior peduncles, as mentioned
elsewhere, showed no structural change.

The pons Varolii .—Microscopical sections of the pons
Varolii exhibited an asymmetry similar to that noted in the
medulla oblongata, and, like it, affecting only the anterior part
of the section, though to a lesser degree. Beyond the
diminished size of the left pyramidal tract there was little
further to note. The fillet, the tegmentum, the posterior longi¬
tudinal bundles, the descending roots of the fifth nerves, and

Fig. 9.

Transverse section of the upper end of the medulla oblongata at its junction
with the pons. The section is asymmetrical, the left side being smaller
than the right owing to the extremely small size of the anterior pyramid,
a. p., on this side. In this, as in the preceding figure, the right anterior
pyramid is more deeply stained than the left. Behind the pyramids, on
each side of the middle line, are seen the olivary bodies, the left coming
nearer to the median raphe than the right; and still more posteriorly the
formatio reticularis, lying upon which beneath the floor of the fourth
ventricle on each side of the middle line the hypoglossal nuclei are
situated, separated from the reticular formation by the posterior longi¬
tudinal bundles. External to the hypoglossal nuclei lie the auditory
nuclei, not well outlined in the figure. Behind and external to the
olivary bodies the ascending root of the fifth nerve, v. a., is imperfectly
seen, and dorsal to this the restiform body, in relation to which the fibres
of the eighth nerve appear on the right side. The portion of the section
lying behind the anterior pyramids is asymmetrical, but presents nowhere
any clear evidence of defect. R., right; L., left. Stained by Pal’s
method, x 2.

the various masses of grey matter, all alike appeared equal on
the two sides and of normal aspect. The various tracts of
nerve-fibres exhibited no difference in staining reaction by Pal's
method on the two sides; in particular it was not possible to
recognise any sclerosis of the left pyramidal tract. So far as
could be judged, also, the condition of the larger nerve-cells in

Digitized by

Google

1903.] BY J. O. WAKELIN BARRATT, M.D. 403

respect of their number, size, and pigmentation was equal on
the two sides.

The mesencephalon , tkalamencepkalon , and prosencephalon.
—As these structures were examined together by means of
frontal vertical sections, it will be convenient to consider them
together.

As regards the mesencephalon, no marked change was noted
in the corpora quadrigemina, which were equal on the two sides.
The superior brachia were not so well seen as is usual, but were
equal on the two sides. The left inferior brachium was present,
but was much smaller than the right. The tegmentum, the

Fig. 10.

Transverse section at junction of the mesencephalon and pons. Asymmetry
is present, affecting only the anterior part of the section, being confined
to the left crus. The remaining structures in the section are well
developed, being quite free from atrophy. In the middle line, and
penetrating a short distance between the bundles of the crura, are some
of the fibres of the upper end of the middle commissure of the cerebellum
darkly stained. More posteriorly is seen the fillet, which is prolonged
backwards on each side, and is equally developed in the two halves of
the section. The lower end of the locus niger, intervening between the
fillet and crus on each side, is not shown in the figure. Dorsal to the
fillet in the middle line is the tegmentum, between which and the grey
matter bounding the aqueduct of Sylvius lie the posterior longitudinal
bundles, also of equal size. Still more posteriorly are seen the fourth
nerves, decussating in the valve of Vieussens. r., right; L., left.
Stained by Pal’s method, x i|.

posterior longitudinal bundles, and the upward continuation of
the lemniscus were also unaltered, while the grey matter
around the central canal, in the tegmentum, and in the locus
niger was similar in the two halves of the section. The
diminished size of the left crus as compared with its fellow has
already been mentioned ; no clear indication of sclerosis by
Pal's method could, however, be here recognised.

Digitized by v^.ooQLe

404 CHANGES IN THE NERVOUS SYSTEM, [July,

The thalamencephalon, as has been stated above, was wasted
on the left side. Frontal sections stained by Pal's method
showed that this wasting did not affect the anterior nucleus of
the left optic thalamus, which by contrast formed a striking
object in the section, from the lower end of which the bundle
of Vicq d'Azyr, which was free from atrophy, descended. The
mesial and lateral nuclei, arid still more the ventral nucleus, of
the left optic thalamus were considerably atrophied. Both the
grey and the white matter were affected, especially the former.
The subthalamic tegmental region also shared in the atrophy,
but it was difficult to decide upon the degree to which its
individual constituents were involved, as the structures below
the left optic thalamus in this region could not readily be sub¬
divided. The middle commissure was present. The mam¬
millary bodies and their tracts were of equal size and similar
structure on the two sides. The right optic nerve was of good
size and equal development; on the left side von Gudden’s
commissure was atrophied, but the lateral root was of good
development. The external geniculate bodies were of nearly
equal size, but the left internal geniculate body was very
atrophied and its cells degenerated, while the right appeared
much larger than natural.

The lenticular nuclei, as far as could be judged, were equal
on the two sides. It was not so easy to compare them as it
was to compare the optic thalami, because in the sections the
former were found to be much more asymmetrically placed than
the latter. Thus in Fig. 4 A, for example, the left lenticular
nucleus was larger than the right, while in Fig. 4 D the reverse
was the case. Owing to a certain degree of displacement of the
lenticular nuclei relatively to each other, it was not possible to
cut the two nuclei at the same time in the same position, but
so far as an opinion could be formed the lenticular nuclei had
escaped, the left not showing any change as the result of the
cortical lesion. The various divisions of the lenticular nucleus
were well defined on the two sides, and preserved their relative
proportion, while no clear alteration of either white or grey
matter was discernible.

The left caudate nucleus was also unaffected. The large
cells of this nucleus were similar in size and number to those
on the opposite side.

Sections of the left internal capsule stained by Pal’s method

Digitized by v^.ooQLe

1903 -]

BY J. O. WAKELIN BARRATT, M.D.

405

showed no alteration in the anterior limb, but the posterior limb
was narrowed (cf. Fig. 4 D), the diminution in size as seen in
sagittal section being greatest in the interval between the optic
thalamus and the upper part of the globus pallidus. In this
situation, however, there was not, so far as could be judged, any
diminution in size of the nerve-fibres, nor was there any recog¬
nisable increase of neuroglia.

The condition of the left optic radiation of Gratiolet and
inferior longitudinal bundle was, like that of the internal cap¬
sule, more readily observed in sections stained by Pal’s method
than in macroscopic sections of the chrome-hardened brain.
Fig. 4 B shows this joint bundle to be defective at the junction
of middle and lower third ; microscopic sections showed that
the defect involved both constituents, the portion of the inferior
longitudinal bundle which was totally absent being greater than
that of the optic radiation, while elsewhere the narrowing of the
former was similarly greater than that of the latter. This
narrowing is not accompanied by any very obvious alteration of
the size of the individual nerve-fibres, though, owing to the small
size of the latter, observation of calibre is difficult. On the right
side the inferior longitudinal bundle was stained darkly, while
the optic radiation was relatively lightly stained, this being the
relation usually observed when these structures are healthy.
On the left side this separation of the two tracts was not every¬
where distinct, and when present this relation was reversed, the
inner tract being slightly darker than the outer.

The long association bundles of the cerebrum were well
developed on the left side only at some distance from the area
of defect, and the degree to which they persist may be judged
by studying Figs. 4 A, 4 B, 4c. In the neighbourhood of the
cortical defect, as these figures show, a mottled appearance was
seen in the white matter. Stained by Pal’s method, the white
matter was here found to consist in many places of neuroglia
quite free from nerve-fibres, or containing such only in very
small numbers.

The cortex of the cerebrum exhibited on the left side the
same appearance as on the right, except at the edge of the
area of defect, where the different layers of nerve-cells became
represented by a single layer of cells showing little cell-proto-
plasm and no distinct cell-processes.

xlix. 29

Digitized by

Google

40 6

CHANGES IN THE NERVOUS SYSTEM,

[July,

Review.

Further reference must now be made to the nature of the
lesion causing porencephaly, and the resulting changes in the
central nervous system must be very briefly summarised and
criticised.

As regards the nature of the lesion, this was obviously
vascular in origin, since it corresponds very closely to the area
of distribution of the left middle cerebral artery. This vessel
must have been blocked just beyond the point at which the
lenticulo-striate branches were given off. Concerning the
cause of the blocking, it is not improbable that this was the
result of an embolus detached from a cardiac valve exhibiting
vegetations, for at the autopsy valvular heart disease of old
standing was found ; and there is a family history pointing to
rheumatic fever in patient’s brother. As, however, the artery
was patent at the time of death, though smaller than its fellow,
it would appear that the plug did not permanently obstruct the
vessel, but that the lumen was subsequently restored, though
only after destruction of the corresponding area of the brain
mantle had occurred.

Turning now to alternative theories, we may consider first
thrombosis of the artery in question, dependent upon localised
arterial disease. This appears improbable, since it implies
disease at a single spot in a single arterial wall, all the other
vessels apparently escaping. Similarly haemorrhage appears
to be excluded by the entire absence of any localised thicken¬
ing of the membranes of the brain, and again by the affected
area coinciding so closely with an arterial area. The latter
circumstance is also opposed to intra-venous thrombosis having
led to the cortical defect.

The age at which the lesion occurred was probably eleven
or twelve months, when the first fits were observed. The few
particulars collected respecting the birth of the patient .are
perhaps not very reliable, since they were obtained at second
hand from the patient’s brother thirty years later. If, however,
the belief expressed that delivery was not difficult be correct,
then the possibility of the cortical defect being due to birth-
palsy—that is to say, to injury during or resulting from delivery
—is negatived, a conclusion which seems supported by the
limitation of the cortical area referred to above.

Digitized by

Google

1903.3

BY J. O. WAKELIN BARRATT, M.D.

40;

To sum up, all the evidence available points to the cause of
the porencephaly being embolism of the left middle cerebral
artery occurring towards the close of the first year of life.

Turning now to the resulting changes in the central nervous
system, these may be summarised as follows:

1. There was a defect in the brain mantle on the left side
involving the operculum, the island of Reil, and the superior
temporal convolution. The floor of this area was formed by
the remains of the subjacent white matter, which was very
defective in medullated fibres. The left hemisphere was small,
and had contracted upon the area of defect ; the left temporal
lobe, seen from below, was also defective in size. The inferior
longitudinal bundle on the left side was defective. As the
destructive lesion of the temporal lobe was confined to the
superior temporal convolution, it follows that the defective
nerve-fibres arose in this gyrus.

2. The caudate and lenticular nuclei were unaffected.

3. The left optic thalamus was atrophied, the atrophy
involving the lateral median and ventral nuclei (especially the
last), while the anterior nucleus was unaffected. The corpora
mammillaria remained intact. The left internal geniculate
body was very small; the right was unusually large. The left
optic radiation was atrophied. The atrophy of the optic thala¬
mus was entirely dependent on the cortical lesion, being outside
the vascular area involved in the latter.

4. The cortico-spinal and thalamo-spinal tracts coming from
the left hemisphere were markedly wasted in the mesencephalon,
pons, and medulla in comparison with the corresponding tracts
of the other side.

5. The cerebellum was normally developed.

6. The spinal cord exhibited a defect of the left antero-
internal column, while the right antero-lateral column was of
defective width opposite the base of the anterior horn. There
was also diminution in size of the right anterior horn.

Two further points may be referred to in conclusion. The
first is that the pia arachnoid was opaque and thickened over
both hemispheres, and that the right hemisphere also showed
some general wasting. This would appear to be independent
of the local cortical lesion, and to be of the same nature as the
brain atrophy, attended with thickening and opacity of the
pia arachnoid, seen in asylums in epileptic patients not exhibit-

Digitized by v^.ooQLe

408

CHANGES IN THE NERVOUS SYSTEM.

[July,

ing porencephaly. The second point is the non-development
of neuroglia in the spinal cord in the situation in which the
right crossed pyramidal fibres should be found, so that no
sclerosis is here recognisable* though a certain amount of
sclerosis is to be seen in the medulla oblongata in the left
anterior pyramid. This is apparently to be explained by the
circumstance that degeneration of the fibres descending from
the cerebral cortex and optic thalamus occurred before myeli-
nation was complete, and thus was attended with less sclerosis
than would occur had the myelinated fibres been fully deve¬
loped.

( ! ) Reference may be made to the cases recorded by Mott and Tredgold,
“ Hemiatrophy of the Brain and its Results,” Brain, vol. xxxiii, 1900, pp. 239—264;
and by David A. Shirres, “ On a Case of Congenital Porencephalus,” Studies from
the Royal Victoria Hospital, Montreal, vol. i, No. 2, 1902. Further references are
given in these papers.

Fio. 4 a. —Frontal section of the brain in the plane A A, Figs. 2 and 3. The
depth of the area of destruction of the brain tissue of the left hemisphere is shown.
Its floor is formed partly by grey and partly by white matter. The chief branches
of the middle cerebral artery are readily recognised on both sides. The left hemi¬
sphere is smaller in section than the right in this and the two succeeding sections.
Owing to the asymmetry of the brain, the section is oblique as regards the basal
ganglia and the optic tracts, opt. tr. In consequence of this the lenticular nucleus
and the tail of the caudate nucleus appear larger on the left side than on the
right. The right optic thalamus is much larger than the left; this is in part
because the latter is cut more anteriorly than its fellow (cf. Fig. 4D). Below
the corpus callosum lie on each side the lateral ventricles, and in the middle
line the fornix. Beneath the fornix lies the third ventricle divided into two parts
by the middle commissure. Still lower are seen on each side the corpora mam-
miliaria, c. m. On the right side the descending horn of the lateral ventricle is seen.
The anterior portion of the left superior temporal convolution, T 1, is seen in the
section (compare with Fig. 2). asc.fr. f, ascending frontal fissure, f. S., poste¬
rior limb of the fissure of Sylvius. T 2, T 3, T 4, T 5, second, third, fourth, and fifth
temporal convolutions respectively. This and the succeeding three sections
represent the brain hardened in potassium bichromate, x f.

Fio. 4 B. —Frontal section of the brain in the plane B B, Figs. 2 and 3. The floor
of the area of destruction of brain tissue is now formed by the remains of the
white matter, which exhibits, as in Figs. 4 a and 4 c, a mottled appearance. The
first left temporal convolution has nearly disappeared, only a portion of its white
substance remaining. The section is somewhat oblique in respect of the basal
ganglia. The left optic thalamus is smaller in section than its fellow, and the left
claustrum is irregular in aspect. Below the corpus callosum are seen the lateral
bands of the fornix, external to which lie the lateral ventricles. Lower down in
the middle line the supra-pineal recess and veins of Galen are seen, and also the
pineal recess, which lies a little to the left of the middle line. Next comes the
posterior commissure, beneath which is seen the upper end of the aqueduct of
Sylvius. On each side is seen the inferior horn of the lateral ventricle, lying
external to the corresponding hippocampal gyrus. /. R., fissure of Rolando.
coll.f., collateral fissure. The other letters as in the preceding figure, x f.

Fio. 4c.—Frontal section of the brain in the plane C C, Figs. 2 and 3, towards
the posterior limit of the area of defect, and immediately behind the posterior
extremity of the corpus callosum. The floor of this area is formed by the remains
of the white matter. The optic radiation and inferior longitudinal bundle taken
together are thinner on the left side below, where a defect is visible at the junction

Digitized by v^.ooQLe

1903.] SIGNIFICANCE OF CENTRAL CHROMATOLYSIS. 409

of middle and lower thirds, than on the opposite side. The lateral ventricles are
dilated; within them the choroid plexuses, also enlarged, are seen. cal.f. t calcarine
fissure. Other letters as in the preceding figure, x |.

Fig. 4 d. —Horizontal section of the Drain, made in the plane D D, Figs. 2, 3,
4 a, 4 b, 4 c. The section passes through the area of defect. The anterior portion
of the left island of Reil still persists, covered by the posterior extremity of the
third left frontal gyrus, which passes much farther backwards than on the right side.
Posteriorly the splenium of the corpus callosum is seen, with a portion of the
lateral ventricle, /. v. t containing the choroid plexus, bounding it on each side. In
front of the splenium is a portion of the velum interpositum, in which the two veins
of Galen lie; and anterior to this, in the middle line, the cavity of the third
ventricle is seen. Externally, on each side, lie the optic thalami, the left being
smaller than the right. Outside the thalami are the lenticular nuclei; the left is
slightly smaller than the right. The caudate nuclei, which lie more anteriorly, are
of equal size. The anterior limbs of the internal capsule are well developed on
both sides ; the left posterior limb is smaller than its fellow, and its anterior end
is indistinct. The basal ganglia are somewhat distorted on the left side. Between
the caudate nuclei lie the anterior horns of the lateral ventricles, separated by the
anterior pillars of the fornix and the septum lucidum, in front of which is the
genu of the corpus callosum, x }.

Concerning the Significance of Central Chromatolysis
with Displacement of Nucleus in the Cells of the
Central Nervous System of Man. By John Turner,
M.B., Senior Assistant Medical Officer, Essex Asylum.

A LARGE amount of both experimental and clinical work
has now accumulated around this subject. I need only briefly
mention the main results of the former, as they have been so
often referred to by others that they are now probably familiar
to all workers in this field.

Nissl, in 1894 or thereabouts, showed that shortly after
section or injury of the axons of the hypoglossal cells, these
cells showed alterations in their appearance. These were—
swelling, then dissolution of the central chromatoplasm, and
displacement of the nucleus towards the periphery of the cell.
After reunion of the axis-cylinders restitution occurred ; if re¬
union was prevented the cells, or many of them, degenerated
beyond repair. Further experiments showed that section of
any motor axons resulted in a similar change in their cells of
origin. Marinesco and others have amply confirmed these
results. As regards sensory cells, an important difference was
noted. Lugaro (1) claims to have been the first to demon¬
strate that section of the peripheral branch of the posterior

Digitized by

Google

410 SIGNIFICANCE OF CENTRAL CHROMATOLYSIS, [July,

root-ganglia sets up this change in their cells, but that section
of the central branch fails to produce any such change. He
now explains this on the assumption that the sensory neurons,
in common with other peripheral neurons, have great power
of repairing peripheral mutilations, and therefore they react
when their peripheral branch, but not when the central, is
injured.

Van Gehuchten (1897) and Warrington (1898) affirm that
by depriving cells of the influence of the afferent impulses
with which they are normally affected the change can also be
produced,—as, for example, when after the severance of the
posterior roots certain of the cells in the anterior horn become
affected.

I have not seen Warrington’s account of his experiments
published in the Journal of Physiology (vol. xxiii, pp. 112—

129), but Barker (The Nervous System , p. 299) gives a fairly full
notice of them, and reproduces some of the figures, and it is
from this source that I take my information. The alteration
was found especially to affect the dorso-lateral group of cells,
one of which is figured. This particular group is apparently
very prone to present such a condition ; so common is it in the
cords which I examine (from the insane) that very few fail to
show it. As will be referred to later on, the same condition
seems to be very general in the cells of the cuneate and
gracile nuclei and Clarke’s column.

Lugaro(i) has recently questioned the truth of this last
view; he does not believe that the typical picture of reaction d
distance can be produced in the way that van Gehuchten and
Warrington suggest. He regards central chromatolysis with
peripheral nucleus as a form of rejuvenescence of the cell in
association with regenerative activity in the injured nerve-fibre.
This is the view of van Biervliet and van Gehuchten, the
former of whom points out the resemblance the reacting cell
has to an embryonic nerve-cell. Lugaro states that types of
cells corresponding to the phases of reaction and repair are
found in certain stages of phylogenetic development.

So much for the experimental side of the question.
Clinically these cells have been met with in the cortex in a
large number of cases, which present both on the psychical
and physical aspects very varied symptoms. The reader
should consult the articles published in Brain , vol. xxiv,

Digitized by v^.ooQLe

I 903 -]

BY JOHN TURNER, M.B.

411

pp. 47—114, by Adolf Meyer, for full particulars regarding
these, where also he will find a bibliography of the subject;
and also the article published in the autumn number of Brain ,
1902, by S. J. Cole. This latter writer deals with the relation
of alcohol to this cell form. I have myself met with between
forty and fifty, and the large number which presented
psychically symptoms of depression led me to suggest that one
of the causes which is capable of setting up the change might
be a lack of sensory impressions passing to these cells from
the periphery, in accordance with the hypothesis that I, some
years ago {Journal of Mental Science , vol. xlvi), advanced, that
states of depression depend on defects in the afferent or
sensory side of the nervous reflex arc.

I have recently re-examined my cases with reference to (1)
the precise character of the cell change ; (2) its incidence in
other parts of the central nervous system besides the cortex
cerebri; (3) the locality and nature of the degeneration, if any,
in the axons in their passage along the cord ; and (4) the nature
of the psychical disturbances associated with these changes ; and
as this has led to some modification in my views I herewith
give a short account of the conclusions I have arrived at.

At the outset I would remark that I have never maintained
that the cell change is a cause of the melancholic condition—
quite the reverse; I hold that the melancholic condition is the
cause (one of the causes) of the cell change, or, more precisely,
that the physical changes underlying the melancholic condition
are accountable also for the alteration in the nerve-cells.

In a communication to this JOURNAL (October, 1900) I drew
attention to the occurrence of this cell change in imbeciles, and
suggested that in these cases also this was the result of paucity
of normal impressions impinging on the cells. Its occurrence
here is difficult to explain, either by the direct toxic theory or
the axonal reaction theory. In this class of cases the cells, so
far as my experience goes, do not show an advanced condition
of the change ; they are large, plump, and still retain well-
developed chromophilic flakes, peripherally and in the den¬
drites, and the nucleus, although displaced, presents an
entirely normal appearance. In earlier communications I
referred to this form as an early stage of reaction d distance .
This I now believe to be incorrect.

It seems to me highly improbable, for example, in Case 3,

Digitized by v^.ooQLe

412

SIGNIFICANCE OF CENTRAL CHROMATOLYSIS, [July,

an imbecile who died at the age of 35, referred to later on, that
these cells were in a transition stage towards a more grave and
irreparable lesion. I see no reason to suppose if this man had
died at a much earlier date, or if he had lived many years
more, that any other than this condition of cells would have
been met with. Fifteen days in the case of injury to axons
(as by haemorrhage) is long enough for advanced changes
to manifest themselves (shrinking, complete absence of chro¬
matoplasm, and very pronounced nuclear changes), and
therefore a lesion of the axons in these imbeciles is impro¬
bable ; a direct toxic action on the cells themselves is also
highly improbable. I believe that it can be most feasibly ex¬
plained here as the result of a state of defective development.
It may be, as Lugaro suggests, that these cells represent
phylogenetically an immature form. I prefer to regard them as
immature, owing to unfavourable conditions of cell environment.
The greater development of the efferent nerve-cells usually
found in man is in all probability associated with the wealth of
sensory impressions they receive. In imbeciles there is un¬
questionably not only a lack of afferent impressions from the
periphery, but also an even greater lack of impressions of an
associative nature—impressions from one cell to another.

I have divided my cases into two classes, in one of which the
cells are similar to those just described ; and these I term the
imbecile type. In the other class are placed those cases where
the change is much more pronounced, so that the nucleus is
more or less affected ; and these I term the genuine axonal
reaction type.

A. Imbecile Type .

The chief characteristics of the Betz cells in this class are—

1. Large size with rounded outline. In many the border of
the cell has an indefinite or frayed-out appearance, such as is
often seen in animals.

2. Well-formed Nissl bodies are present in the apex, den¬
drites, and at the periphery of the cell body, while the centre
has a pale, finely granular appearance.

3. The nucleus is markedly displaced, and may even bulge
out the cell border; but it is large, round, and clear, and
presents a normal appearance.

Digitized by

Google

1903.] by JOHN TURNER, M.B. 413

Vortex cells are common (noted in six out of sixteen cases).

Meynert’s columns are always well defined.

The cortical arterioles are generally thickened, or show an
increase of nuclei in their walls, or have a hyaline appearance
(noted in fourteen out of sixteen cases).

I will now give a short account of the cases in which I have
found this type of cell.

No. 1.—A. S—, female, was never very bright ; got worse at
age of 19. When admitted was fairly nourished ; palate high,
narrow, and asymmetrical; pasty complexion ; imbecile aspect;
smiled and displayed her gums when spoken to; was very
taciturn ; speech fairly clear. Very little information could
be elicited from her. She could tell the number of her
brothers and sisters. Obstinate and perverse. Remained dull
and inanimate, sitting all day unoccupied. Habits dirty;
rarely speaking. Died, after five years’ residence, of tubercular
enteritis, aet. 27.

Autopsy .—Body fairly nourished. Beyond the ulcers of
caecum, colon, and ileum, and an adherent (organised) clot in
the superior longitudinal sinus, nothing was detected to call for
notice in the viscera.

Microscopical examination showed small tubercles and
caseous deposits in the lungs, and the liver showed advanced
fatty degeneration ; the kidneys were natural.

No. 2.—R .T—, female, an imbecile incapable of looking
after herself. Mother a drunkard ; father died of phthisis.
Is eldest of seven ; the others show no mental defects. On
admission was thin, with a rather narrow and highly arched
palate. Very childish and amiable; sits and plays with a doll,
and chuckles when spoken to. Speech very indistinct. She
does as she is told. Beyond having to be dressed and kept
clean, she gave no trouble. Died after seven years’ residence,
aet. 24, of general tuberculosis. At the autopsy the body was
emaciated. Tubercular ulcers were found in the intestines and
a small cavity in one lung. The brain was firm, but otherwise
appeared natural. The kidneys and liver appeared natural,
but were not microscopically examined.

No. 3.—T. E—, male, imbecile suffering from epilepsy ;
sufficiently intelligent to work in a jute factory before his

Digitized by ^.ooQle

414 SIGNIFICANCE OF CENTRAL CHROMATOLYSIS, [July,

admission here. He was 16 years old when admitted, had
frequent and severe fits, and prior to and after them was often
maniacal and violent. He was very impulsive, and on several
occasions had bitten other patients very badly. He was active
and in good health until several months prior to death, during
which time he was confined to bed suffering from phthisis, of
which he died at the age of 35. At the autopsy the body
was fairly nourished. The upper lobe of the right lung was
solidified, and contained many caseous areas. The brain was
firm, but otherwise natural, as also were the other viscera.

No. 4.—S. M—, female, congenitally defective mentally ;
mother of eight children, one of whom was imbecile. She
became worse (mentally) after the birth of her first child, and
since then had been obstinate, sulky, and troublesome. Kept
her bed for some time prior to admission. On admission was
thin and badly nourished, had a surly, forbidding aspect, and
lay huddled up in bed. She would not reply to questions, and
was very resistive. Refused food, and struggled without making
any noise when she was fed through the nasal tube. Was
dirty in her habits ; often very noisy at night. Later on she
began to talk a great deal in a childish, querulous way ; now
ate ravenously. Her legs became contracted, and she developed
a bedsore, and died of pneumonia, aet. 45, three months after
admission. At the autopsy nothing was found in the viscera
to call for remark beyond the pneumonic condition of the lungs,
degenerated coronary arteries, and some shrinking at the
vertex of the brain. The kidneys and liver were examined
microscopically : the former showed some thickening of the
capsule and the arteries, and a small cyst was found; the latter
was in a well-marked state of fatty degeneration. The
posterior spinal ganglia were examined, and the cord for tract
degeneration. The cells of the ganglia did not present the
appearance of axonal reaction. In the cord there was very
slight (practically negligible) Marchi reaction in the posterior
columns, and crossed pyramidal tracts in both the cervical and
lumbar regions. The posterior nerve-roots at their entrance to
the cord were markedly degenerated in the lumbar region, not
at all in the dorsal or cervical regions. The anterior nerve-
roots in the lumbar region also showed considerable Marchi
reaction.

Digitized by v^.ooQLe

I 903 -]

BY JOHN TURNER, M.B.

415

No. 5.—M. F—, an imbecile woman, but with sufficient
intelligence to be an useful house worker. When admitted in
1888 was maniacal and troublesome, but quieted down after
ten months, and remained for ten years a fairly intelligent and
very industrious woman, but weak-minded, flighty, and talka¬
tive. At the end of this period she developed acute melan¬
cholic symptoms, refused food, and emaciated. For the last
year of her life she was a deplorable, miserable-looking
creature, sat all day in a chair, unoccupied, and died at the age
of 49 of pneumonia. At the autopsy there was found
consolidation of both lungs posteriorly. The heart, as is usual
in imbeciles, was very small (139 grammes). The intestines
showed commencing colitis. The brain showed some shrinking
at the vertex, and the lateral ventricles were dilated. The
liver and kidneys were examined microscopically ; the former
showed some increase of interlobular tissue and thickening of
the capsule ; there was some increase of interstitial tissue in
the kidneys. Besides the brain cortex the cells of the cuneate
and gracile nuclei and Clarke’s column were affected, but not
the anterior horn-cells of the cord or those of the posterior
root-ganglia. The cord showed insignificant recent degenera¬
tion of the crossed pyramidal tracts in the cervical and dorsal
regions, and none in the lumbar.

No. 6. —F. B—, female, chronic melancholia with probably
congenital defect. Always more depressed at night. She had
a high, narrow, and asymmetrical palate. After four years’
residence as a quiet, industrious woman, she developed (result
of a fall) cellulitis of one leg with extensive suppuration. She
rapidly became demented and depraved in habits, and died.
At the autopsy the brain, thoracic and abdominal viscera ap¬
peared fairly healthy. On microscopical examination of the
kidneys a slight increase of interstitial tissue was noted, and
the liver showed slight fatty changes. Osmic acid preparations
of the cortex (ascending frontal) showed a natural condition of
the tangential fibres and of the fibres of the medullary portion.

No. 7. —A. E. B —, female, aet. 36, suffered from agitated
melancholia. She had a high, narrow, and V-shaped palate.
At the autopsy no evident changes were noted in the viscera.
Microscopical examination of the kidneys and liver showed

Digitized by v^.ooQLe

416 SIGNIFICANCE OF CENTRAL CHROMATOLYSIS, [July,

that the former were healthy, and that there was very slight
fatty degeneration of the cells of the liver.

No. 8.— E. S—, female, aet. 52, suffered from agitated melan¬
cholia passing into dementia ; palate rather high and narrow.
At the autopsy no very evident cause for her death was found.

Besides the Betz cells those of the cuneate and gracile
nuclei and Clarke’s column were affected, whilst those of the
anterior horns of the cord and the posterior root-ganglia were
not. Practically there was no evidence of tract degeneration
in the cord beyond one or two scattered fibres in the crossed
pyramidal tracts of cervical, dorsal, and lumbar regions.

No. 9.—E. E— , female, suffering from agitated melancholia,
died of pneumonia and pleurisy at the age of 40. There was
a history of alcoholic intemperance in this case. Her kidneys
were tough and contained cysts ; microscopically they showed
increase of interstitial tissue, especially marked just beneath
the capsule, and some fatty degeneration of the renal cells.
The liver showed fatty infiltration. Besides the Betz cells
some of the fore-horn cells of the cord, especially in the lumbar
region, and also some of the posterior root-ganglia cells, were
affected.

Nos. 7, 8, and 9 were more fully described in the British
Medical Journal, October 26th, 1901, “The Physical Basis of
Melancholia.”

No. 10.—H. H—, female, suffering from an acute attack of
agitated melancholia subsequent to influenza. Was only a few
days in residence when she died, aet. 60. Her kidneys were
small and granular.

No. 11.—J. C—, female, senile melancholia; died after a
month’s residence, aet. 67. Had large granular kidneys.

No. 12.— E. H—, female, chronic melancholia of several
years’ duration ; died aet. 73. Had small granular kidneys.

No. 13.—J. P—, male, admitted in an acutely melancholic
condition ; constantly groaning and ejaculating that he is the

Digitized by v^.ooQLe

* 903 .]

BY JOHN TURNER, M.B.

417

most miserable man in the world. Died after five months*
residence, aet. 68. His kidneys were in a state of chronic
interstitial nephritis, with numerous small cysts. Liver natural.

No. 14.— M. A. F—, a female, senile melancholia ; died of
chronic Bright’s disease, with small granular kidneys, aet. 73.

The last two cases I shall refer to did not present symptoms
of depression : both were demented, the man apparently a
recent case, but no history could be obtained ; the woman
probably congenitally defective, with very bad family history.

No. 15.—F. R—, male ; was admitted in a dazed condition ;
faulty in habits, sitting in one posture all day. He died after
a month’s residence, aet. 38, of bronchitis.

No. >16.—H. R—, female, admitted in a maniacal condition,
ultimately passing into a state of secondary dementia. Her
father and father’s sister had been insane, and one of patient’s
sisters was imbecile. Her palate was rather high and narrow.
She died set. 35, and at the autopsy her stomach was com¬
pletely filled with pieces of blanket, sheeting, and hair. Her
kidneys were healthy to the naked eye. Besides the Betz
cells, many of the posterior ganglia-cells were affected, but not
those of the anterior horns of the cord nor the Purkinje cells
of the cerebellum. Her cord showed well-marked old dege¬
neration in the posterior columns in cervical, dorsal, and
lumbar regions, but the crossed pyramidal tracts were appa¬
rently unaffected.

In the above list of cases five were undoubtedly imbecile,
and eleven (including one of the former) were melancholic.
Nos. 10 to 14 inclusive occur in old people.

It is interesting to note that the ill-formed palate, Clouston’s
deformed type, one of the physical stigmata of congenital
defect, is very commonly met with in those not classified as
imbecile {vide Nos. 6, 7, 8, and 16). We shall, however, point
out that this type of palate is not unfrequently associated with
the second class of cases.

I have noted the condition of the kidneys and liver, because
disease of these organs, especially the former, is very commonly

Digitized by v^.ooQLe

418 SIGNIFICANCE OF CENTRAL CHROMATOLYSIS, [July,

met with. Although it would seem to be a factor predisposing
to the condition of nerve-cells, yet it is not an essential one, for
in Nos. i, 2, 3, 7, 15, and 16 these organs were natural
(1 and 7 examined microscopically).

B. Genuine Axonal Reaction Type .

The second type of cell is met with under very varied con¬
ditions both physically and mentally. As I believe that
lesion of the axon is a factor in all these cases, I have termed
them the genuine axonal reaction type in contradistinction to the
first class, in which, probably, the axon is not at fault, and
which are therefore not instances of axonal reaction at all,
although the form of cell simulates it. Whether this condition
of the axon is a secondary result following a lesion of the cell
is a moot point. The weight of evidence, in my opinion, is in
favour of the view that the cell is implicated secondarily to the
axon.

These (Betz) cells present the following features:

They are in the majority of instances small, angular, stain
very lightly, and show practically no Nissl flakes. Very often
a large mass of pale yellow pigment lies all along one side of
the cell—the side most remote from the nucleus. The
nucleus, beyond being much displaced, is generally shrunken
and denser than usual; in some cases, however, it may be large
and ruptured.

I have notes of eighteen cases which correspond to this
type. It will not be necessary for my present purpose to give
details of them, as the form of cell change seems to have no
definite connection with the mental aspects of the cases.

Eight of these had an undoubted alcoholic personal history.
In five the palate was badly formed. The kidneys were
granular in five, and in one large and pale.

The cord was examined for tract-degeneration in two—one
with an alcoholic history, the other without. In both cases
very marked signs of recent degeneration were found in the
crossed pyramidal tracts.

In one case the condition was undoubtedly due to lesion of
the axons ; in this, after a haemorrhage of fifteen days* dura¬
tion, which had destroyed one internal capsule, the cells on the
side of the haemorrhage alone were affected. This case is

Digitized by v^.ooQLe

I 903 -]

BY JOHN TURNER, M.B.

419

interesting as showing the length of time which is sufficient to
set up very advanced changes when the axons are affected.
The cells on the side of the lesion were pale, shrunken, with¬
out chromatoplasm, and the nuclei were profoundly affected.

As regards the incidence of the change in other nerve-cells,
I may say that in this class, as in the first, the hypoglossal cells
are rarely affected, whilst those of Clarke’s columns and the
cuneate and gracile nuclei almost always are.

I am very doubtful whether this condition of these cells has
any pathological significance, at all events when the nucleus is
merely displaced and the peripheral and dendritic Nissl flakes
are well formed, for I have rarely examined any cases in which
these regions, especially the two latter, do not show it more
or less marked ; and I am inclined to think that a peripheral
nucleus and finely granular central chromatoplasm is a con¬
dition normal to these localities. Dr. J. J. Douglas ( Brit .
Med. Joum ., September 14th, 1901) has drawn attention to
the common occurrence of this condition in the cells of Clarke’s
columns.

It is not usual to meet with the alteration in the Purkinje
cells of the cerebellum in either class.

The conclusions I would draw are that we must not class
together as similar all cases of central chromatolysis with dis¬
placement of nucleus.

It may be due to two (perhaps more) different causes ; and
whilst in one of these classes the affected cells seem to bear a
definite relation to the mental symptoms of the cases in which
they occur, in the other they do not seem to have any such
relation.

The first type of cell is found in imbeciles and some melan¬
choliacs, especially senile melancholiacs. There is no evidence
in these that the axons are at fault, and they are met with
under conditions which are opposed to the view that they are
in an early transition state, tending towards a more marked
degree of cell change. In the case of the imbeciles there are
reasons for regarding them as a peculiar form of cell associated
with this defective mental state ; they represent immature cells
which have not fully developed owing to unfavourable environ¬
mental conditions, viz., a lack of sensory innervation. In the
case of the melancholiacs it seems probable that they are also
the result of defective innervation, especially liable to manifest

Digitized by ^.ooQle

420 ACTION OF THE ROLANDIC CORTEX, [July,

itself at an advanced period of life, when the metabolism is at
a low ebb. They would therefore represent a degradation or
dissolution of the cell whereby it reverts to an immature form.

The melancholic condition does not depend upon the
presence of these cells, but the cell condition is due to the
cause which on the psychical side manifests itself in depression.

Although both in imbeciles and melancholiacs, therefore, it is
supposed that the immediate factor which acts on and affects
the cells is similar, there* is no necessity to postulate any
psychical parallel between the two conditions. Whether the
above-mentioned factor operates on a fully developed nervous
system, or on one which is not fully developed, will determine
the respective psychical results following this change in the
cells.

In the other class the cell change is due either to direct
lesion of the cell bodies .or to a lesion of their axons. I am
inclined to think that, at any rate in the cases with an alcoholic
history, the second alternative is the correct one. And as
we are able to definitely assert that lesions to the axons will
set up the change in their cells of origin, I prefer to accept this
explanation in those cases where we find such a condition
rather than invoke another—a problematical cause about which
we have no certain knowledge.

Reference.

(i) Lugaro, ‘Riv. Speriment. di Freniatria,* 1902, f. i, p. 981 (account
taken from abstract by W. Ford Robertson, Review of Neurology and
Psychiatry, vol. 1, No. 1).

On the Action of the Rolandic Cortex in Relation to
Jacksonian Epilepsy and Volition . By A. B. Kings-
ford, L.R.C.P.Lond., M.R.C.S.Eng.

The feature of Jacksonian epilepsy to which I wish to call
attention is the periodicity of the discharge. Whether we
regard the lesion as “ irritative ” or “ discharging,” it is, at all
events, chronic; and whether we regard the discharges as going

Digitized by CjOOQle

I 903 -]

BY A. B. KINGSFORD, L.R.C.P.LOND,

421

direct from the cortex to the efferent nerve-cells, or as causing
convulsions in a more roundabout way through subcortical
systems, they are, at all events, periodic. How, then, do chronic
lesions cause periodic discharges ? The answer which I wish
to put forward is suggested by certain passages in Mercier’s
Psychology , Normal and Morbid , p. 283, which run as follows :
—Speaking of how organic bodies may contain a store of
motion which can be liberated by the impress of motion from
without, and after likening this property to that of animals and
their power of movement, the author continues, “But animal
organisms have a further property which most inorganic bodies
have not. They are continually adding to their stores of
motion, and by these continual additions their store at length
becomes surcharged. The tension of the contained motion
reaches such a pitch that the containing resistance is no longer
sufficient to keep it in bond, and it breaks out, possibly without
the provocation of added motion, certainly with minimal pro¬
vocation.” Later on, when discussing “Will and Desire,” ( 2 ) the
same author writes of nervous mechanisms, “ There are many
machines used in the arts, which depend for their actuation on
the gradual filling of a vessel with water. The vessel is of
such a shape and so supported that, as it fills, the centre of
gravity shifts, until, at a certain degree of fulness, the vertical
at the centre of gravity falls without the base; the vessel then
capsizes, empties its contents, regains its previous distribution
of weights, rights itself, and begins to fill once more.”

Let us extend the analogy a little.

Suppose the overturning of the vessel to be partly regulated
by an elastic string so as to allow of its filling a little more full
than it otherwise would without capsizing, then we can imagine
the arrangement and power of the string to be such as to allow
of the vessel discharging a little when the limit of stability was
passed, and to effect the righting of the bucket again before
much of its contents are emptied out. Suppose, moreover, the
upper end of the string to be fixed to the arm of a lever
capable of moving towards and away from the bucket under the
impress of external circumstances, e.g., the wind.

Some such an arrangement as this may be taken to represent
the Rolandic mechanism and its controlling action over (all)
subcortical centres in health.

Now let us suppose the elastic string to become weakened
xlix. 30

Digitized by v^.ooQLe

422

ACTION OF THE ROLANDIC CORTEX :

[July,

as by “ perishing,” then it might happen that the bucket could
never fill as full as it did at first without discharging some of
its contents, and that an excessive discharge would follow any
sudden inclination of the lever towards the bucket.

The action of a faulty control mechanism such as this
would be fairly analogous to that of the diseased Rolandic
cortex.

This point of view involves a twofold assumption :

1. That the discharges, causing convulsions, start from sub¬
cortical centres, and represent in fact a spontaneous overflow of
their continually accumulating energy.

2. That the function of the Rolandic cortex is to control
such discharges, and to determine their direction when allowing
them to issue.

As these assumptions are not warranted by any great
authority it will be necessary to examine the grounds for them,
commencing very briefly with the current theories of action of
the Rolandic area and the main evidences upon which they are
based. At the outset of our inquiry we are confronted by
considerable difference of opinion. Thus Schafer ( 2 ) says (of
the Rolandic areas), “In spite of the fact that movements have
resulted from their stimulation, we are not justified in terming
these portions of the cortex motor , but may regard them as
sensory, and may look upon the movements as being set up
by a motor-discharging centre elsewhere as the result of
nervous impulses reaching it from the sensory region of the
cortex.” While Ferrier ( 3 ) writes, “ Sensory and motor centres
are not coincident, or at any rate not co-extensive, in the
motor area. Sensation may be abolished by lesions altogether
outside the Rolandic area. Paralysis of cortical origin may be,
and frequently is, independent of impairment of cutaneous or
muscular sensibility in the paralysed limbs.” And Bastian,( 4 )
after denying the existence of motor centres in the cerebral
convolutions, says, “To argue that groups of cells have motor
functions merely because stimuli issuing from them evoke
movements when they impinge upon motor ganglia is quite on
a par with the argument that an organ has sensory functions
because fibres come to it from sensory cells.” Dr. Bastian
then continues, “ The centres in question are rather sensory in
nature, and are probably intimately concerned with certain
groups of kinaesthetic impressions, whatever other functions

Digitized by ^.ooQle

1903.] by a. b. kingsford, l.r.c.p.lond. 423

they may subserve or with whatever other centres they may
be in intimate relation.”

These extracts illustrate sufficiently for our purpose the
well-known controversy about the functions of the Rolandic
cortex, which might almost be called the battle-field of the
nervous system. The case for the existence of motor centres,
or even of sensori-motor centres, rests on the evidence afforded
post mortem by Jacksonian epilepsy and on the results of
experimental stimulation of the so-called centres in the higher
animals and in man.

On this point Sir William Gowers ( 6 ) says, “ Of all the
regional diseases of the brain in man, lesions of the convolu¬
tions stand almost alone as a cause of convulsion, and experi¬
ments demonstrate that irritation of the cortex in the motor
region has the same effect.” “The results of experiments
seem, indeed, conclusive.” Accepting Gowers* facts, I suggest
that the results of experiments are susceptible of another inter¬
pretation. Concerning these results Sir Michael Foster ( fl )
says, “In considering this point ” (/. e., the question of localisa¬
tion) “ it must be remembered how rude and barbarous a method
of stimulation is that of applying electrodes to the surface of
the grey matter compared with the natural stimulation which
takes place during cerebral action. The one probably is about
as much like the other as is striking the keys of a piano at a
distance with a broomstick to the execution of a skilled
musician.” Now if thumping a piano is at all likely to
damage it, much more must similarly “ barbarous ” treatment
be likely to damage the working of a far more delicate
mechanism such as the Rolandic cortex. And so Foster’s
simile warrants, I think, the hypothesis that the results of
experiments on the Rolandic cortex are attributable to the
injurious effect of the stimulation. Moreover Hitzig( 7 ) is
reported as saying that he “ found that simple exposure of the
pia is followed by marked injury to the convolutions lying
below, and that there is often implication of those contiguous
to them. The uncovering of the membrane of the motor zone
led not only to motor impairment in the extremities, but also
—save in one case—to impairment of vision, and in all the
cases to impairment of the reflex movements of the eyelids.”
It is generally agreed among physiologists that whatever other
functions the Rolandic cortex may have, it has certainly some

Digitized by v^.ooQLe

424 ACTION OF THE ROLANDIC CORTEX, [July,

inhibitory power. In 1892 Dr. James Shaw ( M ) wrote, “ Inhibi¬
tion is primarily a function of the motor area,” and since that
date Sherrington (and others) have brought forward evidence
sufficient to prove it.C* 7 ) Whatever the exact nature of inhibi¬
tion may be, it must mean exertion of force through some
distance, involving a continuous expenditure of energy while it
lasts. Any damage done to the Rolandic mechanism is likely
to impair its working. As with disease, so with injury—in
either case there may be, as Mercier says, increase of process;
but there must always be defect of function, and this, I
believe, is the true explanation of the apparently active
response to electrical stimulation on the part of the Rolandic
cortex—namely, diminution of its inhibitory action leading to
over-action or discharge of the lower automatic centres. That
even a minimal stimulation is on the way towards causing
damage serious enough to interfere with function is extremely
probable when we consider, that prolonged stimulation causes
visible hyperaemia with convulsions, and that a condition of
disturbance quite invisible is likely to interfere with the
function of so delicate a mechanism as the Rolandic cortex.
But to regard the case as one of defective action of the
Rolandic cortex only is, I think, to take an incomplete view of
the relation of the upper and lower centres. If the latter
are constantly being charged with motion, as suggested by
Dr. Mercier, derived chiefly from the food assimilated, how is
this motion distributed ? What becomes of it more especially
when the organism is at rest ? Now the upper centres are
often spoken of as storehouses of motion or nervous energy,
and from whence (apart from the food) is their energy stored
up ? I would suggest that when the supply of energy in the
lower centres exceeds the demand, during the intervals of
quiescence, such excess may pass off to the upper centres and
there be stored up for future use, undergoing perhaps some
change of form in the process—just as the energy of an
electric current may be stored in the form of energy of
chemical separation in a secondary battery. But the body
itself presents a still more suggestive analogy. Sugar is inter¬
mittently thrown into the portal blood-stream in larger
quantity than is required at the time, and is accordingly
stored up in the liver, undergoing a change of form into
glycogen in the process, and is restored to the blood in a

Digitized by v^.ooQLe

I903-]

BY A. B. KINGSFORD, L.R.C.P.LOND.

425

continuous, though variable stream, as required by the organism.
Now, if matter may undergo this kind of storage, why may not
motion, since both are forms of potential energy, and the
storage of either is an economy? For I take it that the
inhibitory action of the upper centres on the lower is a steady
output of motion or energy tending to preserve and build up
those lower centres when partially exhausted, in return, so to
say, for the surplus motion intermittently received from them
when replete. So much for a possible mode of inhibition,
considered as a nervous economy. There is yet another point
of view from which inhibition appears an economy in the
scheme of the nervous system. It has been shown, as already
stated,( 8 ) by Sherrington and others that there are certain
definite inhibitory centres in the cortex, and, moreover, that
some of these are in close proximity, not to the supposed
excito-motor centres for the same group of muscles, but to
those of their respective antagonistic group of muscles. From
the point of view that all the centres are fundamentally
inhibitory', it would seem that agonist and antagonist centres
are so coupled together that on receipt of a volitional stimu¬
lus the inhibitory action of the agonist is lowered, with a
corresponding increase in the inhibitory action of the anta¬
gonist. The experiments of Dr. Charles Beevor ( 9 ) favour this
view, for he has shown that while directly antagonist muscles
are relaxed, the synergic muscles may be, and generally are,
called into play. Now it is obvious that in any such exercise
as walking it is an economy of force to lower the resistance
against which the agonist group has to work, and still more
of an economy if the very process of lowering the resistance of
antagonists is, from another point of view, a storing up of energy
in them ready for their turn to become agonists. Such, I
believe, is what actually occurs, for when antagonists are relaxed
there must be a diminished output of that form of energy from
lower, perhaps spinal centres, which maintains muscular tone,
and such diminution implies a damming back of the ordinary
continuous outflow, t. e. y a storing up of motion. The calling into
play of synergic muscles along with the directly agonist muscles
is thoroughly in harmony with the action of lower centres
educated (so to say) by volitional methods, as will be shown
later. Furthermore, if it be true, as I suggest, that even
minimal stimulation of the Rolandic areas disturbs them

Digitized by v^.ooQLe

426 ACTION OF THE ROLANDIC CORTEX, [July,

enough to check or even stop their action for a time, it becomes
easy to understand why mechanical stimuli should have so little
effect. Such gross forms of stimulation can hardly disturb,
without destroying, so delicate a mechanism. To borrow again
Foster’s simile, it is like thrusting a broomstick among
the wires of a piano in search of harmony. Thus the
inhibition hypothesis of Rolandic action has advantages
over current doctrines as regards both economy and sim¬
plicity. It is now necessary to see how far any such theory
can account for the phenomena of volitional, and of involuntary
or automatic, actions, and for the paralysis due to removal of the
Rolandic areas. We may take the latter first, as. the study of
paralysis will necessarily help us to distinguish the volitional
components of actions, the execution of which is largely
involuntary in detail. That the paralysis caused by removal,
destruction, or physiological isolation of the Rolandic areas in
the lower animals is a purely volitional one is evident from the
behaviour of such animals after operation. Broadly speaking,
such animals are capable of gratifying their natural desires ; the
lower the animal in the vertebrate scale the less the removal of
even the whole of its cerebrum seems to interfere with its daily
routine. All the actual movements of such higher animals as
the rabbit seem perfectly adapted for the gratification of its
ordinary desires ; what it has lost with its cerebral hemispheres
is mainly memory of special movements acquired by education,
and of the complex perceptions which help to control both them
and conduct generally. Thus a rabbit runs heedlessly past a
heap of carrots, only avoiding it as an obstacle, while a dog is
for ever on the move, and wastes rapidly in spite of feeding
ravenously. As far as the actual movements are concerned,
Foster says that a dog whose Rolandic cortex has been removed
“ can, after recovery from the operation, carry out voluntary
movements so well that it is difficult to detect any deficiency in
this respect.”( w ) Again, if in the dog, says Foster, “the pyramids
in the bulb be divided without injury to the cortex, but with
consequent degeneration of both pyramidal tracts below the sec¬
tion, such a dog is able, apparently, to execute all the ordinary
voluntary movements of which a dog is capable, though no re¬
generation of the pyramidal tracts takes place.”( 29 ) And Schafer,
speaking of removal of one cerebral hemisphere in dogs by
Goltz, says, “ Such animals . . . show in their ordinary move-

Digitized by v^.ooQLe

1903.] by a. b. kingsford, l.r.c.p.lond. 427

ments an extraordinarily slight amount of motor paralysis,
though apparently rendered incapable of performing such a
purely volitional acquired action as the giving of a paw.”( s0 ) In
monkeys which are subjected to similar experiments like results
have been obtained, but generally with more extensive and
more permanent loss. Moreover in them a wholly new phe¬
nomenon makes its appearance, viz., the contracture which follows
removal of their Rolandic centres, and which follows also lesions
of the corresponding parts of the brain of man. “ This state of
hypertonicity,” Schafer suggests, “ may be due to the cutting off
from the lower centres of the inhibitory impulses which they
habitually receive from the cortex cerebri, while excitatory
impulses which reach them from the cerebellum are still
passing.^ 10 )

These facts suggest that the mainspring of all movements is
essentially automatic, but with a constantly developing voli¬
tional control as we rise from the fish to man ;

That the controlling or volitional elements become the pre¬
dominant feature of the most highly organised animals and
man, and is proportional to the complexity of their environ¬
ment ;

And that in form the volitional element is entirely inhibitory,
what is called an act of will being simply a special relaxation,
diminution, suspension (or failure) of inhibition.

The facts both of physiology and pathology point to the
Rolandic cortex and pyramidal tracts as the organs through
which such control or volition is exercised.

Both Foster and Schafer agree in stating that there are
undoubtedly two paths of volitional impulses, and so far as I
can find this is not disputed. Foster, in 1897, left the question
of the function of pyramidal tracts quite open.( n ) After dis¬
cussing the effect of section of the pyramids, he says, “We
can hardly doubt that while the pyramidal tract was intact the
animal made use of it, and we may further infer that the move¬
ments of a dog without the pyramidal tracts are different from
those of a dog in which these are intact, though we cannot
state exactly what the differences are.” And Schafer ( 12 ) quotes
Donaldson as saying, “ The activity of the lower level cells
is in all animals brought about by two sets of impulses, the
one set derived from the sensory nerves passing from their
termination in the grey matter of the lower level centres either

Digitized by v^.ooQLe

428

ACTION OF THE ROLANDIC CORTEX,

[July,

directly to the motor cells, or more probably through inter¬
mediary cells, which play an important part in effecting the co¬
ordination required for purposeful movements. The other set
of impulses, also in the first instance derived from the sensory
nerves, pass to the cortex, and are thence sent down (perhaps
along the fibres of the pyramidal tracts) to the motor nerve-
cells, or rather probably also to the intermediary co-ordinating
mechanism. In the lower animals this second set plays an
insignificant part in producing the ordinary co-ordinated move¬
ments of the animal ; in the higher animals an important part,
so that, in them, the cutting of it off from the lower centre
cells removes a great part of the impulses by which they are
normally stimulated.”

Now it is only the conclusion Donaldson arrives at which I
venture to differ from. We have evidence of some inhibitory
function exercised by the Rolandic cortex, and also that when
lesions cause degeneration of the pyramidal tracts contractures
set in (in most monkeys and in man) from over-action of lower
centres due to loss of control. We are therefore entitled to
assume that the pyramidal tract is the path of inhibitory influ¬
ences. We have seen, furthermore, that animals deprived of
their hemispheres exhibit not only loss of memory and percep¬
tion, on which volitional control is largely based, but also
of acquired movements; and the destruction of either the
Rolandic cortex or the pyramids deprives the animal of all
the actions which he has learnt by education, e. g ., giving the
paw. This brings us at once to the question of the part played
by volition in the execution of movement. It is obvious that
volition plays no part in the actual execution of movements
which are effected unconsciously, but can only appear when the
execution of movements is based on some conscious memory of
similar movements in the past. Such revival serves the purpose
of further adaptation of movement in one of two ways, i. e. y
intensively or extensively. The adaptation is intensive when
the correspondence, with an unvarying environment, is made
more perfect or complete, as in learning to cycle or firing at a
target. And it becomes an extensive adaptation when more
variable circumstances are taken into account, as when the
cyclist learns polo or the rifleman goes sniping. This is the
educational function of volition in the regulation of movement.
The other function is that of suspension of action, which may

Digitized by v^.ooQLe

1903 -]

BY A. B. KINGSFORD, L.R.C.P.LOND.

429

come into play either when the mind is made up, pending the
arrival of the right moment for action, as when the prize-fighter,
with every muscle tense, watches his opportunity to deliver a
“ settler ; ” or to gain time for irritation to cool, as when a man
pockets a vindictive letter at the pillar-box for re-perusal in the
morning. Here the inhibitory character of the volition is most
apparent, and usually adds enormously to the effectiveness of
the action when it comes at last. The arrangement of the
pyramidal tracts, distributed as they are to the whole series of
motor centres (or their intermediary connections) in the spinal
cord, strongly suggests that these tracts constitute the pathways
through which this volitional control is exercised. This
mechanism might indeed be compared, functionally, with those
of some Invertebrata, described by Dr. Haycraft, which are so
well adapted for securing sudden and effective leaping move¬
ments of the whole organism. Apart from the formation of a
decision—the process, that is, of willing, with which we are not
immediately concerned,—this is the only part which volition
takes directly in the execution of well-adapted movements,
namely, that of releasing the trigger or letting go. Indirectly
volition plays a further part in the reinforcement of actions, as
in volition with effort; but this is not directly associated with
the execution of movements, and only clumsily so at best. It
has, moreover, an explanation of its own. This view, which
assigns to volition only a transitory rdle in the execution of
particular movements, allows it much greater scope in the
regulation of series of movements or actions, and a predomi¬
nance over combinations of series of actions or conduct. In
general, all that we are vividly conscious of is the aim in view ;
thus we wish to be on the opposite side of the street, and forth¬
with we make series after series of movements with that aim in
view, and presently find ourselves at our goal—sometimes,
indeed, far beyond it for want of attending to our automatic
actions. Not merely are we hardly conscious of our move¬
ments, but similar series may be successfully carried out in the
complete unconsciousness following an epileptic fit. Moreover
any interference with the automatic processes is prone to spoil
the performance. Apart from the possibility of all our ordinary
movements being carried out involuntarily in certain abnormal
states of consciousness, e.g :, after epileptic fits, in somnambulism,
and when hypnotised or under the influence of alcohol or drugs,

Digitized by

Google

430 ACTION OF THE ROLANDIC CORTEX, [July,

we have the further facts that though muscles may be paralysed
as far as the execution of the will is concerned, they may still be
quite capable of giving expression to emotions, notably in the
case of those supplied by the facial nerve when it is affected by
supra-nuclear palsy. And Beevor ( 13 ) says that in hemiplegia
you may have the latissimus dorsi paralysed as an arm muscle,
but functional as a bilateral muscle of expiration, and contracting
when the patient gives a voluntary cough. From which it is
clear that the machinery is sufficient without volition for the
execution of all completely adapted movements.

The mode of expression of emotions Mr. Darwin ( u ) says is
innate or hereditarily organised, and, though more modifiable
by circumstances acting through the will than reflex actions,
is less plastic than the instincts of recent acquisition. Such
instincts are the mechanisms whose state of repletion has the
conscious accompaniment called Desire, and whose overflow is
controlled to a greater or less degree by the higher centres of
volition according to the organisation of the instinct. Those
instincts which have unduly escaped from such control and
gained an independence which is unserviceable to the organism
are those described by Dr. Mercier as parasitic mechanisms ;
and these actuate conduct or the more complex series of
actions in ways inimical to the interests of the organism, just as
the lower centres actuate the simpler series of movements in
ways inimical to the safety of the organism in Jacksonian
epilepsy. The defect in both cases I believe to be essentially
defect of control of the lower by the next higher centres, the
difference being merely one of the relative rank of the lower
centres in the two cases, for the lower or instinctive centres of
conduct would perhaps be higher than the controlling centres
of mere movements. We have, then, the three modes of origin
for movements—the instinctive, the emotional, and the reflex,—
not sharply marked off from one another, but differing in their
progressive independence of volition. The question next
arises how far in volition we have another mode of originating
movement. Such initiation I believe to be an indirect one
only. Along with the revival in memory of ideas of actions
there comes the idea of the association of pleasure or pain with
the action contemplated, and in correspondence with which
comes a secondary desire to realise the pleasure or avoid the
)ain, as the case may be. And this secondary desire may

Digitized by CjOOQle

! 9 ° 3 -]

BY A. B. KINGSFORD, L.R.C.P.LOND.

431

powerfully reinforce, or inhibit, the primary one, and determine
the balance between desire and control. The more vivid and
extensive the memory of the associated relations of pleasure
and pain, the greater will become the influence of the control
over the desire, and the more elaborate the mechanism under¬
lying concurrently progressive desire and control. That such
progressive development has taken place in man seems
suggested by his brain structure, with its enormous controlling
agency—the last to be developed in the individual,—and by
the progressive development of similar though inferior agencies
in the lower animals, especially mammals, culminating amongst
them in man’s nearest relative, the ourang. Now the remark¬
able fact of there being two volitional tracts, as described by
the best authorities—an indirect or subcortical, and a direct or
pyramidal one,—seems quite in accordance with the view that
the subcortical one serves for the direct initiation of movement
through desires,and the pyramidal for inhibitory control of move¬
ments, a control which has obviously increased in man, as his
Rolandic centres and pyramidal tracts have, as compared with
those of other mammals. Foster speaks of the indirect route
as apparently falling into disuse, which suggests that the
direction of movements, becoming more and more referred to
the controlling centres as man’s correspondence with the outside
world increased, has now become very largely a matter of
relaxation of inhibition. Be this as it may, it seems that it is
only because the enormous majority of men’s actions are in the
educational stage referred to, and worked through the Rolandic
centres, that the paralysis caused by their destruction in him is
so much more complete than in the lower animals, especially
when we reflect that the limb muscles are for many purposes
always being educated, and that those whose education is most
complete are just those which escape most and recover most
readily after lesions causing pyramidal degeneration.

It might be supposed that destruction of part of the Rolandic
system and corresponding loss of volitional control should leave
the lower centres all the more free to act with the production
possibly of movements or convulsions ; but you cannot alter one
part of an organisation and leave all the rest just as before.

First there is the effect of shock, which is proportionate to the
size and importance of the part removed, and the brunt of
which falls on the most elaborately organised of the mechanisms

Digitized by

Google

432 ACTION OF THE ROLANDIC CORTEX, [July,

associated with the mutilated part, while the simpler and more
completely organised mechanisms recover more quickly, and
also more completely. Thus the operation may permanently
alter the relation between subcortical and spinal centres for the
worse.

Secondly, the removal of a constant controlling force should
result not in spasmodic actions, but in a chronic overflow of
energy from the lowest and least affected mechanisms. And
this is just what we see in the early and late rigidities, due
largely to over-activity of spinal centres, and affecting both
agonist and antagonists simultaneously.

Furthermore, on our hypothesis the accumulation of energy in
the subcortical centres would especially be interfered with, i. e .,
any excess from time to time might very well leak away and be
lost as one of the consequences of the operation. Suppose, how¬
ever, we could by other than surgical means suspend or diminish
the controlling influence of the cortex with minimum disturbance
of the subcortical centres ; then we might well expect to get
some display of automatic action. And so we do, as is seen in
the automatisms (often very elaborate) which follow attacks of
petit mal, in somnambulism, and in hypnotism. The basal
elements conspicuously lacking in all these states are those of
conscious memory and perception, with their joint controlling
influence.

Whether the actions are due to spontaneous overflow, as in
petit mal, or to suggestion, from within, as in somnambulism, or
from without, as in hypnotism, the striking feature of them all
is the faulty or defective adjustment to the totality of the en¬
vironment. The difference between them and the convulsions
of Jacksonian epilepsy seems merely the difference between the
plane of combined series of movements called actions and the
plane of mere movements ; as we know that the Rolandic cortex
is the seat of the trouble in the latter, we may fairly assume that
in the former the defect is one of association systems next above.

Another mode of diminishing cortical control is by adminis¬
tration of anaesthetics, and the automatisms to which these give
rise are distressingly obvious both to the anaesthetist and the
surgeon, and sometimes to the friends of the patient.

Before passing on to see how this hypothesis harmonises
with the leading features of epilepsy, it is well just to say that
however doubtful may be the possibility of “ stimulating ” the

Digitized by

Google

1 903 -]

BY A. B. KINGSFORD, L.R.C.P.LOND.

433

Rolandic cortex to action, there is no doubt that other and
lower parts of the nervous system may be so stimulated. That
there is some essential difference between the two is evident
from the difference of the curves obtained. The difference is
probably one of completeness of organisation with a corre¬
spondingly stereotyped character of response. It is quite con¬
ceivable that the responses of subcortical parts of the brain
to stimulation may be nearly as stereotyped as that of a piece
of nerve, seeing how stereotyped by practice become our
actions and habits.

The characteristic feature of an epileptic discharge is the
progressive and correlated increase of the violence of the spasms
and the intervals between them. Commencing with contrac¬
tions so small and so frequent as to appear fused in the
so-called tonic spasm, the intermissions soon become more
evident, and the separate spasms more forcible, till the last of
all, which generally comes with surprising violence just when
the fit appears to be over. This feature, as Dr. Mercier( 16 )
pointed out long ago, is suggestive of a discharge taking place
against an increasing resistance, resembling, as it does so
closely, the discharge of electric sparks from a static machine
while the distance between the conductors is being slowly in¬
creased.

In our case the tendency to discharge on the part of the
automatic centres must lessen with every actual discharge
which takes place. So an uniform resistance would suffice to
prolong the intervals between the discharges. But the general
fact that the discharges, as measured by the force of the
muscular contractions to which they give rise, increase pro¬
gressively in amount, proves that usually the resistance is an
actually increasing one. If so, whence comes this gradually
increasing resistance ? It is difficult to believe that it also is
a function of the same centres which are discharging at the
moment from “want of stability.” Thus Gowers ( 16 ) says, “ The
process of inhibition which plays so prominent a part in many
minor attacks, and in the initial stage of many severe seizures,
seems at present to baffle our efforts to explain it.

“It was formerly regarded as the result of an increase in that
resistance in the nerve-centres which normally controls and
limits nerve activity. The resistance was supposed to be a
function pf nerve-cells related to, but distinct from, that which

Digitized by

Google

434

ACTION OF THE ROLANDIC CORTEX,

[July,

causes their discharge. But when scrutinised this is merely a
translation of the phenomena observed into terms of nerve
physiology. The fact of ‘ inhibition/ of arrest of action, is
certain, bu* its nature is not elucidated by its description as
increased resistance. 1 We need to have some conception of
the process by which activity is permitted and prevented, and
of that we have at present no discernment.”

That there is indeed a difficulty is more than evident when
we compare with this what Mercier said of the action of nerve-
centres generally and the muscles they serve. The passage
runs thus :

“ That a stimulus is necessary to set the centre in action all
will admit, but that another is necessary to terminate the
action will be to many a new proposition. But yet it is
sufficiently obvious. It is no more possible that the centre can
stop of its own accord (unless, indeed, it be entirely exhausted)
than that it can start of its own accord. For a centre to cease
acting from sheer exhaustion is so extremely rare that it
virtually never occurs in the normal organism.”( 17 ) Further
on the same author says, “ We must, therefore, conclude that
the action of nerve-centres is arrested .... by the impact
of an extraneous force.”( 18 )

Here is not only a recognition of the difficulty, but, as I
think, a foreshadowing of the way out of it. For if we suppose
that the actual discharge takes place from the parts below the
cortex—the mesencephalon (and, perhaps, cerebellum),—and
that the cortex exercises only the function of inhibition (which
function,.Gowers [ 19 ] says, is certainly exercised somewhere, and
which Sherrington has shown to be a function of the cortex),
the difficulty so completely exposed by Gowers vanishes.
For it is easy to imagine that, though in disease the normal
output of inhibitory current from the Rolandic cortex—the
normal rate, i. e ., of conversion of potential into kinetic energy
which the maintenance of such current implies—may be below
par, there yet may be some store of potential energy available
for conversion on particular occasions. It is, further, easy to
imagine that such conversion may take time, whatever its
determinants, just as the conversion of liquid nitrous oxide into
laughing gas takes time, and can only continue at a rate pro¬
portional to the .access of heat, or thermal energy, from without.
Now when we consider the relative complexity of the processes

Digitized by v^.ooQLe

1903-]

BY A. B. KINGSFORD, L.R.C.P.LOND.

435

which determine a development of inhibition on the plane of
action, it seems more than probable that such development
may require a relatively considerable time.

On the one hand, it seems clear that the ultimate effect of
the majority of stimuli must be mainly inhibitory; otherwise,
with a progressive intelligence and an increasing correspondence
with an ever-widening environment (and the susceptibility to
its manifold stimuli which that implies), man must surely have
become the most restless animal on the face of the earth.

So far is this from being the case that, while a busy man is
respected as one whose activity is productive, a mere busy¬
body is said to run about “ like a dog in a fair.*’

On the other hand, it seems clear, too, that stimuli can only
act as inhibitory influences indirectly in the first instance, i. e.,
by a revival in sequence of a group of nerve-processes under¬
lying a state of incipient action, and of another group of
processes, the physiological substratum of some unfavourable
(or painful) memory, associated with the state of action towards
which those stimuli at first directly incite the organism. As
the sequence of presentation and inhibition becomes fixed by
repetition, the presentation itself, from being an exciting cause
of action, becomes the symbol of the unfavourable memory
which lapses from consciousness as the mechanism becomes
organised and the process itself correspondingly expedited.

In our case it may well be that such conversion of potential
into kinetic energy, which the regain of control by the Rolandic
area implies, may be chiefly determined by the sequence, on
innervation impulses, of the kinaesthetic impulses (unconsciously)
received from the tensely contracted muscles—a state of muscle
which, if too long continued, must from time immemorial have
been unfavourable to the organism.

The fact that a fit can occasionally be arrested by artificially
increasing the intensity of these impulses, as by forcibly resist¬
ing the movements of the limb, favours this supposition.

Furthermore it may possibly be that the action of a ligature
in arresting Jacksonian fits depends partly on the principle of
pressing the muscular nerve-endings as well as on the receipt of
painful impressions from the skin, which tend to excite the in¬
hibitory action of the cortex.

Moreover it is probable (as suggested by Dr. Shaw) that
these kinaesthetic impressions are (some of) the first to become

Digitized by v^.ooQLe

436 ACTION OF THE ROLANDIC CORTEX, [July,

associated with impressions of pain,—to exercise, that is, an in¬
direct inhibition by awakening a memory of unfavourable
experience in advance of a similar second experience. So we
may expect them to be the last to be lost in disease. A round¬
about process such as this will obviously require time, and that
time is not likely to be shortened by disease.

Here it is convenient to call to mind that just as the new¬
born infant is without control over its movements, so is the
whole of its Rolandic cortex inexcitable. Not that it is by
any means unable to move after birth, or, indeed, for some
months before, for its movements are excessive simply from
want of control—a control which develops pari passu with its
pyramidal tracts and the excitability of its Rolandic cortex.
Certain features of the anatomy and physiology of the inex¬
citable Rolandic cortex between the “ motor ” areas lend
support to the view that the “motor” cortex and the pyramidal
tracts are essentially inhibitory in function.

Thus it seems that after extirpation of these parts, more
especially towards the frontal region, the time of spinal reflexes
is shortened. And again, if these parts be stimulated by very
strong induced currents, in the dog, we have prolongation of
latency and diminution of intensity of such reflexes. Such
inhibitory effects, moreover, appear more marked in the front
than in the hind limbs, and to travel by both anterior and
antero-lateral columns of the cord.

Now if these areas are a species of foci through which the
complexus of nervous processes underlying perceptions and
ideas are brought to bear on “ sensori-motor ” centres (or, as I
should call them, inhibitory centres), and if the action of such
processes, etc., is mainly inhibitory—as I have endeavoured to
show,—there is no difficulty in understanding the loss of in¬
hibitory control which follows their removal. As for the
increased inhibition which follows their stimulation, it would
seem that here we may have another rough imitation of painful
or unfavourable stimuli transmitted along well-organised paths
to the “ motor ” inhibitory centres and heightening their
action. It remains now to see how far the inhibitory theory
may serve to explain some of the principal phenomena of
epileptic after-states.

First, the general distribution of symptoms as between arm
and leg is in accordance with the hypothesis of inhibition.

Digitized by

Google

1903.]

BY A. B. KINGSFORD, L.R.C.P.LOND.

437

Thus the more frequent commencement of unilateral convul¬
sions in the arm, its greater weakness, and, more frequently,
absolute paralysis, are all explicable by the supposition that
the control of the arm is more specialised in one hemisphere.
That paralysis may follow a “ sensory ” fit without any convul¬
sive manifestation, and that it is often in inverse proportion
to such local convulsions (when they do occur), requires a
further explanation.

Assuming with Gowers i 20 ) that the paralysis following a
sensory fit is an inhibitory paralysis, I suggest that whereas
the discharge—realised in consciousness as a sensation—
actually results in the liberation of motor discharges from
subcortical centres, through other than pyramidal pathways,
these motor discharges are overtaken and neutralised, so to say,
before their exit from the spinal cord by inhibitory currents
from the Rolandic cortex through the short cut afforded by the
pyramidal tracts.

The paralysis seems to me as possibly a result of the
reversal now obtaining of the normal relation between the
subcortical centres and those in the spinal cord. The latter
are now strongly inhibited, while the former are partially
exhausted.

A like explanation may serve to account for the dispropor¬
tion often seen between the motor spasm experienced and the
subsequent paralysis. Here, again, I suppose the paralysis to
be inhibitory, but that in these cases the belated inhibition is
only partially successful in arresting the convulsion.

The spasm is the outward expression of the difference
between subcortical motor discharge and cortical inhibitory
current; the paralysis the difference, so to say, between the
remaining available innervating energy of subcortical centres
and the cortical inhibitory resistance against which they have
to act. So, too, with the case recorded by Gowers ( 21 ) of
a patient who, after a slight and transient spasm of the
hand, “ felt as if the arm were being raised above the head in
violent spasm, while it was really hanging powerless by his
side.”

Here, on receipt of kinaesthetic impulses from the hand,
there seems to have been a confused realisation in consciousness
of the innervation current, which possibly would have proved
sufficient to raise his arm above his head in the manner
xlix. 31

Digitized by v^.ooQLe

438 ACTION OF THE ROLANDIC CORTEX, [July,

described but for Rolandic interference. His feeling, I should
say, was a kind of auto-suggestion.

Sir M. Foster has compared electrical excitation of the
cortex to thumping a piano. But the Rolandic cortex seems
to me more like the key-board of an organ, an instrument
charged with motion or energy and called into action from
time to time as that energy is released by the impress of
external circumstances.

The Rolandic cortex is the organ for the execution of
volition, and its influence on movement is like that of the
driver's hands on the progress of a carriage and pair, or a
cyclist's hands on that of a bicycle. While it has everything
to do with the direction of the movement, it has nothing to do
with energising it, and this is comparable with the action of
the coachman who checks his horses first on this side and again
on that. And just as after many repetitions the horses and
the cyclist may progress without either conscious guidance or
assent, so volitional acts become concurrently perfected and
involuntary. The action of synergic muscles seems to illus¬
trate the influence of volitions on movements. They shape the
movement, so to say, by subtraction. Thus Beevor(**) says,
“If you take hold of an iron bar and supinate as hard as you
can, you will find your triceps is contracting strongly, but as
soon as you flex the elbow-joint the triceps leaves off. The
same thing holds good, but less so, in the case of pronation.
The pronators of the arm are the pronators radii teres and
quadratus ; but as the former is a slight flexor of the elbow-
joint, when you pronate you also flex the elbow-joint. And
there, again, the triceps steps in and prevents the elbow from
being flexed.” The process of subtraction is clearly one of an
inhibitory kind, though partial in its application, preventing one
part of the action while permitting the rest.

Volition in the organism plays a part like that of law in the
body politic, which, though strong to restrain, is powerless to
drive, and is but a dead letter when not backed by a mass of
public feeling.

In his last work, Facts and Comments , Herbert Spencer
has insisted on the great importance of the feelings as the
mainspring of action. And Mercier,( M ) discussing “ Freewill
or Choice,” says, “Granting that the willing is the choice of
one mode of action rather than another,.will is

Digitized by v^.ooQLe

1903 -]

BY A. B. KINGSFORD, L.R.C.P.LOND.

439

only half accounted for, for we have yet to explain the power
behind the mechanisms, the influence of which determines that
any action at all shall be taken with regard to ... . circum¬
stances.As usually put, in every act there is the

choice and the motive for the choice; and while the choice is a
matter of judgment and attention, the motive is in every case a
desire, an instinct, or a quasi- instinct.*’ Thus desire and choice
make up the process of willing, while suspension of action
during the stage of judgment and attention, and “letting go”
or yielding to the prevailing desire when decision is reached,
make up the execution of the will. To take one more authority,
Professor William James,( 34 ) writing of “ Volitional Efforts,”
seems unable to come to any other conclusion than that “ for
scientific purposes one need not give up ” Professor Lipp’s
theory that “ so far from the feeling of effort testifying to an
increment of force exerted, it is a sign that force is lost, ....
even if indeterminate amounts of effort really do occur.”
“ Before their indeterminism,” James says, " science simply
stops;” *. e. y James is unable to identify any other factor in voli¬
tion than the determining factors already dealt with. “ The
operation of free effort,” says James,( 25 ) “if it existed, could only
be to hold some one ideal object a little longer, or a little
more intensely before the mind. Among the alternatives which
present themselves as genuine possibles it would thus make one
effective; and although such quickening of one idea might be
morally and historically momentous, yet, if considered dynami¬
cally, it would be an operation amongst those physiological
infinitesimals which calculation must for ever neglect.” If
volitional education is the process of suspension and letting go,
less and more, in accordance with the results of trials and error
—made under the impelling force of some primordial desire for
further adaptation,—and the whole execution of the will is no
more than this, what need have we for assigning any such func¬
tion as the term “ excito-motor ” implies to the Rolandic cortex
and pyramidal tracts, the undoubted instruments of volitional
execution ?

For my own part, I suppose that the feeling of effort is the
mental accompaniment of the nervous friction (if one may be
allowed such an expression) entailed by the rush of nerve-
currents from many associated areas towards one centre through
tracts which are as yet but little pervious. Pain seems like the

Digitized by

Google

440 ACTION OF THE ROLANDIC CORTEX. [July,

friction of organic life, and the feeling of effort seems somewhat
allied to it, while both friction and effort imply waste. The
essence of volition with effort seems to be suspension of action,
perhaps (through the pyramidal system) by the secondary, but,
as we say, higher desire, pending the arrival of reinforcements of
associated memories, etc., which ultimately may secure its satis¬
faction and its triumph over the lower desire.

Is there, however, any evidence more directly in favour of
my hypothesis than that hitherto brought forward ? The
case published by Oebeke, and quoted by Gowers^ 26 ) and
perhaps a somewhat similar case, observed by Gowers him¬
self, seem to furnish such evidence. Sir William’s descrip¬
tion of Oebeke’s case runs as follows :—“ A patient who had
been liable to general epileptic fits from birth was seized
in adult life with left hemiplegia, due, as was afterwards dis¬
covered, to haemorrhage in the central ganglia of the right
hemisphere. The epileptic fits continued to occur after the
onset of the hemiplegia, but affected only the unparalysed
side.” That is the description of the case, referring to which
later on Gowers again speaks of the lesion as occurring in the
central ganglia. Interpreting the meaning of the case, Gowers
says, “The arrest of conduction from the right cortex pre¬
vented the effects of its discharge, showing that the convolutions
of one hemisphere cannot act on the limbs of the opposite side,
at least to a considerable degree, through inferior commissural
connections.” But Gowers does not say whether the internal
capsule was involved by the lesion, and in the absence of that
evidence it seems to me as likely as not that the “ fons et origo ”
of the convulsive discharges was destroyed by the haemorrhage,
or, if not wholly destroyed, was so weakened as to more or less
restore the balance between its tendency to discharge and that
of the presumably weakened Rolandic cortex to restrain such
discharges.

Lastly, has this theory any bearing on treatment ? Now
certain convulsive diseases, like rickets, chorea, and hysteria,
are all markedly benefited by a high proportion of fat in the
diet, with massage and rest to promote its assimilation and
retention as useful auxiliaries. All these diseases are charac¬
terised by a defect of control. If epilepsy shares this feature
in common with the others it may be that like treatment would
prove beneficial for it too in early cases. The striking value

Digitized by v^.ooQLe

I 9 <> 3 ’] CLINICAL OBSERVATIONS IN ACUTE MANIA. 441

of a fatty diet in curing rickets seems especially suggestive, as
the convulsions of rickets, when neglected, seem so often to
pave the way for the permanent epileptic habit.

( l ) Psychology, Normal and Morbid, p. 301.—( a ) Text-book of Physiology, vol. ii,
p. 723.—( 3 ) Allbutt*s System, vol. vii, p. 304.—( 4 ) Brain as an Organ of Mind,
1890, 4th edit., p. 587.—(*) Epilepsy, 2nd edit., p.215.—( 6 ) Text-book of Physiology,
p. 1132.—( 7 ) Review of Hitzig’s book, Y. Med. Sci., January, 1903.—(®) Schafer,
Physiology, p. 712.— Clin. Journ., August ijth, 1902.—( 10 ) Schafer, Physio¬
logy, vol. ii, p. 731.—(“) Physiology, p. 1149.—( ia ) Schafer, Physiology, p. 703.—
( l3 ) Clin. Journ., August 13th, 1902.—( l4 ) Expression of Emotions in Man and in
Animals, p. 351.—( 15 ) Nervous System and the Mind, p. 54.—( w ) Epilepsy, 2nd
edit., p. 225.—( ,7 ) C. Mercier, Nervous System and the Mind, p. 73.—( ,8 ) Ibid.,
p. 74.—( ,# ) Schafer, Physiology, p. 712.—(**) Epilepsy, 2nd edit., p. 122.—( 21 )
Ibid., p. 123.—( n ) Clin. Journ., August 13th, 1902.—( a ) Psychology, Normal
and Morbid, pp. 323, 324.—( 54 ) Psychology, vol. ii, pp. 576, 577.—( a ) Ibid., vol.
ii, p. 577.—(**) Epilepsy, 2nd edit., pp. 103 and 218.—(^) Sherrington, Spinal
Animal, pp. 19, 20.— ( M ) Shaw, Epitome Mental Diseases, p. 223.—( a ) Foster,
Physiology, p. 1149.—C 30 ) Schafer, Physiology, ii, p. 704.

Further Clinical Observations in Cases of Acute Mania ,

particularly Adolescent Mania . By Lewis C. Bruce,
M.D., Physician Superintendent, Murthly.

Following up my observations made upon the blood of
patients suffering from acute continuous mania read before this
Association at the autumn meeting, I have been able to
observe three cases of acute continuous mania in adults which
relapsed while in the asylum. The results of the first series of
observations were that in every case of acute continuous mania
there existed a leucocytosis which persisted after recovery
indefinitely. I advanced the theory that this leucocytosis was
a protective leucocytosis. In the three patients who relapsed
the leucocytosis was found to have fallen to below 13,000
per c.mm. of blood, instead of being nearer 20,000 per c.mm.
of blood, which is characteristic of the recovered cases of
mania. The polymorphonuclear leucocytes averaged 60 per
cent, in two of these patients, and 47 per cent, in the third.
In one of these patients the attack passed off in two days, and
the leucocytosis at once rose to 25,000 per c.mm. of blood.
The other two patients passed into a definite second attack,
and their leucocytes averaged 15,000 to 16,000 per c.mm. of
blood, with a polymorphonuclear percentage of 60 or below

Digitized by

Google

442

CLINICAL OBSERVATIONS IN ACUTE MANIA, [July,

6o. The fact that the leucocytosis fell in each patient at the
commencement of the attack, and rose at once in the patient
who recovered from the relapse, strengthens the hypothesis that
acute continuous mania is an infective disorder, and that im¬
munity from maniacal attacks rests upon the resistive power
of the individual patient. This hypothesis receives further
support from the fact that there exists in the blood of patients
suffering from acute mania a specific agglutinin. During the
month of November a patient suffering from acute mania was
admitted to Murthly. The patient was so ill that I did not
think she would live many days. I isolated from the blood a
very small coccus, which was a pure growth, hut, as the
patient was exhausted, I regarded the organism as a terminal
infection. The patient improved, however, and three weeks
later I tested the agglutinative power of her serum upon this
organism in a dilution of i in 30. Agglutination was com¬
plete in three hours, while the serum of a member of the staff
in a dilution of 1 in 20 produced no action in twenty hours.
Since then I have made fifty agglutination tests with this
organism. Only ten of these cases, however, have been pure
cases of continuous mania. Eight gave a decided definite
agglutination, one was doubtful, and the tenth—one of the
patients above noted, who relapsed—gave no reaction. No
“ control ” serum ever gave a reaction, nor did the serum of
these patients suffering from mania agglutinate other organisms.
The agglutinin in the blood was therefore a specific agglu¬
tinin.

With regard to the observations made on cases suffering
from adolescent mania, I desire in the first place to explain
what I mean by the term “ adolescent mania.” The term
adolescent mania is used so loosely that it may include almost
any of the types of mental disease seen during adolescence.
The type of disease upon which the following observations
were made is a form of recurrent mania. Each maniacal
attack is of short duration—a few days to two or three weeks
at the very outside,—and between attacks the patient is appa¬
rently quite well. The attacks invariably set in with gastric
disturbance, the pulse becomes rapid, the arterial tension rises ;
the temperature may rise to 99 0 F., but rarely goes above
ioo° F. Sleeplessness is a constant symptom. Self-control
is lost rather suddenly as a rule, and the patient becomes

Digitized by v^.ooQLe

1903.]

BY LEWIS C. BRUCE, M.D.

443

acutely maniacal. The mania is of a type which might be
termed delirious, as little impression is left on the patient's
mind after the attack is past as to what has happened. The
pupils, as a rule, are widely dilated, the tendon and skin
reflexes are exaggerated, and the skeletal muscles present
jerking movements and fine fibrillary tremors. As the attack
wears off, the patient shows signs of exhaustion. The tem¬
perature falls to subnormal, and occasionally is paradoxical.
The pulse-rate falls, sleep returns, the patient takes food
greedily, and in a few days is apparently recovered. In the
periods between the attacks the patient is apparently healthy,
the only symptoms being a persistently high leucocytosis and
a rather low temperature, which every now and then becomes
paradoxical. The attacks come on irregularly ; in women some¬
times at the menstrual periods, but not necessarily so. In this
form of disease the menstruation in women may be irregular,
but rarely suppressed, as it is in other types of insanity occur¬
ring during adolescence. A recovering patient gains weight;
the attacks come on at longer intervals, and are shorter and
less severe. If recovery does not set in, each attack seems to
leave some damage behind, until finally, even in the intervals
between attacks, the patient is obviously insane. Even when
dementia sets in there are recurrent periods of excitement
with intervals of quiet. The patients were all well developed,
and no satisfactory exciting cause was ever detected. Heredity
undoubtedly is the predisposing cause.

The clinical observation to which, however, I devoted most
attention was changes in the blood. I have fairly recently had
four such cases under observation, and I examined their blood
continuously,—in one case for over six months. I found that
in every case there was a persistent leucocytosis, which im¬
mediately prior to an attack of mania fell somewhat, then
during the attack rose perhaps as high as 40,000 per c.mm. of
blood, and during the periods of interval fluctuated between
13,000 and 27,000 per c.mm. During attacks the polymorpho¬
nuclear cells were relatively increased, but at other times
averaged 60 per cent. After recovery the leucocytosis per¬
sisted. A patient discharged eighteen months ago was
examined last month, and the leucocytosis was 16,000 per
c.mm. I have only been able to examine in three cases the
agglutinative power of the blood upon the organism obtained

Digitized by v^.ooQLe

444 CLINICAL OBSERVATIONS IN ACUTE MANIA, [July,

from the case of acute continuous mania. All three agglu¬
tinated the organism completely in a dilution of i in 20. The
serum of six other cases of adolescent insanity which did not
present the clinical symptoms of recurrent mania failed to
agglutinate the same organism.

When one takes the clinical symptoms, the leucocytosis, and
agglutinative action in these adolescent cases, and compares
them with the same symptoms in acute continuous mania in the
adult, there is a striking resemblance. Everything points to the
fact that it is the same disease process modified by the age of
the patient. One further fact strengthens this hypothesis. On
purely empirical grounds I treated four cases of adolescent
mania with antistreptococcus serum. Injected subcutaneously
the serum produced no result. Given in 10 c.c. doses by the
mouth,the following were the results obtained:—In Case No. 1
there was absolutely no result. In Case No. 2, within thirty
minutes of the administration of the serum the patient became
quieter, the pulse fell from 1 o to 15 beats in the minute, and
the temperature fell i°, but the course of the attack was not
arrested. In Case No. 3, within fifteen minutes of the adminis¬
tration of the serum the patient regained self-control, the pulse
and temperature fell, and the effect lasted for about two hours.
A second dose of 10 c.c. arrested the attack. Two subsequent
attacks were arrested in the same way. The patient made a
good recovery, and I attribute the recovery to the action of the
serum. In Case No. 4 the administration of serum also seemed
to arrest the attack. On such slight grounds I cannot, how¬
ever, advocate the use of antistreptococcus serum in such cases.
I merely record the result of an empirical experiment as adding
support to the view that acute mania is an infective disorder.
During the attacks of mania the patients were confined to bed
and placed on milk diet. Between the attacks, exercise, baths,
and diet were all used to raise the patient’s resistive power to
the highest pitch.

The accompanying chart illustrates the clinical symptoms of
pulse, temperature, arterial pressure, and leucocytosis in an
adolescent female, aet. 21, who suffered from recurrent mania.

(The leucocytosis is represented by x-x, and the arterial

pressure by x • • • .) On June 28th the patient was con¬
valescing from an attack of mania. It will be noted that the
arterial tension is high and the pulse is rapid. On July 4th the

Digitized by

Google

$JUM ” I«

BY LEWIS C. BRUCE, M.D.

Digitized by

BISS

446 CLINICAL OBSERVATIONS IN ACUTE MANIA. [July,

pulse increased in rapidity. The arterial tension began to rise
on July 5th, and on July 6th the patient lost self-control and
became acutely maniacal. The leucocytosis on July 8th rose
to 26,000, and on the following day to 30,000 per c.mm. of
blood. The maniacal attack was over by July 13th. There¬
after the arterial tension and pulse-rate fell, and the temperature
became subnormal. The leucocytosis remained high, however,
with occasional unexplainable rises, as on July 23rd, when the
leucocytes were 28,000 per c.mm.

* The next maniacal attack commenced on August 18th, and
in every way resembled the attack shown on the chart so far as
temperature, pulse-rate, arterial tension, and leucocytosis went.

Discussion

At the Meeting of the Scottish Division at Glasgow, March 27th, 1903.

Dr. Alexander Robertson said he would like first of all to express the
pleasure with which he had listened to Dr. Bruce's paper. It was very pleasing to
know that so many of the younger superintendents of the asylums engaged in
work of this kind. He was not, however, quite sure that he altogether understood
what Dr. Bruce meant when he said that this condition of mania was an infective
disease.

Dr. Bruce. —I mean bacterial disease.

Dr. Robertson (continuing) said it was a most important conclusion to arrive at.
He would like to ask Dr. Bruce, and put it to the meeting generally, if the presence
of leucocytosis was not likely to be the effect of the toxin, the leucocytosis helping
recovery. Going further back than the toxin they might find that the cause was
a varied one similar to what they had been accustomed to look for, such as strain,
with, perhaps, an unstable building up of the nervous system. A very slight thing
might then cause an abnormal metabolism with all its attendant effects, and he
rather thought that that was the mode of progression in many cases of mania.
He held that the antistreptococcus serum was very uncertain in action. He had
used it, and the results were not at all satisfactory, and he would be inclined to
think that the recovery in the cases which Dr. Bruce had referred to might just
have been in natural course. At all events, he thought Dr. Bruce would require a
far greater number of cases than he had submitted to substantiate his views.

Dr. Marr said he had listened with very much pleasure to Dr. Bruce’s paper.
He had no experience of the particular forms of insanity that Dr. Bruce had
referred to, ana had not inquired into the phenomenon of leucocytosis qua in¬
sanity. In some cases of acute delirious mania he had used antistreptococcus
serum, but it had no beneficial effects. On the contrary, in one case it seemed to
have a bad result, and he had given up using it.

Dr. George Robertson said that he also had been very much interested in the
paper just read, and in Dr. Bruce’s facts regarding acute mania. Some eighteen
months or two years ago there was a run of new cases in the hospital with which
he was connected which had a typhoidal look about them, and on being examined
a large proportion of them had the reaction. Since then they had continued to
examine the blood, and in a great many cases—particularly those of a more or
less stuporous and confused nature—it was found that the reaction was given. He
had not been able to draw any definite conclusion from these facts, but he certainly
thought that antitoxins developed in the blood in the course of insanity, and that
good information was to be obtained by pursuing these investigations. It would
likely be found that there was no particular organism, but probably a large series
of organisms whose toxins produced a condition of insanity, and, amongst these,
probably the typhoidal organism was one which produced a condition of stupor or

Digitized by

Google

I903-] REMARKS ON SUICIDES IN PUBLIC ASYLUMS. 447

great confusion. He was sorry that his observations were not of a very definite
nature, but, so far as they went, they bore out Dr. Bruce’s results.

Dr. Yellowlees asked how Dr. Bruce had thoroughly satisfied himself that
these blood changes were the cause of the nerve disturbances, and how he had
become perfectly certain that they were not its results.

Dr. Easterbrook said he might mention that he had used antistreptococcus
serum in two or three cases, but without any great result or any particular benefit.

Dr. Bruce (in reply) said, taking up the first criticism as to how he knew that
the increased leucocytosis was the cause of recovery, he had never said for one
moment that it was the cause of recovery. It was merely an index of what was
going on in the body of the patient. All who knew Ehrlich’s theory of immunity
knew what a complicated theory it was. If his contention as to the causation of
acute mania was correct, then it followed that recovery from such conditions was
due to the formation of some antibody in the blood and tissues of the patient.
Such antibodies are produced not only by the leucocytes, but apparently by other
cells which are capable of forming antitoxins in the blood. He thought, however,
that most people, even Ehrlich himself, were willing to admit that the leucocytes
were the cells which contributed very largely to the formation of antitoxins in the
blood which brought about the result of immunity and recovery. It was wrong,
therefore, to say that the leucocytosis was a cause; it was merely an index of
certain tissue and chemical changes. If Dr. Alexander Robertson would do him
the honour of reading the last paper which he contributed on acute mania, and
which was published in the last number of the Edinburgh Neurological Journal ,
he would see that he had made continuous observations in quite a number of
cases; and if he looked at the last number of the Journal of Mental Science he
would also see that he had made observations in a good many cases where he had
introduced a c.c. terebene into the tissues subcutaneously. The result of this was
to induce a high leucocytosis. He had found that when a high leucocytosis was
induced the patient almost invariably improved. He did not bring it forward as
a method of treatment, but it did good in some cases, and in one or two cases it
actually cut short a maniacal attack. He brought it forward more as a physio¬
logical experiment, as it was interesting to know that by inducing a leucocytosis
some antibody was formed in the blood of the patient. Whether it was true or
not that maniacal conditions were due to the toxins formed by a great number of
organisms he did not know, but he was coming round more to the view that in a
great many cases the disease was due to the toxins of a specific organism; and
when they got that specific organism, then they would be able to apply the anti¬
toxin. He thanked the members for their attention.

Some Remarks on Suicides in Public Asylums . By

Harry A. Benham, M.D., Medical Superintendent, Fish¬
ponds Asylum, Bristol.

Gentlemen,— It is now some eight years since I had the
pleasure of receiving the South-Western Branch at this Institu¬
tion, and I take this opportunity of expressing the pleasure it
gives me to see you here to-day.

I was requested to contribute a paper at this meeting, and
came to the conclusion that it might be both profitable and
interesting to analyse the statistics relating to suicides which

Digitized by ^.ooQle

448 REMARKS ON SUICIDES IN PUBLIC ASYLUMS, [July,

have occurred in the public asylums of England and Wales
during a given period, in the hope that a useful purpose might
be achieved by a careful examination of the facts upon which
these statistics are based ; and finally, that by contrasting the
figures thus analysed with the ascertained facts it might be
possible to discover whether, to those who, like ourselves, are
responsible for the care and well-being of our patients, there
are any precautions left available to reduce still further the
percentages of suicides of those under our charge.

I have, therefore, taken the Blue Book annually presented
to Parliament by the Commissioners in Lunacy as my basis,
and subjected the figures to be found there to a tabular
analysis, under headings convenient for the purposes stated,
which is placed in your hands for reference ; I have also care¬
fully considered the detailed facts set forth in the same volume,
and drawn conclusions, after carefully examining the circum¬
stances under which in each case the act of suicide was
committed.

The reports available cover the years from 1890 to 1902,
thus embracing a period of twelve years—sufficiently long, I
think, to justify the adoption of any conclusions that may
be arrived at.

During this period 201 suicides occurred, 126 being men
and 75 women, out of something approximating to 788,000
under treatment, this being a percentage of 0 0025, or 2f per
10,000. In 30 cases, 17 men and 13 women, the act was
committed prior to admission. Ten men and 6 women com¬
mitted suicide after effecting their escape, and 11 men and 9
women did so after being allowed out on trial. Deducting
these numbers, it will be seen that 88 men and 47 women
actually committed suicide whilst in the asylum. I have
appended a slip to the table which I have placed before you
showing the manner in which the 16 deaths happened after
escape, thus reducing the suicides to 135, the number I
propose to consider.

On referring to the table you will see that of these,
40 of the men and 32 of the women were regarded as
actively suicidal ; and also that negligence was present in the
case of 27 men and 24 women, 51 in all ; whilst in 18 cases,
1 o men and 8 women, a doubt on this point existed ; so that
477 P er cent • of the men were actively suicidal and 68 per cent.

Digitized by v^.ooQLe

I 9°3-]

BY HARRY A. BENHAM, M.D.

449

of the women, and that negligence was found to exist in 30*6
per cent, amongst the men and 51 • 1 per cent, amongst the
women. The conclusion to be drawn from these figures is
that in both instances there was less care and discretion shown
by those who were responsible for the care of the women. You
will also observe that in 112 cases the act was committed by
day, and in 29 by night. Of those committed by night I
found that negligence existed in 18 cases, 10 men and 8
women, and in one case it was dbubtful if this were so.
Taking the suicides committed by night, the smaller number is
probably accounted for by the fact that not only is a smaller
number of hours in question, some of which are passed in
sleep, but also that all the suicidal patients are at that time
concentrated in observation dormitories. Such is the result of
my investigations. It would be interesting to know whether an
examination of the same facts and figures by, say, some of
those who are listening to this paper, would lead even approxi¬
mately to the same conclusions.

As to the means adopted for committing the suicidal act,
hanging heads the list, a little over 50 per cent, of the total
number adopting this method, viz., 46 men and 26 women.
Cut throat comes next, 15 men and 3 women having effected
the act in this way.

A glance at the table will enable you to see the proportion
in which other methods were successful.

I now propose to offer a few observations on the means
adopted for the prevention of suicide, not with the idea that I
am suggesting anything novel, but in the hope that by eliciting
some exchange of experience, or even expression of opinion, I
may be doing something helpful to us all in the treatment of
these most anxious of all cases. It is only at these divisional
meetings that we seem able to bring forward examples of our
everyday work and compare notes, so to speak, to our mutual
benefit and advantage.

In this asylum all suicidal and homicidal patients sleep
under observation, as do all newly admitted cases, until, in the
opinion of the medical officers, they can safely sleep else¬
where. For the first three nights all newly admitted patients
sleep in blankets only. All suicidal patients are concentrated
in two, or at the most three wards, each of which is specially
staffed. Caution cards, as approved by the Commissioners in

Digitized by

Google

450 REMARKS ON SUICIDES IN PUBLIC ASYLUMS, [July,

Lunacy, are in use in these cases, and these are revised
monthly or oftener. No hat-pins are permitted to be worn by
nurses when on duty. In the wards the uniform cap is only
permitted to be fastened with a safety pin. A uniform hat is
provided for outdoor wear, to which an elastic band is attached,
and nothing else is allowed to be used.

Each attendant and nurse has a locked receptacle provided
in his or her room in which any sharp instrument, such as
razors, scissors, etc., can be placed ; a special key being pro¬
vided for the officer in each instance, thereby leaving no excuse
for dangerous articles to be left unguarded.

The head attendant or deputy remains on duty until the
charge night attendant has taken over the care of the house
and ascertained that all the patients are alive; and the charge
night attendant remains on duty in the morning until the head
attendant or deputy has resumed charge in the same manner.
All medicines are taken from the surgery in locked baskets by
the head attendants, who are responsible for their distribution
to the various wards. Every dose is given by the charge
attendant, or, in the event of absence, by the deputy, and the
bottles are kept in locked cupboards in each ward.

On no pretence is any patient allowed to take anything to
bed. This I regard as most important. No less than eight men
and four women in the number referred to committed suicide by
the neglect of this precaution, the means varying from a secreted
handkerchief to a piece of sharpened tin.

No patient is allowed to leave the dormitory to go to the
lavatory. Night commodes are provided, and are dealt with by
the night watch when necessary at the hourly visit. This I con¬
sider a highly necessary precaution.

The vigilance of the night attendants is tested by the Cox
Walker system of electric clocks and record in the superinten¬
dent’s office, and any neglect to peg is at once made the subject
of inquiry. In the infirmary dormitories the clock is pegged
every quarter of an hour, and in others every half-hour. The
most actively suicidal cases sleep in the immediate vicinity of
the station of the night watch.

For some years I have adopted the plan of assembling
the charge attendants and nurses and discussing with them
the pros and cons . of the various suicides which have taken
place during the year, particulars of which are recorded in the

Digitized by

Google

1903]

BY HARRY A. BENHAM, M.D.

45 I

Blue Book. I have found them to take an intelligent interest
in the cases under review, and it has resulted more than once in
the adoption of a precaution not hitherto practised here, whilst
the staff have undoubtedly been made more efficient in the per¬
formance of their duty.

On referring to the table you will see that eleven men and
nine women committed suicide whilst on trial.

Without going so far as to say that this practice of allowing
patients out on trial is not permissible or even desirable in some
cases, especially when it enables a weekly sum to be allowed, I
regard the responsibility of sharing the risk with friends—some
of whom, as we all know, are too eager to take it, whilst others
are not sorry to find any reasonable pretext for returning a
troublesome friend or relative to the asylum—as a very great
one, and the above figures show that it is not unattended with
risk. I may say that we very rarely resort to this method here.
I am well aware that many superintendents whose judgment I
value very highly are of a contrary opinion.

Holding as we do the view that notwithstanding every pre¬
caution that may be taken these catastrophes are bound to
occur, I cannot, I think, do better than end with an extract
from a report of the Commissioners in Lunacy contained in
the Blue Book referred to, as follows:

“ The 'precautions which have been taken of late years have
reduced the chances of suicide to a very small measure, but it
seems unlikely that these acts can ever be wholly prevented.
A time comes in every case of amendment when the precau¬
tions must be relaxed, and a medical superintendent, deceived
by the artifice of a patient, may be led to grant such relaxation
too soon ; on the other hand, in a case of real improvement,
a sudden and overpowering impulse to suicide may return and
may lead to self-destruction before protection can be given.
To keep up restrictions beyond the time of apparent necessity
has some injustice for the patient, and the greater evil of
leading attendants to regard them as something less than
imperative and something to be interpreted by their own
private judgment. Discretion in this matter rests absolutely
with the medical superintendent, a discretion which, as is
shown by our returns, is exercised, on the whole, with remark¬
able success.”

Digitized by v^.ooQLe

452 REMARKS ON SUICIDES IN PUBLIC ASYLUMS, [July,

Summary of Suicides in County and Borough Lunatic Asylums
from 1890 to 1901 ( inclusive ).

Year.

Act

committed
in asylum.

Act

committed

before

admission.

Act

committed

after

escape.

Act

committed
whilst on
trial or
leave.

Actively Culpable
suicidal.1 negligence.

Doubtful
or pre¬
ventable.

M :

F. T.

T. M.

F.jT.

1890

—

- -

—

7 4

>1 *

1891

—

- -

—

1 2

4 2

—1 2

1892

—

8 2

—

■893

—

— 3

—

8 1

—

-—

1894

—

1 1

—

3 2

—1 1

1895

— 1

—

5 | —

—

21 2

1896

— 2

—

5 2

—

— —

1897

—

— —

—

6 3

—

—.—

1898

—

_ 2

—

6 3

* 3

1899

—

1 1

5 2 i

2 5

1900

1 3 ]

2 1

I ,

1 2

4 2

— !

—

2 2

1901

' IO

2 1

4 ^

11 4

H x !

Totals

53 |

I 5 II 7

x 3

i°

6 16

72 27

5 i

8 18

By day.

By night.

Unknown.

Total,

Means adopted, viz.

Hanging .

5 *

—

Drowning.

—

|Cut throat

—

Strangulation .

! Killed on railway

Killed by waggon

—

Suffocation

—

Jumping from win-

—

Poisoning.

—

Running head against

—

wall or tree
Swallowing hat-pins.

Swallowing needles .

—

Swallowing spoon

—

Injuries to abdomen .

—

Self-mutilation .

—

Evulsion of tongue .

—

> —

—

Scalding .

—

— 1

i —

—

Burning .

—

Flinging self over

—

! —

—

bridge

Flinging self over

banister

Injury by axe

—

I _

—

| Totals .

73 !

112

! 18

I 7

151 ^

After escape. —Hanging, 2 males ; drowning, 2 males, 3 females; cut throat, 1 male ;
killed on railway, 5 males, 3 females. Total, 10 males, 6 females.

Digitized by v^.ooQLe

1 903]

BY HARRY A. BEN HAM, M.D.

453

Discussion

At the Spring Meeting of the South-Western Division, April 28th, 1903.

Dr. Miller said that they were handicapped by the fact that their employees
were people who, in ninety-nine cases out of a hundred, had some other employ¬
ment to return to directly they were dismissed from the asylum, and if they got
into trouble (in the case of females) they could go either into service as kitchen-
maids or into one or other of the factories, thereby losing nothing by such dis¬
missal. He dealt at some length with the modern system of construction of
asylums, whereby cases of actively suicidal patients could be more carefully and
easily observed by the nurse in charge. He spoke of the amount of time which
was given up by the nurses to the observation of these patients, which prevented
them from doing anything else. He stated that at Warwick he never allowed in
any ward more than four observation cases at a time; and another rule is to limit
the hours of continuous duty for nurses who are in charge of such cases. A large
number of the suicides, he stated, were said to take place at night. How many
take place between 5 a.m. and 8 a.m. P In his experience most of the acts are
committed in the early hours of the morning, when the patients are getting up,
or in the evening when they are going to bed.

Dr. Macdonald said Dr. Benham’s paper was a most interesting and practical
contribution on a difficult subject. He thought with regard to these cases that the
special suicidal notices should not be issued without most careful consideration by
the medical staff, and that frequent consultation ought to take place, so that no
special card might be continued longer than is absolutely necessary. To reduce
these cases to four in a ward was, he thought, quite right, and he would like to
reduce them to even less than that; and, rightly or wrongly, when he got more
than three or four cases at a time he did not leave them all in one ward, it being
too much strain upon the nurses. We get, he said, lots of cases which we are
told are suicidal, but unless the patient has actually made an attempt 1 do not adopt
one of the special cards, and I have not yet had reason to regret it. He spoke of
the great care which should be taken to prevent patients from picking up things
belonging to the attendants, and from going into their rooms.

Dr. Hartnell spoke of the desirability of giving a change to both the patients
and the nurses, and of the good which would result by transferring them from time
to time to different wards. He stated that, as a rule, when once a patient had a red
card on he was very loth to remove it until he had excellent reasons for doing so.
He had at the present time one patient who had had one of these special cards for
the last eight years, and even now she makes attempts upon her life. It is, he
said, very well to blame your attendants for being careless, and to say they ought
not to let these accidents happen ; and he gave an instance showing how difficult
it was to guard against accidents in suicidal patients.

Dr. Cotton remarked that they frequently get suicidal patients who had been
sent into prison.

Dr. Baskin referred to the question of discharging patients upon trial. He said
it was quite a customary thing to discharge patients on trial, and some of them
came back again. There is, of course, a great deal of difference between the dis¬
charge of a patient from a county asylum and a city asylum. In the former case
the patient can be discharged much more freely—not having to return to city life.

Dr. Benham stated that he would have liked to hear more fully the opinion
of the meeting as to the discharge of patients on trial. He expressed pleasure at
listening to the various expressions of opinion, which had not always been in agree¬
ment with his own. With regard to Dr. Miller’s statement that four observation
cases in one ward were sufficient, he thought perhaps it might be a good thing for
the nurses, but not for the patients. He stated that he had in his asylum as many
as twelve suicidal cases in one ward at a time, which was specially adapted for
their treatment.

XLIX.

Digitized by t^.ooQLe

454

NOTES ON HALLUCINATIONS,

[July,

Notes on Hallucinations. III. By Conolly Norman.

“ Cest lentendement qui veoid et qui oyt ” dit Montaigne , et
cette pensle profondiment vraie doit servir de base d toute thlorie
rationnelle des hallucinations. Mais il est de notion vulgaire en
psyckologie que lentendement ne permit ni la lumiere ni les
sons. Cest par des modifications myst/rieuses des centres nerveux
que Intelligence est avertie des manifestations extlrieures qui
viennent frapper les organes sensoriels .— BALL, Lemons sur les
Maladies men tales, 1890.

The theories by which it has been endeavoured to explain
the existence of hallucinations are manifold. In this field, as
in so many others where we watch the play of mental pheno¬
mena, our point of view varies from time to time, so that the
explanations which were once deemed more or less satisfactory
become unmeaning when the problem to be solved has itself
shifted ground.

The early theories as to hallucination may be described as
three:

1. The psychical theory .—This is commonly spoken of as
Esquirol's theory. Esquirol (*) says, “ A man who entertains
the firm conviction that he actually perceives a sensation at a
time when there is not within the purview of his senses any
object capable of calling up the sensation, is in a state of
hallucination. He is a visionary.” Again, “ Hallucination is
a cerebral or psychical phenomenon which is accomplished
independently of the senses.” And again, “ The habit of
always associating sensation with the external object which
usually solicits and provokes it lends reality to the products of
the imagination or of the memory, and persuades the victim
of hallucination that what he actually feels could not exist
without the presence of external bodies. The supposed sensa¬
tions of the hallucinated are images, are ideas reproduced by
memory, associated by imagination, and personified by habit.
Man then gives corporeal substance to the products of his
understanding; he dreams while he is awake.” Ldlut, who
is an advocate of the same general view, described an hallu¬
cination as “an idea which exteriorises itself” (se projette au
dehors). Moreau de Tours elaborated Esquirol’s comparison

Digitized by v^.ooQLe

1903.] BY CONOLLY NORMAN. 45 S

of the dreamer, and even went so far as to say that very often
insanity is really only the continuation of a dream. Falret
and many others adopted the psychic theory, and it no doubt
contains a certain truth, but only if it be accepted in so large
and general a sense as.to be of little value. It takes no account
of physical conditions which cannot be overlooked in any
modern study of hallucination.

2. The sensory theory .—According to this view hallucinations
have their origin in the sensory organs themselves or in the
basal ganglia. This theory is associated with the names of
Foville, Luys, and Ritti.( 2 ) That peripheral irritation in the
sense organ itself, or in the nerve-trunk, has often an important
determining relation to the origin of hallucination, cannot be
denied. But in most instances such irritation cannot be
proved, and is not even suggested, except theoretically, so
that the chief use to which these exceptional cases can be put
is rather the disproof of the purely psychical than the proof of
the purely sensory view.

3. The psycho-sensory or mixed theory .—Baillarger is commonly
spoken of as the author of this theory, which received extensive
support for a considerable period of time. Ball, who adhered
thereto, speaks ( 3 ) of this doctrine as “ the hypothesis according
to which hallucinations are always psycho-sensory : psychical,
because they have their foundation in the patient’s mind, in
the accumulated treasures of the intelligence and of the
memory; sensory, because they always have their seat of
origin (point de depart) in the senses.” He compares the
condition of affairs which produces hallucinations to a tuning-
fork tuned to give a certain musical note but requiring to be
struck by an external force in order that the note may be pro¬
duced.

This theory takes into account two elements which un¬
doubtedly exist in hallucination, but the mode of their syn¬
thesis is not thereby accounted for, so that it can hardly be
said to offer an explanation of the phenomenon.

It should be said here that Baillarger only applied the
psycho-sensory theory to a certain class of hallucinations. For
another, as we shall see presently, he offered another explana¬
tion not to be distinguished from that of Esquirol.

Each of the doctrines which we have examined has apparent
support in a number of observed facts, and yet each is insuf-

Digitized by v^.ooQLe

[July.

456 NOTES ON HALLUCINATIONS,

ficient, the last, which is the best, being little more complete
than the others.

The theory which next claims consideration is that of
Tamburini,( 4 ) who regards hallucination as being dependent
upon an irritation of the perceptive or psycho-sensory centres
in the cortex. This theory was not immediately and generally
accepted when first promulgated, but it has since that time
steadily increased in favour. In fact, it is so far conformable
to everything that we know of the basis of sensation that in the
present state of our knowledge we must almost accept it as
axiomatic. We know that a sensation means a change, an
occurrence—call it dynamic, molecular, chemical, what you
will—in a certain portion of the cortex. We know that this is
ordinarily brought about by an irritation conducted from a
peripheral organ along a nerve-track. We know from the
occurrence of hallucinations of vision in those who have
become blind, of hearing in those who have become deaf, and
of dolorific, tactile, and muscular sensibility in those who have
undergone amputation of the members involved, that sensation
can occur where the peripheral receiving organ has ceased to
exist or ceased to receive impressions from without. On the
other hand, we know from cases of deafness or blindness arising
from central disease that the destruction of a cortical sense
centre is followed by the obliteration of the sense in question.
The conclusion, then, appears unavoidable: that of which we
are conscious as a sensation is change occurring in a sensory
centre ; whatever its remoter origin, whatever its ulterior cause
may be, hallucination also must mean change in a sensory
centre—change of a similar kind to that which takes place in
ordinary sensation, though not necessarily identical in mode or
degree. Tamburini seems, when he first enunciated his theory,
to have held that the condition of irritation in the psycho-
sensory centres in hallucination is analogous to the irritation in
the psycho-motor centres which gives rise to epilepsy. The
similitude consists in this, that in both cases energies uncon¬
sciously stored up in the centres are set free in a manner which
may be called spontaneous,—that is to say, otherwise than in
response to the customary stimulant. As, however, motion,
although it may be held primarily and on ultimate analysis to
depend on the influence of stimuli coming from outside the
organism, is yet normally related to external irritation in a

Digitized by v^.ooQLe

I903-]

BY CONOLLY NORMAN.

457

much more remote and complicated way than is sensation, it
would appear that the analogy is not very close. For that
reason, probably, subsequent authors have apparently not found
it valuable for the better comprehension of these problems.
Putting aside, then, the question of this analogy, it may, I
think, be said that Tamburini’s theory has now been universally
accepted, and that for the present, at least, further theories can
only expand or complete it.

Such expansion and completion is the aim of Tanzi, who has
dealt with the question of hallucinations in a paper published
in December, 1901 (“ Una teoria dell* allucinazione,” Riv. di
Patol. Nero, e Ment ., vol. vi, fasc. 12). This author believes
that “ while, with the classic data on the subject, it is impos¬
sible to conceive a genesis of hallucination different from that
which Tamburini has formulated/’ certain recent physiological
advances enable us now to lay down the basis of a more com¬
plete and harmonious theory.

Tanzi accepts fully the general views of Flechsig as to the
existence of association centres, and believes that in these
hallucinations have their origin. “ The origin,” he says, “ of
all genuine hallucinations is transcortical. . . . The mechanism
of hallucination consists in the retrogression of an image, more
or less complex, more or less conscious, which descends from
the psychical zone into the sensory centres whence it had come ”
(that is, in its elements, or primarily), “ and thus assumes anew
the exact form of a sensation, so as to be mistaken for reality.”
This mechanism only operates, he believes, in pathological or
abnormal conditions by anatomical paths appropriated to the
centrifugal connection between the psychical or supra-sensory
zone and the cortical centres of pure sensation, even though
the paths in question may be normally destined for other
functions more or less determinable. These paths appear
undoubtedly to exist, there being fibres in the sensory centres
which descend from the superior centres and seem to have a
centrifugal function. Flechsig regards them as moderators of
sensation; Ramon y Cajal as exercising a tonic action in con¬
nection with the process of attention. At any rate Tanzi holds
that even without these centrifugal fibres it is possible, though
not probable, that the superior centres may act upon the sensory
centres through the paths which are usually centripetal. That
this inversion of the usual direction of the current, though it

Digitized by ^.ooQle

458

NOTES ON HALLUCINATIONS,

[July,

seems in conflict with the law of dynamic polarisation, is not
to be absolutely excluded in abnormal conditions, appears to
be indicated by the results of experiments on Melapterurus elec -
tricus. In this fish the electric organ is innervated by one single
fibre of great size. If one of its smaller branches be dissected out
from the electric organ, but not divided from the nerve-trunk,
and if it be then stimulated, a complete discharge of the electric
organ occurs. Therefore, in this laboratory experiment at
least, there has been centripetal and centrifugal conduction
along the same fibre.

In connection with this example of centripetal energy travel¬
ling along lines normally centrifugal, we must remember that
Tamburini seems to accept the views of Hagen, Griesinger,
and Krafft-Ebing that the irritation of the sensory centre
extends itself over the entire nervous apparatus, to which
it pertains as far as the extreme peripheral termination,
whereby the hallucination receives the appearance of reality.
Kandinsky ( 5 ) observes with some force that this is illogical,
as, if this be so, the theory of the localisation of halluci¬
nation in the sensory centre does not save us from calling
in the whole sensory apparatus, and believing that a sensory
excitation can travel along centrifugal lines. There are, how¬
ever, other reasons for believing that such extension occurs,
more potent, it would seem, than any necessity for a sensation
exteriorising itself in order to produce the sense of reality,
which should not be necessary in accordance with the main
tenour of Tamburini’s argument.

I may here, perhaps, refer to the observations of Max Simon,
fils 9 (*) on impressions residual to visual hallucinations. That
author, while admitting that the fact of which we are conscious
in hallucination is an occurrence taking place in the cortex, lays
down that with hallucination the entire sensory tract from the
cortex to the peripheral extremity is thrown into the same con¬
dition that normally exists when a true (objective) sensation is
produced by an external agency acting upon the periphery, and
so ultimately upon the corresponding cortical centre. He con¬
siders that this is proved by the circumstance that in some
cases of hypnagogic hallucination, when the image seen is
coloured, it occurs that when the eyes are opened and the
image has disappeared a phantom is seen presenting colours
complementary to those of the original hallucinatory image. A

Digitized by v^.ooQLe

i9°3-]

BY CONOLLY NORMAN.

459

great number of similar observations have been recorded.
Brewster’s note that the image in visual hallucination may
become double when the eyeball is pressed has been confirmed
by other observers. Bostock observed that the images may
follow the movements of the eyes. Accepting Tanzi’s view
that an hallucination is a representation taking a retrogressive
course and pathologically converted into a sensation, there
seems to be no reason why the same retrogressive action should
not be supposed as descending to the periphery, if, at any rate,
the ordinary direction of transmission along a nerve-fibre can
be reversed. The artificial visual hallucinations of the hypnotic
state have been observed to follow ordinary optical laws, to be
reduplicated by pressure on an eyeball, or by the interposition
of a prism, and so forth. Yet we cannot believe that the peri¬
pheral organ is directly affected by the procedure which pro¬
duces hypnosis; the influence here must come from above,
whether from the sensory centres direct, or from the psychical
acting through the sensory centres. That hallucinations ever
have a peripheral originTanzi denies. Naturally he does so in
accordance with his theory, and he is entitled to point out the
fact that many persons afflicted with ear or eye disease suffer for
months or years from “ sounds ” or “ lights ” (true, though
pathological sensations), and never develop hallucinations.
This contention is just, and its bearing upon the origin of
illusion is important. Let us put aside cases of what is dis¬
tinctly delusional interpretation, and consider mere illusion. I
described in my last communication a case of a man who suffers
from chronic catarrh of the middle ear, which has produced
very distinct deafness in one ear. In this ear he hears the
voices of his blasphemous and obscene traducers. In what sense
can it be held that this man’s auditory hallucinations have deve¬
loped on illusions,and that these aredue,again,tochroniccatarrh
of the middle ear (one of the commonest of diseases in our
wretched climate) ? Furthermore this particular patient exhibits,
as I have mentioned, an interesting visual condition. He gazes
into fragments of thick green glass (broken beer-bottles) and
sees things and persons and moving panoramas therein. When
I cannot see these objects in his talisman, he points triumph¬
antly to the sparkling cracks produced by the lines of fracture
running through the glass. Who does not perceive the analogy
between the scintillations in the glass which we know this poor

Digitized by v^.ooQLe

460 NOTES ON HALLUCINATIONS, [July,

man sees and the noises which we have every reason to believe
he hears in his deaf ear ? And how can we believe that one
any more than the other is the cause of the concurrent hallu¬
cination ? This man's bits of glass are to him what the magic
mirror is to the Eastern necromancer—what the little pool of
ink held in his palm is to the Egyptian boy whom the wizard
makes see therein complicated visions. But in this latter case,
not the play of light on the surface of the ink, but the sug¬
gestion of the hypnotiser, is the true cause of the boy's vision.
Closely analogous, also, to the visions of my patient are many
complex illusions, very close to, if not identical with, hallucina¬
tions, and owing their apparent point of origin to some simple
sensory impression. Such is the experience which M. Maury
relates of himself.( 7 ) In recounting this matter that author
mentions that he was very short-sighted, but Ball, in quoting
the case, significantly points out that Maury was particularly
liable to hallucinations. Of course we know that he was sub¬
ject to those hypnagogic hallucinations of which he has given
so full and admirable a description. His peculiar liability to
phenomena of the sort no doubt supplies, as Ball suggests, the
necessary tertium quid. Maury’s case was this :—He was crossing
the Pont Neuf and saw before him a cuirassier on horseback
and in full uniform. He distinguished the soldier’s helmet, his
plume, his cuirass, and the rest of his dress. On approaching
more closely he found that the object at which he was looking
was a porter carrying a large mirror-plate on his back. The sense
of vision had furnished only the sparkling of the glass in the sun ;
the details of the cuirassier on horseback and in uniform were
hallucinatory. All kinds of instances of illusion or hallucina¬
tion apparently taking its origin in true sensory impression are
familiar even outside disease; but it is the condition of the
psychical centres which makes the difference between a true
and false perception. The old proverbial rhyme says truly
enough, “ As the fool thinketh, so the bell tinkleth.” Every one
must have experienced how on a night journey by rail the
horrible clatter of the train seems from time to time to fall into
the rhythm of a familiar tune. “ It is possible," says S^glas,^)
“ to demonstrate experimentally that a slight and vague sensory
excitation is sufficient to determine the sensory form under
which the intellectual action calling forth hallucination shall
manifest itself (crystal-vision, shell-hearing)."

Digitized by v^.ooQLe

*903-]

BY CONOLLY NORMAN.

46l

All these phenomena are intelligible without adopting the
now untenable notion that the hallucinations have a mere
sensory in the sense of peripheral origin, and without re¬
turning to the generalisations of Esquirol as to the purely
psychical nature of hallucinations—generalisations which are too
wide to be of any value in the present state of our knowledge,—
provided we go a step further than Tanzi, and admit that an
irritation commencing in the psychical centres can by retro¬
gressive action descend not only to the centres of sensation, but
further downwards, even to the periphery, throwing the whole
nerve-tract into a state of abnormal activity.

There is a very important class of hallucinations which Bail-
larger ( 9 ) was the first among medical writers to describe, and
which he separates absolutely from the psycho-sensory. He
considered that among the majority of sufferers from hallucina¬
tion sensory impressions are produced as real as those which
give rise to normal sensations; and such impressions, due to the
double action of the imagination and the organs of sense, he
called, as we have seen, psycho-sensory hallucinations. But
he also held that there are hallucinations which are purely
psychical. He entertained a very strong opinion on this point,
saying that “ these false perceptions, which we shall no longer
call sensory, appear to be related almost exclusively to the sense
of hearing, and cannot be confounded with true hallucinations
except by the insane.” He further pointed out that psychical
hallucinations had been recognised by the mystic religious
writers long before physicians had noticed them. Evidently
the latter observation is true, and betrays the unfortunate fact,
which is so true a reproach to our craft, that we only too often
decline to see facts which do not square with our preconceived
theories. Since Baillarger’s time there have been added to his
own excellent studies a multitude of others, pre-eminently those
of S£glas,( 10 ) who regards the inner voice as an hallucinatory
condition of the cinaesthetic centres. These “ voices,” which
are not distinctly heard, and yet have a strong resemblance to
voices, or are described by patients as “ voices ” for want of*
any other name, are by that author regarded as depending
upon an engagement of the motor speech centres. Lugaro, in
his recent work,( n ) has disputed the propriety of calling these
conditions psycho-motor, pointing out that many of them do not
present distinct motor phenomena, and preferring to return to

Digitized by

Google

462

NOTES ON HALLUCINATIONS,

[July.

Kandinsky’s designation of pseudo-hallucinations. It does not
seem as if the designation of these conditions, so admirably and
fully described by S£glas, is really a matter of much conse¬
quence, since if we regard the engagement as rather one of the
function of language than either distinctly sensory or motor, we
seem to escape the difficulty. Lugaro appears to fully accept
the theory of Tanzi, and to desire to press it further than that
author has done.( 12 ) One feels that his closely argued con¬
tention against the phrase psycho-motor hallucination is really
a matter of terms rather than of facts.

His cases have been observed with most minute care, and
although his main contention appears to be very disputable, we
cannot but admire the power of observation which this accom¬
plished pathologist has displayed in clinical work. He tells us
that it is worth while and even necessary to apply to the analysis
of a psychological phenomenon known for some time the very
simple methods of old-fashioned psychiatry—examination and
observation. Unfortunately, here, as in other branches of our
science, facts need interpretation, and the interpretation of
clinical facts in psychiatry presents certain peculiar difficulties.
One of these arises from the fact that not only ordinary people,
but even students of psychiatry have only a limited vocabulary
with which to express the less familiar operations of the mind.
When a patient talks of a “ voice ” that comes to him from
some supernatural source, which is as distinct as the voice ot
his interrogator (we have all heard patients talk thus), and like¬
wise tells us of “ an inward voice ” which is not audible, which
is not really a voice, and which only resembles a voice by its
externality and by its intrusive character, the problem that we
have first to solve appears to be whether this mode of descrip¬
tion by the patient is solely due in the latter case to the poverty
of language, or whether the necessity of language is not itself
an expression of the deeper fact that the thing which suddenly
thrusts itself into consciousness, quite uncomformably with the
current of the patient’s ideas, is not truly a sensation, essentially
the same in nature as the more easily recognised pathological
sensation (hallucination) of hearing. How are hallucinations
to be described to us who neither experience the subjective
auditory perception of the spoken, nor yet the inner voice?
The former is easy of description, for every ordinary person has,
like the patient, the objective sensation of hearing to serve as a

Digitized by v^.ooQLe

1903.] BY CONOLLY NORMAN. 463

standard ; but the “ inner voice,” when it is described to those
who have not experienced it, must be likened to something
else, and probably presents the same difficulty as describing
colours to a blind man. A well-known medical writer on this
subject (some account of whom will be found in an obituary notice
at page 316 of vol. xxxvi of the Journal of Mental Science) had been
himself the victim of “ pseudo-hallucinatory ” trouble, yet his
account of the condition in no way clears up the phenomena
which he recorded with unselfish zeal. One of Baillarger’s
patients, a highly cultivated lady who, in spite of long illness,
had not become demented, had suffered at the beginning of her
ailment from psycho-sensory auditory hallucinations. These
lasted only about a year, and were followed by psychical hallu¬
cinations, from which she suffered for twenty-six years anterior
to Baillarger’s note. “ She heard thought at a distance by the
aid of a sixth sense, which she called the sense of thought .”
“ By the aid of her sixth sense she knew all that she wanted to
know, and heard thought at very great distances. The voices
intermingled, and it required a great deal of attention not to
confuse them together.” She accepted Baillarger’s challenge to
engage in a mental conversation with him, and while he sat quite
still she answered his supposed questions with short sentences
at due intervals. (Her answers, by the way, have a manifest
bearing on her delusions.) She maintained that she had heard
all her physician’s questions “ without any sound striking her
ears. The speech was clearly pronounced, the words distinctly
articulated just as would have been the case if I had really
spoken slowly with the object of being thoroughly understood.”
The patient’s notion of a sixth sense seems to me to have the
advantage of Baillarger’s somewhat vague notion of a psychical
hallucination, but in this particular instance S6glas’ view as to
the psycho-motor nature of these manifestations certainly offers
the best explanation; the lady was talking to herself, being
rather a motive than an auditive person. That she was not
conscious that she spoke to herself proves nothing. S6glas
rightly insists upon the fact, which had not escaped Baillarger,
that many patients with psycho-motor hallucinations will, while
listening to an internal voice, move their lips as if speaking, or
give utterance to a low muttering sound, or even speak quite
audibly, and yet maintain that they have taken no part what¬
ever in the conversation. Now in such cases it is impossible

Digitized by v^.ooQLe

464 NOTES ON HALLUCINATIONS, [July,

to exclude the action of the motor speech centres, since we
have visible or audible proof of their co-operation; yet the
patient is unconscious of their action, and in describing his
“ inward voice ” may appear to be only driven to use this
phrase by the necessity of language.

A case of Cramer’s ( 13 ) which Lugaro refers to is in the
highest degree instructive, but does not appear to justify the
contention of Lugaro; for here we seem to have a demonstrative
proof of S6glas* doctrine that psychical hallucinations depend
for their immediate mechanism on the muscular sense, however
obscure the patient’s description may be. Cramer’s patient
was a deaf mute, who had learned finger language and lip
language early. He had verbal hallucinations of two kinds:
obscene abuse was conveyed to him chiefly by finger language ;
epithets of praise and dignity were conveyed to him by lip
language. Cramer interrogated him and received his replies
in writing. The patient used the phrase “ hear” to express his
reception of his hallucination, till reminded of its inexactness,
as he could not hear. He then explained, as we have said,
that certain words came to him by one kind of dumb language,
certain words by another. It appeared that he had not distinct
visual hallucinations, and so it was pointed out to him that he
did not see anyone who moved lips or fingers to communicate
with him. He then fell back upon the explanation that the
communication was one of mind to mind, and that it was
worked by magnetism and by “a machine.” Perhaps this
may be a case of psychical hallucination; if so, that phrase,
I submit, is so elastic as to be meaningless. It would appear,
on the other hand, that this deaf mute’s experiences prove
S6glas* case. The higher synthesis here is the function of
language, the function by which we receive and communi¬
cate ideas. The sensory centres engaged, whereby the patient
was conscious of his hallucination, are the centres of muscular
sense. The symbols by which this man thinks must be mainly
derived from muscular sensations, though it may be admitted
that visual impressions would probably be of more importance
to him than to those who can hear. We who hear, in our
silent thought, think more of the spoken word than the visual
image; hence perhaps the relative frequency of auditory hallu¬
cinations ; but among deaf mutes the conditions would
naturally be different. We know that among those who hear

Digitized by

Google

1903 ] by CONOLLY NORMAN. 465

there is much difference between the auditive, the visual, the
motive,—those who think chiefly by symbols that have their origin
in heard, seen, or spoken language respectively. Cramer asked
his patient, “ In what language, lip language or deaf and dumb
(finger) language, do you think ? ” and his patient answered,
“ Very different; the deaf and dumb never express themselves
in sentences; all abbreviated/’ Cramer then asked, “ Do you
think with the mouth ? ” and the patient replied, “ No, not with
words, only with signs.” This man, then, thought in motor
symbols derived probably indifferently from the two methods
of language which he had learned in infancy. That he should
hear (apprehend) one class of words by lip movements and
another by finger movements is analogous to the observations
made by Baillarger, S6glas, and others (observations confirmed
by cases described in my last paper) of patients who hear one
kind of voices in their ear and another in their throat. Such
cases like that curious form of unilateral hallucination in which
the patient hears different voices in the two ears ( u ) suggest cer¬
tainly a remote cause in the supra-sensory region, but they do
not exclude the activity of the sensory centre or centres.

The two following cases seem to show the intimate connec¬
tion of auditory verbal hallucination with psychical or psycho¬
motor hallucination, and even serve to indicate that they are
phenomena having a point of common origin.

Case 21,083. — Male, aet. 36, married, railway porter and
soldier. Mother and a maternal aunt have been patients in
this asylum. This man is said to have enjoyed good mental
health till October, 1901, when, returning from service in the
South African War, he found that his home had been broken
up through the misconduct of his wife, who had been unfaithful
to him and had sold his household goods. He then went to
live with his mother, and seems to have been depressed, fretful,
absent-minded, and unfit for work. Spent the months of
February and March of the year 1902 in the lunatic wards of a
workhouse; then lived with his mother again; and, having
become threatening and violent to her, was admitted to the
Richmond Asylum on August 26th, 1902. He was a well-
developed, well-nourished man, free from indications of physical
disease. He was depressed and hypochondriacal. Pitied him¬
self, and protested that he had done no harm, tearfully declar-

Digitized by ^.ooQle

466 NOTES ON HALLUCINATIONS, [July,

ing his love for his mother. Said he felt nervous and weak
and absent-minded.

Early in September he occupied himself in farm work,
though he was dull and self-absorbed. He said he “ did not
feel well; something came over his head which he supposed
was nervousness.” Later in the month he refused to work,
assigning as a reason that something came across his forehead;
something was in his head which prevented him.

In October, 1902, his self-absorbed manner and listening
attitudes suggested hallucinations of hearing, but these he
denied. When spoken to he was dull and listless, and he com¬
plained, “ I am very much depressed and grieved and down¬
hearted.” He could assign no definite reason for this con¬
dition.

On November 5th, 1902, he had an outburst of noise and
violence, apparently reactive to hallucinations of hearing.
These outbreaks recurred several times during the month,
lasting a day or two. In the intervals he was dull, surly, and
silent. On one occasion he refused food because he was per¬
secuted and had no peace.

On November 26th, 1902, he complained that he was tor¬
mented by “ voices ” talking to him and crying to him con¬
tinually and giving him no rest. They talk about all his past
life, and they abuse him and reproach him.

In December, 1902, he improved in self-control and became
tranquil. On the 23rd of that month, this note was made by
me:—To-day he is dull, with fixed, stupid, and depressed
expression. Of his own accord, he talks chiefly of weakness
and abdominal pain, both apparently fanciful (or hallucina¬
tory ?).

When questioned does he ever hear “ voices,” he at once
replies that he used to hear voices. “ I hear them,” he says,
“when I am bad (i. e . 9 ill). I last heard them when I was last
bad,—that is, about a month ago. They were like the voices of
my mates in South Africa; they said that my mates here were
against me, and things like that.” Questioned as to why he
had been excited, he said the voices had driven him to it; they
gave him no rest. Then he volunteered this statement:—“ I
do not hear voices now; at least it is more like a thought that
comes through my mind. A thought is put into my mind about
something that happened to me and my mates in South Africa,

Digitized by v^.ooQLe

1903.] BY CONOLLY NORMAN. 467

or something of the sort; it comes ‘ sudden like.' I do not hear it
now. It is like a thought. I only hear voices when I am bad.”

The case continues under observation. Patient exhibits
recurrent periods of excitement (that is, sullenness, restlessness,
and violence), with alternating periods of calm, with mild
depression and hypochondria. In the former conditions he
hears “ voices 99 which are associated with outbursts of rage ;
in the latter, “ thoughts ” take the place of voices.

In this case it will be perceived that the intrusive “ thought ”
has the same character of suddenness—that is, of disconnec¬
tion with what was before in consciousness—and produces the
same sense of interruption that the " voices ” do. “ It comes
4 sudden like.’ ” It is also imperative—is a form of Zwange -
danke. “ A thought is put into my mind.” The patient is not
educated, and is not very intelligent at best. Perhaps on that
account his unprompted statements to me about his case are
the more valuable, as they express real and unsophisticated
feelings: sensations, as I hold in either case; morbid sensa¬
tions, no doubt—that is to say, hallucinations,—in both cases,
but as much sensations in the one as in the other.

Case 20,664.—Female, aet. 30, a countrywoman, of late
years lay sister in a convent. Stated to be free from hereditary
taint, but the family history is very imperfect. Personal history
is likewise scanty. Patient had been in a private asylum, and
was said to have been about six months ill when admitted to
the Richmond Asylum, Dublin, on January 18th, 1902. She
was a well-developed and well-nourished young woman, with a
well-formed calvarium and somewhat coarse face, rather prog¬
nathous, with thick lips and receding chin. She gave one the
idea that she was not a person of high intelligence, and she
had a reticence of manner, perhaps due to bucolic upbringing.
Quiet and precise. She said she was sent to the asylum on
account of voices which she heard, which are nearly all gone
now. She heard voices speaking to her from France, giving
her orders. These were bad voices, telling her to do bad
things, and striving to make her worse than she was. They
tried to ruin her soul. She also heard some voices that seemed
good, and which she tried to obey. These told her to mortify
herself and to be obedient. There are some wicked persons
who have the power of working upon her spirit. They endea-

Digitized by ^.ooQle

468

NOTES ON HALLUCINATIONS,

[July,

voured to turn her eyes from her work. In the certificate on
which she was admitted it is stated that she not only heard
voices, but believed that spirits entered her body. Questioned
as to the latter notion, she admits that spirits entered her body,
but she believes that she has got rid of them. Has not heard
any voices these two days.

January 19th, 1902.—She gave my colleague, Dr. Fleury (to
whom I am indebted for most of the notes on this case), to
understand that “ it is nearly three months since the voices
troubled her to any extent.” “ Now and again it is as if a
thought were put into her mind from them.” They were
spirits—some good, some evil.

25th.—Admits that she has heard the voices a little since she
came here, “ but they can hardly be called voices now.” She
seemed to describe the event that takes place at present as a
sort of inward intimation, though she does not use that phrase.
“ There was a time when they were actual voices. They said
everything. They seemed to have knowledge of all she did
and said. At times she saw something like a shadow. Thinks
they were spirits. It was not fancy. The good voices told
her to do things that were right, and if she did not obey she
had scruples.” It is noted that she is a quiet, well-behaved
person, good-tempered, and helpful in the infirm ward, where
she works.

February 1st.—Hears nothing the last few days. Her
persecutors accuse her of things she has not done. They used
to try and make her do wrong.

18th.—Does not hear actual voices, but now and again has a
feeling as if some one had a knowledge of her thoughts and
mind. Though it is, she says, a long time since she heard an
actual voice, she will not admit that the voices were fancy.
There is a tendency towards delusive belief as to the actions of
the other patients being designed to annoy her.

March 18th.—Says she has been hearing the voices about
two years. She sometimes obeyed them (apparently the good
ones only) and mortified herself at their order. Some of the
voices, on the other hand, were very vile, and wished her to do
all the harm possible. She has not heard the voices much
since she came to the asylum, but she thinks they are real
voices.

April 18th.—Admits to notions that the nurses talk about

Digitized by v^.ooQLe

I903-]

BY CONOLLY NORMAN.

469

her rudely and call her names. This is, no doubt, delusional.
She is, in fact, a silent, tranquil person, very industrious and
useful, and a favourite in the ward. “Sometimes patient hears
little voices, not very much. It is from people outside.”

May 18th.—The people here annoy her, but not intention¬
ally. Denies that she now hears voices, but has an experience
which she finds a difficulty in describing, but which appears to
be a communication of the nature of a thought which is put
into her mind. Does not know who effectuates this. “ Always
thought there was somebody speaking to her from France.”

July 18th.—“A little annoyance, not much.” Sometimes
hears whisperings, but does not pay attention to them. Denies
that they are fancy.

October 18th.—Hardly ever hears voices now, and at any
rate pays no attention to them.

December 22nd.—I suggested to her that the voices which
she heard were fancy. She said, “ The voices were not fancy.
I imagined they were French people. Some were good, some
bad. When I hear them at all now they are only whispers,
but mostly I do not hear them, only a knowledge of the matter
comes into my mind.” This “ knowledge ” is, she told me, sug¬
gested by the same influences as formerly directed the voices:
“ I believe they are French people.” There were two sorts of
voices, some for her good, others striving to make her bad;
some striving to put bad spirits into her, some good. “ They
tried to make me say and do wrong things, but I don’t think I
ever gave way to them.” Latterly the voices have not been so
troublesome; “ it is now more as if I had a knowledge of some
one that is speaking to me.” Endeavouring to explain further,
she says, “ If I let myself think of the thing at all, something
like a little knowledge will come into my head; but the first
instant that I feel it coming—hear it coming—have some
opinion of it coming ”—(she used all these three phrases as if
hesitating or correcting herself)—“T can keep it away by not
thinking of it.”

On December 29th this poor woman was discharged, as I
deemed she could safely return to the community where she
had served. I have not heard of her since that date.

In both these cases we liave phenomena which are virtually
the same—distinct auditory hallucinations, giving place to an

xlix. 33

Digitized by v^.ooQLe

470

NOTES ON HALLUCINATIONS,

[July,

inward intimation which the patient describes as “ a thought.”
The latter evidently belongs to the class which Baillarger calls
psychical hallucinations, and Hagen, Kandinsky, and Lugaro
pseudo-hallucinations. The fact that the “ thought” is sub¬
stituted for the voice, and that in the case of the woman above
described they appear to be occasionally confounded, points to
the essential identity of the two conditions. Furthermore both
phenomena have the same intrusive, unexpected, surprising,
and compulsory character, which leads the female patient to
attribute both the " voice” and the “thought” to the same
mystic external agency. It is true the patients distinguish the
one from the other, naming one a “ voice,” and describing the
other in terms which seem to place it among purely mental
operations. To me this appears to present no special difficulty,
for I have been in the habit of teaching that there is a sense of
mental action, rarely appearing above the threshold of con¬
sciousness in the normal state, it is true, and differing from
other senses in that respect, but often rendered very evident in
morbid conditions through its disturbances. We are at present,
of course, not able to point either to the exact mechanism of
this sense, nor to its seat, but that should not hinder us from
recognising its existence. There is still much that is obscure
about the muscular sense; for a long time it was altogether
obscure, but these circumstances have not prevented every one
from long ago accepting it at least as a working hypothesis. I
do not see under what other category save that of sensibility we
can bring the many complaints of our paranoiac patients as to
their mind being interfered with, their thoughts being com¬
pelled, their power of attention being destroyed, etc. The
intrusive thought is regarded by the patient as belonging to an
order of events identical with the ordinary sensory hallucina¬
tions. Thus I have a patient who sees indecent pictures and
figures which are flashed before his eyes, hears indecent words
spoken, feels that his genitalia are tampered with, and that his
mind is forced to dwell upon indecent thoughts which are
thrust into it. (Of course every clinical observer will recognise
that this case is very far from rare.) My patient attributes all
these operations to a common agency. In a manner so do I,
though not in;his manner. Of his hallucinations the most clearly
cut are the auditory; they most closely resemble the common
operation of the auditory sense; they are the most clearly

Digitized by v^.ooQLe

1 903-3

BY C0N0LLY NORMAN.

471

dependent upon an engagement of a cortical sensory centre.
The voices are simply heard. Less distinct are the visual
troubles: they are not merely described as something seen;
they are visions that are flashed before the patient. The
hallucinations of the genital sense have not the definiteness they
sometimes possess, for they are not accompanied by distinct
tactile sensations in the region of the sexual organs, but they
have the disconnected and intrusive character common to the
auditory and visual troubles. So also with the feeling that
mental action is interfered with. The very nature of the func¬
tion engaged here prevents that distinctness which auditory
hallucinations so often exhibit; but we have the characteristics
of a sensation—something coming from without and striking
suddenly into the consciousness, something which the con¬
sciousness rather suffers than does. I fail to see how these four
classes of morbid sensations can be differentiated, save by the
functions engaged, or how we are to class some of them as
hallucinations and some otherwise.

We may pause here for a moment to consider the occurrence
of hallucinations of the genital sense, for it seems to me that
the variety of forms in which we find genital hallucinations
throws instructive light upon the question of pseudo-hallucina¬
tions of the other senses. Some patients experience voluptuous
dreams, which we may for the present purpose consider as
physiological, or they experience conditions of erethism (con¬
gestion, etc.) of the genitalia in waking moments, which are,
perhaps, also physiological; these conditions have to the
patient the appearance of being intrusive, and are by him or
her attributed to external agencies. This we may call delusive
interpretation, and liken it to the illusions of certain other
senses. But other patients in their waking moments are
wearied and tormented by sexual sensations unaccompanied in
their inception by any special local conditions of the genitalia
which may account for them, and seemingly independent of
such conditions. To be sure, in many cases what begins as a
mere sensation ends in excitation of the generative organs,
leading, in the male, to ejaculation of the contents of the
vesiculae seminales; but this is not always the case, nor even as
often as one might expect, knowing how easily complete sexual
orgasm is produced in states of irritable weakness. Now in
many cases we find that hallucinations of the genital sense,

Digitized by

Google

472

NOTES ON HALLUCINATIONS,

Duly,

subjective specific sensations, are associated with other hallu¬
cinations. The most obvious, though probably not the most
common, of the other senses engaged is the tactile sense. Thus
male patients complain of the genitalia being handled ; female
patients of sensations of dilatation of the vagina and of titilla-
tions apart from, though concurrent with, specific feelings.
Sometimes there is concurrent olfactory hallucination. Male
patients not unfrequently tell me that they are made to perceive
odours of the female genitalia. I need hardly refer to the
obscene visions and the obscene auditory suggestions to which
many patients are liable,—the former, I think, relatively more
frequent in men, and the latter in women. Again, we have
obscene thoughts thrust into the mind, or the mind compelled
to dwell upon obscene thoughts. At this extreme we border
upon obsession. From time to time we meet cases exhibiting
various combinations of these states, or all of them. How are
we to say that some of them are hallucinations and others not ?
How are we to distinguish here between hallucinations and
pseudo-hallucinations; between psycho-sensory and psychical
hallucinations ?

Is it not rather evident that a function is engaged here, and
not any one sense, and that the engagement of this function
may bring about the engagement of any one of the divisions of
sensation which either ordinarily or extraordinarily subserve
that function, or that it may indeed cause the engagement of
them all ?

In other words, does not this once more point to a synthesis
taking place in some centre other than that from the specific
activity of which we are conscious of any particular sensation ?
We know that in the higher nervous motor centres individual
muscles are not so much represented as groups of muscles
performing specific functions. The study of hallucination
would seem to show that the sensory centres in the cortex are
probably associated together in an analogous way. As sensa¬
tion is much more complex than motion (if for no other reason,
yet for this, that motion—at least the functional motion referred
to—is represented in sensation), therefore the associations of
sensation are qf far greater complexity than those belonging to
motion. Though we believe with Tamburini that the sensation
of which we are conscious denotes a change in a cortical
sensory centre, yet unless in case of purely elementary sensa-

Digitized by

Google

1903 ]

BY C0N0LLY NORMAN.

473

tions (such as many dolorific sensations, ocular sensations of
mere colour or flashes of light, auditory sensations of mere
noise) we do not seem to have pure sensations; and we are
therefore apparently necessitated to think either that a certain
degree of synthesis of sensations takes place in the special
centre of the predominant sense, or else that synthesis occurs
in a higher centre receiving representations (symbols) from
several centres. Such a centre is an associative centre of
Flechsig, or a psychical centre, and I think with Tanzi that
the examination of hallucinations seems to confirm generally
Flechsig’s doctrines.

(*) Esquirol, Des maladies mentales, 1838, tome i, pp. 159, 191, 192, 201.—(*)
Dago net, Traiti des maladies mentales, 1894, p. 63.—( 3 ) Ball, Lemons stir les
maladies mentales, pp. hi and 112.—( 4 ) Tamburini, Revue scientifique , 1881.—
( f ) Kandinsky, Kritische und klinische Betrachtungen im Gebiete der Sinnestdu-
schungen, 1885, p. 148.—(®) Max Simon defines hallucination thus:—“ A sensory
perception without an external object to give it birth ” (compare Ball, “ A percep¬
tion without an object,” Lemons sur les maladies mentales , deux. £d., p. 62; and
Bianchi, “ A subjective perception,” Trattato di Psichiatria , p. 200). in another
place Simon asks, “ What is an hallucination in point of fact ? ” and answers,
“ A sensation which runs along a sensory nerve in a direction the reverse of normal
impressions” (Le monde desrtves, deux. 6 d., pp. 72, 93, 103). Simon does not
claim originality for this view, which he says was entertained by Morel, who again
followed Buchez. I have not been able to verify the reference to Morel, which
is rather vague; but elsewhere that author says, “ I reject none of the definitions
of hallucination; I give my adhesion to none ” (Maladies mentales, deux, tome,
p. 472).—( 7 ) Maury, Le sommeil et les r&oes, quatrifeme £d., p. 78, cf. Ball,
Maladies mentales, p. 64.—( 8 ) S£glas, u Les hallucinations unilatferales,” Annales
medico-psychologiques, 8me s£rie, tome 6me, p. 230.—( 9 ) Bail larger, Des hallucina¬
tions, etc., 1846, pp. 385 et seq .—( 10 ) S^glas, Lemons cliniques sur les maladies
mentales, 1895, pp. 13 et seq.; Troubles du langage chez les aliSnis, 1892, pp.
117 et seq.; and several earlier papers referred to in these works. S£glas refers
to the fact that Fourni£ and Max Simon (see the work above quoted, p. 103)
had regarded these conditions as disturbances of the function of language, and
that L£lut had already suspected this connection.—( u ) Lugaro, “ Sulle Pseudo-
allucinazioni (Allucinazioni Psichiche di Baillarger),” Riv. di Pat . Neru. e Mentale,
Genn. e Febb., 1903.—■(**) Lugaro, op. tit., “ It is probable that this fundamental
disturbance depends on an elective and systematic lesion of special cortical
neurons. The system engaged cannot be either sensory or motor, because the
sensibility and the motor capacity are intact; nor can it be a system set apart for
the association of images, because the memory and ideation are preserved; the
lesion must therefore engage a system of neurons set apart for the supreme
co-ordination between representations, the corresponding emotions, and the execu¬
tion of acts.”—(“) Cramer, u Ueber Sinnest&uschungen bei Geisteskranken Taub-
stummen,” Archiv. f. Psych., Band xxviii, s. 875.—( u ) Exemplified in a case at
present under my care, in which a female patient who suffers from auditoiy hallu¬
cinations hears in her right ear the voice of her priest comforting her, and in her
left the voice of the devil tempting her and suggesting suicide and despair.

Digitized by v^.ooQLe

474

SUPERANNUATION ALLOWANCES,

[July,

Superannuation Allowances for Scottish Asylum
Workers. A Discussion opened by J. Carlyle John¬
stone, M.D., at the Spring Meeting of the Scottish
Division of the Medico-Psychological Association,
Glasgow, March 27th, 1903.

Dr. Carlyle Johnstone, introducing the discussion, said:
It is several years since any active steps have been taken by
the Scottish Division, or by the Association itself, to obtain
retiring allowances for the officers and servants of Scottish
district and parochial asylums. Nothing has been done in the
interval by the State or the local authorities to satisfy our
reasonable claims or to remove the special injustice under
which Scotland suffers. A memorial on this subject was pre¬
sented to the Lord Advocate by the Scottish Division in 1877,
and a similar memorial was presented to the Secretary for
Scotland, Lord Lothian, in 1887. The representations of the
Division were politely received, but no practical results have
followed. It may be considered that it would be futile to send
in a third petition ; but the present Secretary for Scotland has
never been approached by our body, and he may fairly consider
that if we do not ask for pensions we do not want them.
There is reason to believe that at any moment a Bill for the
amendment of the Scottish Lunacy Acts may be introduced
into the House of Commons. We should leave no stone un¬
turned in order to secure that in this Bill provision shall be
made for the granting of superannuation allowances in all
Scottish public asylums. I have brought this question before
the Asylum Workers’ Association and the Parliamentary Com¬
mittee of the Medico-Psychological Association, and both of these
bodies have now memorialised Lord Balfour on behalf of the
Scottish asylum workers. In my opinion our Scottish Division
should do the same. The conditions of service in Scotland are
so anomalous, so grossly unfair as compared with those in
England and Ireland, that, if only we keep on protesting and
agitating the matter, we may reasonably expect by our con¬
tinual importunity to obtain justice sooner or later. At each
General Election we ought to approach every candidate for
Parliamentary honours, lay our case before them, and obtain
from them individually, if possible, an expression of their sym-

Digitized by v^.ooQLe

DR. URQUHART.

475

I903-]

pathy with our claim and a promise to vote for a Bill which
shall satisfy this claim. This is what we ought to have done
at the last General Election. I hope that this meeting will
resolve that this shall be done at the next one. It does not
appear to me to be opportune to approach Members of Parlia¬
ment at this moment. In a decaying House, with a dwindling
majority on the side of the Government and many Members
proposing to go into retirement at the dissolution, we can
scarcely expect Members to pledge themselves to vote for what
cannot be regarded asa“ popular ” or “ economical ” measure.
But we ought, I think, to get into touch with Lord Balfour at
once, and make plans for bringing pressure to bear on all
Scottish candidates at the General Election, which may
possibly occur at an early date.

With regard to the case for pensions in Scottish public
asylums, I need not say much. The arguments in favour of
such pensions must be familiar to you all. Their soundness
has been recognised by the Legislature in its enactments for
the sister countries. They apply to Scotland with exactly the
same force as to England and Ireland. What we have to
protest against is the utterly unreasonable and unjust anomaly
under which we labour in Scotland. Whatever we resolve to
do, let us carry out one common policy; let us continue to
insist that retiring allowances shall be provided for by statute ,
and that the conditions under which these allowances are to
be granted shall be at least as full and fair as those which
have been provided for public asylums in England and Ireland.

Dr. Urquhart understood that the Parliamentary Committee
had made no suggestion for the drafting of a clause relating to
pensions, but that could be considered in the future. Mean¬
while they must keep pace with the times. There was no doubt
that a Lunacy Acts Amendment Bill was ready to be brought
before Parliament on the first opportunity, and they could not
afford to let the opportunity pass. If they were really earnest
about this question they must act now, and act in concert. The
Association was under obligation to Dr. Carlyle Johnstone in
attacking the question once more. Seven years ago a com¬
mittee of the Scottish Division had obtained a report upon the
position of affairs and the possibilities of action. That com¬
mittee inclined to compromise, by instituting a system of self-
help, especially by the annual subscriptions of individuals and

Digitized by v^.ooQLe

476

SUPERANNUATION ALLOWANCES,

[July,

committees to the Royal National Pensions Fund for Nurses.
They had the benefit of the advice of Mr. J. A. Robertson, C.A.,
than whom there was none more competent, relative to that
Fund, which had been started with very large endowments; and
they were well received by Sir Henry C. Burdett, the Founder;
but there was a considerable opposition to any such scheme
being advocated by this Association. That opposition was
never tested in Scotland; but it had been tested in England, and
the objections were so wide-spread and so great that the Scot¬
tish Committee were asked to suspend their report until the
English Lunacy Bill was passed, when it was hoped that thereby
pensions would be assured to the workers in the English
asylums. Consequently nothing had been done to remedy the
grievance under which Scotland laboured. Indeed, at the present
moment they were in a worse position than formerly, because
the latest Irish Act had apparently rendered pensions permissive,
whereas they were formerly compulsory in Ireland. He need
not detain them with the recital of how their colleagues were
striving to remedy this latest injustice. In Scotland they had
difficulty in bracketing Royal asylums with District asylums,
because no Bill could be framed to make pensions compulsory
for the first-named, depending, as they must, upon their yearly
income. But the District asylums were in a different position.
The officials in these institutions ought to have similar pro¬
vision for superannuation to that granted to other classes of
civil servants. The state of affairs in England at the present
moment resembled the position in Ireland. When the latest
Lunacy Bill for England came before the House of Lords the
Marquis of Ripon said that Yorkshire had provided for its
asylum workers in an effective manner which did not require
the establishment of pensions in the future, and that he there¬
fore must move for the deletion from the Bill of any clauses
regarding pensions. It was rather startling thus to be told that
Yorkshire had solved the problem in a manner satisfactory to
the County Council, to the Marquis of Ripon, and to the em¬
ployes of the Yorkshire asylums. But on examination it was a
fraud, a palpable and gross fraud ; it was a contracting-out of
moral obligations on the payment of a compensation equal to
about one third of the sum required. As a matter of fact
nothing of the kind had been done which justified the Houses of
Parliament in their dealings with this question, and the Lords

Digitized by v^.ooQLe

DR. URQUHART.

1903.]

477

were entirely misled by the Marquis of Ripon if they attached
any importance to his speech.

Had the Association learned anything in regard to this
question of pensions ? Did they stand where they had stood ?
Were they going to accept the compromise which their Com¬
mittee had worked out with Mr. Robertson, the compromise
that each person would have a deduction made on his salary,
and that the Committee would add so much, and that in the
event of a person leaving before the insurance, as it were,
matured, he would get back his own contributions, the re¬
mainder going to augment the pensions of those who had not
yet retired ? He did not think so. He thought that they
must rather depart from that position, and take their stand
upon the rights of the question. He urged them to immediate
action. Of course, they had no great political influence ; they
were not considered by Whig or Tory; but they could make
themselves heard, and at any rate they had the satisfaction of
knowing that what they were asking for was a real necessity in
the best interests of the insane. They were charged with the
interests of the insane, and in their interests they could approach
Members of Parliament and the Secretary of State for Scotland.
At the last election in Perth they sent a deputation from
Murray’s Asylum to confer with the candidates for Parliamentary
honours. That business-like man, Mr. Whitelaw, at once said
that, if returned to Parliament, he would vote for the establish¬
ment of asylum pensions. Mr. Wallace, the present member,
said that they were preaching to the converted, and he would
hold himself pledged to assist them in every way. They had
the strongest possible case.

He therefore urged that the asylum workers should inter¬
view all the Members of Parliament for Scotland. He doubted
if they would get anything without “ lobbying ” the Members,
and showing them individually the justice of their claim. Unless
it were shown that, besides talking and writing at large, they were
determined to impress upon them individually that this was a
proper concession to the Scottish asylum workers, what would
they get ? They might go to Lord Balfour, and receive the same
polite response as they had previously got from the Marquis of
Lothian :—“ Yes, this is a thing that ought to be done, but I
cannot imperil my Bill by the word ‘ pension ’ within the four
corners of it.” While what they represented was true and

Digitized by v^.ooQLe

478 SUPERANNUATION ALLOWANCES, [July,

just and right, their claims were practically ignored. The
Commissioners might prepare a Bill in which pensions would
be authorised, knowing and sympathising as they did with the
asylum workers; but when it arrived at Dover House the blue
pencil might again work havoc with their claim. The Govern¬
ment sends through the most urgent amendments of the law;
but the question of pensions was not urgent for the Govern¬
ment.

How long were they to go on talking? If they got every
Scottish Member of Parliament pledged to support the prin¬
ciple that they had so long advocated, they could go to Lord
Balfour and say, “ Here are all your supporters and all your
opponents ready and willing to confer on Scotland what England
and Ireland already possess.” Otherwise he (Dr. Urquhart)
was afraid that they would just remain where they had stood
since 1858. Members were no doubt familiar with Dr. Hayes
Newington’s circulars in regard to this question, and his com¬
parison of the police service with the asylum service of the
country. These ought to be carefully studied. It would not
do for them to put forward any scheme in detail without very
carefully considering it, but rather in the first instance occupy
the broad ground that asylum workers have a right to super¬
annuation allowances for which they have worked during the
best years of their lives on salaries and allowances inadequate
to make other provision for old age.

Dr. Alexander Robertson would only say that he ap¬
proved of Dr. Urquhart’s suggestion to bring as much influence
as possible to bear upon the Members of Parliament. In
bringing the matter before the House of Commons it would
be advisable, he thought, not to bring it as a Government
measure, but as an ordinary measure, backed by the support of
as many Members as possible.

Dr. Watson thought it would be most important in attempt¬
ing to introduce anything of this sort into Parliament, not only
to obtain the support of influential Members of Parliament, but
also to obtain support from the members of the Lunacy Boards
and the Parish Councils. Nobody knew better than the Chairman
what might be gained by taking them into their confidence.
No doubt some would oppose a scheme for pensions in Scotland
unless very substantial contributions were made by those who
expected pensions, and if such contributions were made he

Digitized by v^.ooQLe

DR. MARR.

I903-]

479

thought the Parish Councils and Lunacy Boards might be
induced to supplement them in some way.

Dr. Ireland, in reference to the proposal that the super¬
intendents and others in the asylums should make a com¬
pulsory deduction from their pay, said that had been done to
his cost in the Bengal Army, and these compulsory deductions
had stood very much in the way of their getting increased
pensions from the Government. The Government looked upon
it in this light,—that after so many years’ service they would get
£ig 1 of retired allowance, but, at the same time, if they waited
a few years they could get £300 from their own funds, making
some £ 500. The Government did not consider where it came
from ; and, after all, it was taken out of the compulsory savings
of the members. It would have turned out a very much better
policy if the officers of the medical service had saved the money
themselves, because, for example, if they retired before their
time they lost all their money. He would warn them that the
experiment of compulsory deductions was a dangerous one.
He had not the slightest doubt that before their younger
friends were prepared to retire or were gazetted out, pensions
would be provided for them. As to political influence, he was
extremely doubtful; for, all told, they could not elect a single
Member of Parliament.

Dr. Keay did not quite agree with what Dr. Ireland said
about their political influence. He had discussed this matter
with his own staff in Inverness, and had found that there were
twenty-five ready to vote for the man who would support
asylum pensions in the House of Commons; and if every
medical superintendent took the trouble to explain matters
they would find that a good many votes could be cast.

Dr. Marr said that the Glasgow District Lunacy Board,
which was also the Parish Council, was at first against the
principle of superannuation, but is now in favour of it. The
scheme which had been brought under the notice of his board
required many alterations, and was essentially a scheme of
contributions on the part of the officials, on the one hand,
and the District Lunacy Board, on the other hand, to the
extent of 5 per cent . on the salaries and emoluments. It was
proposed that 2 \ per cent, should be contributed by the officials
and 2 J by the Lunacy Board. The sum thus acquired would
act as a superannuation fund. Despite Dr. Keay’s remarks,

Digitized by v^.ooQLe

480 SUPERANNUATION ALLOWANCES, [July,

he knew that it was very hopeless to put forward a Bill of the
nature suggested. Twenty-five votes against any Member of
Parliament in or about Glasgow would not materially affect
the results of any election. The advances made to get local
Members of Parliament to favour the scheme had not pro¬
duced any appreciable effect. While he was in favour of
bringing forward a Bill to put them on the same level as
English and Irish asylums, he thought the scheme to which
he had referred would be the one that it would be necessary
ultimately to adopt.

Dr. Parker said that if they agreed to the principle of
partial contribution by the workers they could probably work
hand in hand with the Poor Law officials. Such a Bill was at
present being prepared in connection with the Poor Law, and
it would be unfortunate if their influence on this matter should
be split, when they might possibly work together. He did not
see how pensions were to be got without their agreeing to give
something themselves, and his own feeling in the matter was
that the most practical way, and the way most likely to be
successful, was that they should agree to contribute some¬
thing.

Dr. Yellowlees said that with the income which they had
at present the asylum workers had no means of saving, and
could not afford to make a contribution from their pay, because
with them it would really be deferred pay. He quite agreed
with what Dr. Ireland thought about that. He understood
that at the meeting of the Parliamentary Committee they had
in this particular matter the help of the British Medical
Association.

Dr. Carlyle Johnstone. —Not in this instance ; they had
nothing whatever to do with the representation.

Dr. Yellowlees thought they could get much more from
the Parliamentary Committee of the Association, especially
with the aid of the British Medical Association, which was
very powerful, and which was, of course, represented very
largely in Scotland.

The Chairman said that there was one thing that must be
gratifying to the Association, viz., that one prominent Parish
Council, referred to by Dr. Marr, was in process of rapid con¬
version to the necessity of superannuation. Everybody con¬
nected with the Poor Law service knew that the Parochial

Digitized by v^.ooQLe

1903-]

DR. GEORGE ROBERTSON.

481

Boards and Parish Councils had set their faces dead against any
scheme of superannuation for their officials, because in his
opinion superannuation carried with it a fixity of office, and did
not suit some of them who wished to have the privilege of
capriciously dismissing an official, which would be lost if such
a scheme were put in operation. He did not think there was a
board that had not broken the law by appointing old officials to
sinecures and paying them a certain salary, for which they did
no duty.

Dr. Carlyle Johnstone (in reply) said that the Secretary
for Scotland had been approached by the Parliamentary Bills
Committee of their Association, and also by the Asylum
Workers’ Association of Great Britain and Ireland; and he
thought that they themselves should approach him also, because
Lord Balfour might say he had never heard anything about
pensions in Scotland. He begged to propose that a Committee
be appointed to draft a memorial to be presented to the Secre¬
tary for Scotland in favour of pensions for the workers in the
Scottish district and parochial asylums. Personally, he
thought it would be a mistake for them to draft a measure at
the present time; but if they were to draft a measure, what they
should specify should be terms as good as were enjoyed by the
workers in England and Ireland. As to the altering of the word
“ may ” to the word “ shall,” he did not think the alteration
would ever be made. His own view was that they were asking
too much in proposing to insist that every person after so many
years’ work in an asylum should have a pension. He would
leave the question perfectly open in regard to the exact drafting
of the clauses.

Dr. Ireland seconded the motion.

Dr. Yellowlees said that he agreed with Dr. Carlyle
Johnstone as to the use of the word “ may.” From personal
experience he thought that the word “ may ” might be got, but
that the word “ shall ” would not work out so well.

Dr. Carlyle Johnstone said he would like to add, as a
rider to his motion, that, when Parliament dissolved, instructions
be given to the Secretary of the Division to arrange for a
meeting, or otherwise, so that they might make a combined
movement upon the candidates for Parliament.

Dr. George Robertson said he understood that a number
of the Members of Parliament had already agreed to the

Digitized by v^.ooQLe

482 SUPERANNUATION ALLOWANCES. [July,

proposal. He might say that both the candidates in his
district were asked, and they were both agreeable to the giving
of pensions to asylum workers. If they made inquiries they
would find that there was a considerable number of Members
of Parliament who had agreed to pensions being given to
asylum workers.

Dr. Urquhart moved, as an amendment, “ That before the
memorial is presented, the medical superintendents of Scotland
be asked to ascertain the views of the Members of Parliament
in their respective districts.’* He thought it would strengthen
the memorial if such an action were taken, and he was quite
sure, as Dr. Robertson had indicated, that they would be sur¬
prised at the amount of support that they would receive from the
Scottish Members of Parliament if they only took the trouble
to approach them.

Dr. Alexander Robertson seconded the amendment.

Dr. Carlyle Johnstone thought it was a very inopportune
moment to make such a movement.

Dr. Carlyle Johnstone’s motion was then put to the meeting,
and was agreed to.

Dr. Urquhart further proposed that, in order that the
medical superintendents might have every information before
them in approaching Members of Parliament, the small Com¬
mittee which he hoped would be appointed to carry out the
memorial should communicate to them all the available in¬
formation.

Doctors Bruce, Carlyle Johnstone, and Urquhart were
appointed as a Committee to draw up the memorial.

Dr. Carlyle Johnstone proposed that the memorial should
simply be transmitted to the Secretary for Scotland by the
Secretary of the Division as from the Division, and they might
add, of course, that they should be glad to wait upon Lord
Balfour at his convenience.

Dr. Urquhart thought, in that case, that any member of
the Scottish Division who would take the trouble to form part
of the deputation ought to be asked to Edinburgh.

The Chairman said the Committee should have power to
add to their number if any personal representation was made.

Dr. George Robertson asked if the opinion of the Mem¬
bers of Parliament was to be obtained by the members of the
Association.

Digitized by v^.ooQLe

I903-] granular ependyma in general paralysis. 483

The Chairman. —Yes, before the presentation of the me¬
morial.

Dr. Yellowlees said that the result of such an action
would be that they would be able to say they had a considerable
number of Scottish Members of Parliament who were in
favour of the proposal.

Frequency of Occurrence of Granular Ependyma in
General Paralysis . By J. V. Blachford, M.D., Senior
Assistant Medical Officer, Fishponds Asylum, Bristol.

A granular condition of the ventricular ependyma has long
been recognised as a pathological condition in various cases of
insanity, and is so common in cases of general paralysis that
we are surprised when it is not present. It is, however, by no
means confined to that specific class of case, but exists in others,
and, although not so frequent, is sufficiently common to make
one inquire into its cause and as to its bearing, if any, on
insanity.

The subject has been mentioned and discussed from time to
time, but so far as I can ascertain, though hints have been
thrown out and suggestions made, no positive proof has ever
been afforded as to its origin.

I have examined the post-mortem records of this asylum for
several years with a view to ascertain—(1) in what number of
cases of insanity granular ependyma is found, (2) in what class
of cases it most frequently occurs, (3) whether age or the
disease immediately causing death appears to have any in¬
fluence on its production.

Of 246 males, 64, or 26^ cent., were considered to be cases
of general paralysis; and of these, 44, or 68*8 per cent., were
found to have the ventricular ependyma granular; while in 20
it was not so.

Of 226 females, 19, or 8*4 per cent., were general paralytics ;
and of these, 14, or 737 per cent., had the ependyma granular;
while in 5 it was not so. Besides the cases of general paralysis
presenting these post-mortem appearances, there were 27 males

Digitized by v^.ooQLe

484 GRANULAR EPENDYMA IN GENERAL PARALYSIS, [July,

and 11 females in whom the ependyma was granular, though
they did not present the symptoms of general paralysis. Of
these male cases having granular ependyma, but not being
certified or recorded as general paralytics, five are reported as
suffering from epilepsy, and of these one had signs of syphilis
and one had double stricture of the urethra. Four suffered
from organic dementia; of these three had signs of syphilis
and one was a case of ataxic insanity. Of the others, in three
there were a distinct history or signs of syphilis, and in two
others a strong probability, one having been in the army for
a number of years. The other had a series of one-sided con¬
vulsions before death.

Of the eleven female cases, three were epileptics, of whom one
had probably had syphilis; two were cases of organic brain disease,
one of these being a case of bulbar paralysis. In two there
were signs of old syphilis, evidenced in the one case by pigmen¬
tation of shin and an old scar on buttock, in the other by the
history of having had ten children, of whom only three are
alive (one being only twelve weeks old), and of the patient having
had an epileptic seizure three weeks before death. In two the
lateral ventricles are described as slightly granular, the fourth
smooth, and in two no indications or anything special to note.

It will be seen from the foregoing statistics that apart
from those cases in which the patients had general paralysis,
the great majority suffered from coarse brain lesions, or were
patients in whose previous history there was a distinct history
of syphilis, or whose occupation was such as to make one
suspect that they may have contracted that disease.

That it is not caused by the disease which immediately
causes death is evidenced by the fact that it occurs in cases
dying of epilepsy, senectus, cirrhosis, bronchitis, cellulitis, and
pulmonary oedema indiscriminately ; while in a large number of
cases dying of the same diseases no traces of granular ependyma
are found. On the other hand, it is not caused chiefly by old
age, for by far the greater number of general paralytics pre¬
senting the appearance died under 50 years of age, and many
at a still earlier period; and there are many cases of over 70
years in which the granular ependyma was not present. In this
connection there is one significant fact, viz., that although it
is occasionally present in young cases this is rarely so in those
above mentioned. One male was 16 years of age, a congenital

Digitized by v^.ooQLe

BY J. V. BLACHFORD, M.D.

1903.]

485

imbecile with pegged teeth, who was blind, probably the result
of keratitis; and one female 17, a congenital epileptic, also with
pegged teeth; while all the others not general paralytics were
over 25 years, and most of them considerably over 30.

Taking those cases, therefore, which are not general para¬
lytics, we find that—(1) it occurs more frequently in men than in
women; (2) it occurs in middle or after middle life; (3) it is
generally connected with some coarse organic cerebral lesion,—
in all these points resembling ataxy and general paralysis,
diseases concerning which there is an ever-increasing tendency
to attribute their cause to syphilis.

As regards the cases of general paralysis, I am sorry that we
have very little positive history of syphilis, but this fact is
accounted for by the difficulty often experienced in eliciting
such information.

Dr. G. E. Watson, in an analysis of twelve cases of juvenile
paralysis, in eleven of which the ependyma is noted as granular,
states that in eight cases congenital syphilis was certain, and
that in no case could it be excluded,—very strong evidence
that that disease was the common cause, or at any rate the
cause of the condition of the ependyma.

Dr. J. Bolton, in a communication to the * Archives,’ discusses
the occurrence of granulation of the ventricular ependyma ; he
states that it is common in all varieties of insanity. The
examination of the above 472 cases certainly does not confirm
this statement, the condition being exceptional except in cases
of general paralysis or coarse brain lesions. He also suggests
that it is due to the cholin and nucleo-proteid in the cerebro¬
spinal fluid. I have not examined specimens microscopically,
but the evidence of the majority of those who have goes to
prove that the granulation is due to proliferation of the
neuroglia which lies subjacent to the epithelium of the ven¬
tricles, and not to any increase in the lining cells themselves,
as we should expect in cases of direct irritation by the fluid of
the ventricle.

Dr. Bolton, however, brings very weighty evidence in favour
of the syphilitic nature of the lesion. In eighty-three cases he
states that syphilis was found to exist in 59 per cent ., and was
highly probable in eleven more.

Thus from the evidence afforded by the investigation of cases
by others, not only of those of Drs. Bolton and Watson men-

XLIX. 34

Digitized by v^.ooQLe

486

CLINICAL NOTES AND CASES.

[July,

tioned above, and of those which have recently occurred in this
asylum, we must, I think, admit that the probability that the
granular condition of the ependyma is due primarily to syphilis
is strengthened; and if that be admitted the frequent occurrence
in general paralytics is very suggestive of the cause of the
disease.

Clinioal Notes and Cases.

A Case of Chorea and Pregnancy with Insanity . By

Robert Jones, M.D.Lond., M.R.C.P.Lond., F.R.C.S.Eng.,
Medical Superintendent, Claybury Asylum.

J. D—, a domestic servant, aet. 21, single, admitted June 15th,
1903. Four months pregnant on admission. The family
history showed^ that two brothers died of phthisis, and the
father died of apoplexy. There was no insanity in family, no
history of alcohol, nor were the parents related. Patient’s
heart was normal, no albuminuria, no chorea before. She
was of a bright and cheerful temperament, and always steady
and temperate.

History on admission .—Patient when admitted was four months preg¬
nant. Had been much depressed for some time, but became acutely
distressed after an interview with her lover. Marriage was arranged,
then broken off. Grieved over being pregnant, and after a period of
depression, lasting two weeks, she became noisy and excited, screaming,
refusing to remain in bed, or answer questions.

On admission patient was in poor condition, exceedingly depressed,
rolling about, had to be supported in a chair. Ground her teeth, and
still refused to answer questions.

One week after admission she became exceedingly maniacal and noisy,
and was placed in padded room.

Within two weeks of admission she developed well-marked left hemi-
chorea. On arsenic and extra nourishment.

Within one month there was more marked mental reduction, and she
could not answer the slightest question.

Three months after admission, and seven months pregnant, she was
becoming worse. Her habits were defective; exceedingly noisy and
restless.

Five months after admission she was confined of a stillborn child.

Digitized by v^.ooQLe

I 903 -] CLINICAL NOTES AND CASES. 487

Eight months after admission (three months after confinement) she
was quieter and more tractable.

Five months after confinement she was clean, tidy, and industrious ;
considerably improved.

Seven months after confinement her ideas were much clearer, and she
was pleasant in her manner, and bright.

Nine months after confinement, and fourteen months after admission,
she was discharged recovered.

Patient was readmitted, after an interval of two years, on July 9th,
1896. She was again pregnant, from five to six months. The certificate
stated her to be noisy, very troublesome and quarrelsome—especially
at night,—and using foul and obscene language.

Her previous history was that a month ago (four to five months
pregnant) she changed in her manner, but severe symptoms only
occurred ten days before admission.

On admission there was great motor excitement. She pitched about
and had severe choreic movements, this time on right half of body, and
but slight on left. There was no aphasia, but she spoke with difficulty.
When speaking she would use bad language without provocation,
bite her tongue, and laugh in a silly manner. Was very irritable,
wanting in self-control, and somewhat dull. She had numerous bruises
from the chorea movements, but did not complain.

In three weeks the chorea improved under treatment, but it was
present three months afterwards and during the last month of her
pregnancy. Before labour movements were very violent, and she would
have thrown herself out of bed if chloroform had not been administered.
She had marked opisthotonos; she was grateful for being held, and
was sensible and apologetic between the pains, and until chloroform was
administered.

The labour was normal, a male child, somewhat premature, and
nearly four months after admission.

Three months after confinement chorea was still present in the hands,
and there was slight mental weakness, although she was somewhat
improved. She steadily improved, and one year after confinement the
improvement was still maintained.

Fifteen months after confinement (nearly one and a half years after
admission) she was discharged recovered. She was to have been
married after her discharge, which is now nearly five years ago, and
nothing further has been heard of her.

Remarks .—The relation of muscular movements to mental
disturbances is one in regard to which our knowledge is
limited, and one which requires further elucidation. Those of
us whose practice occurs among persons admitted into
asylums for the insane not infrequently have to do with cases
of chorea. In our experience we find, at one end, acute
motor disturbances accompanying cases of acute mania,

Digitized by v^.ooQLe

488

CLINICAL NOTES AND CASES.

[July,

and at the other, cases of almost absolute muscular negativism
in those suffering from what has been exceedingly well de¬
scribed by Hayes Newington as “ anergic stupor.” Between
these two extremes we have all kinds of muscular movements,
varying from the epileptic fit to rhythmical athetosis, para¬
myoclonus, and spasmodic twitchings, including also a wide
range of uncontrolled movements which can only be described
as hysterical.

Bodily fatigue is demonstrably injurious to thought, and
Kraepelin has shown that muscular exhaustion weakens brain
power in definite curves and ratios. In my experience a
blunting of the faculties, indicated by loss of energy and mental
dulness, is more characteristic of the insanity accompanying
chorea than mania or melancholia, and the term “partial
dementia ” seems a more appropriate description of the mental
failure. The term dementia, however, is so vague that some
confusion has arisen in regard to it. Authorities differ as to its
meaning; some use the term merely in regard to the intensity
of the symptoms, and apply it to all cases in which there is a
suspension of the instincts, volition, and thought—regardless
of its pathology or its prognosis; that is to say, a set of
symptoms which may be evanescent, and which are regarded
as merely functional. In the present case the chorea, during
the first attack, was on the left side—a distinct left hemichorea.
In the same patient, in the second attack, the chorea was more
marked on the right side, although there was distinct weakness
of some of the muscles on the left side. Some authorities
regard dementia in the light of prognosis only, and apply the
term to those cases in whom there is no recovery; whilst others
use the term for cases in whom a definite pathological condition
exists, and in whom there is permanent brain damage due to
disease, and the condition is not functional.

As to the limitation of chorea to one or other side, it is
acknowledged that when the condition is unilateral the limita¬
tion is more apparent than real, for although a rhythmic and
involuntary spasm is more marked upon one side, some of the
muscles of the other side are also affected; and we know that
bilaterally affected muscles are commissurally associated, so
that when a disturbance of a certain group of neurons on one
side takes place, the vibration is conducted to the corresponding
group on the other side, which become, in effect, a single

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

489

nucleus, and movements which would be limited to one side
transgress the median line. I believe that some cases described
as chorea are not in reality true chorea, and that a group of
tics, or rhythmical athetosis, or the tremor of disseminated
sclerosis, or post-hemiplegic rigidity may be included in such
descriptions.

As to the pathology of this condition, but little is definitely
ascertained. Although chorea has been described as a cerebral
manifestation of rheumatism, both rheumatism and morbus
cordis were absent in my case, and there was no definite
connection with hysteria. We know of one definite form of
chorea, viz., the senile (Huntingdon’s chorea), which is almost
invariably connected with mental disturbance; and in a case
described by Bolton a definite change was recorded in groups
of Betz cells—cells which reach their highest form of develop¬
ment in man, in whom co-ordinated and specialised movements
attain their highest elaboration. That chorea occurs without
atrophy excludes the anterior horn-cells of the cord, and that it
occurs in young persons in whom there is neuronic instability,
and that it affects groups of muscles, also favours the cortical
neuron theory. Moreover, that it is a condition brought on by
grief, worry, and various forms of emotional excitement also
suggests a cortical lesion. In our case the first pregnancy of
a single woman, the shame and disappointment, the great
physical and mental changes which accompany pregnancy and
the arousal of the maternal instincts for the first time, probably
suggest disturbances in the higher cells of the cerebral cortex.

It is an accepted fact that the organ diseased may give a
type to the insanity, and that women suffering from affections
of the generative organs are more likely to have delusions
connected with sexual matters. It is a well-ascertained fact
that puerperal insanity is characterised more than any other
by lewd and indecent suggestions and bad language, although
in many instances it is difficult to believe that the persons
affected could ever have heard or known of expressions such as
they use—in such marked contrast are these to their former
conduct and habits of life.

As to the date of onset, in the first attack chorea appeared
after the fourth month, in the second after the fifth month, so
that presumably the act of quickening had no place as a factor
in causation. As to abortion being considered frequent in

Digitized by v^.ooQLe

490

CLINICAL NOTES AND CASES.

[July.

cases of chorea, the patient whose case is described proceeded
to full term after each of the two attacks. The severity of the
chorea increased on each occasion until after delivery, when it
gradually subsided—on the first occasion three months after
confinement, she being well within five months of childbirth ;
whilst on the second attack she was not well until a year after
confinement. This may suggest relief by premature delivery,
but I think there are strong contra-indications to this course,
and the balance of opinion is against it. As on this occasion
patient went out to be married, and five years have elapsed
without her readmission, one may surmise—there being no
further history of her—that the habitation as head of her
husband’s home, and presumably the avoidance of worry, may
account for the fact that she has not returned.

As to the statement made that pregnant women are more
liable to a mental breakdown when the sex of the child is male,
this is another of those unfounded assertions which, once circu¬
lated, gains credence. In over fifty cases of pregnant women
admitted suffering from the insanity of pregnancy into Clay-
bury Asylum, and there delivered, the sexes of the infants were
evenly divided.

A recent paper by Drs. Cecil Wall and Russell Andrews read
before the Medical Society of London (May nth, 1903) afforded
a valuable contribution to the relationship of insanity and
chorea in pregnant women. The paper related to chorea in
pregnancy, and the authors divided their cases into those in
whom chorea occurred in association with a high grade of
development and in whom rheumatism was common, and
those who showed signs of mental deficiency and frequently
also stigmata of physical mal-development. The authors stated
that the determining cause of chorea in pregnancy was usually
mental worry, often caused by the fact of pregnancy. “ The
onset of movements at or about the time of quickening in a
large proportion of the cases suggested the nature of the deter¬
mining cause. Sudden shocks might also be the immediate
cause of chorea. The loss of the power of control in chorea
might find expression not only in the physical irregular over¬
action, but sometimes also in emotional outbreaks, in some
cases reaching to a degree of mania or melancholia. It was
suggested that chorea in pregnancy was determined by mental
worry, over-strain, or shock acting upon a brain of which the

Digitized by v^.ooQLe

1903-] CLINICAL NOTES AND CASES. 491

controlling power was lowered by pregnancy; and the original
stability was abnormal owing to antecedent rheumatism or
chorea, or because it had never reached the normal standard
of development. Of 40 cases of chorea in pregnancy, in 37
patients it occurred in the first pregnancy eighteen times. In
10 cases the first pregnancy was not attended with chorea, but
chorea occurred in later pregnancies. In 6 cases it occurred
in subsequent pregnancies. There was a previous history of
chorea in 23 patients. There was a history of rheumatism
without chorea in 5 patients. There was no such history in
9 patients. The apparent cause in these 9 cases was—shock
in 2, husband out of work in 1, secondary syphilis in 1, and
unexplained 5. The month of pregnancy in which the move¬
ments began was—4 in first, 3 in second, 4 in third, 9 in fourth,
7 in fifth, 6 in sixth, 2 in seventh, and 3 in last. There were
5 fatal cases, and 5 patients out of 37 were single women.
The proportion of cases in which spontaneous abortion oc¬
curred was very little, if at all, higher than in ordinary
pregnancy. In subsequent pregnancies there was not neces¬
sarily chorea.”

Some Visceral Lesions in Acute Insanity. By George R.
Wilson, M.D., Physician Superintendent, Mavisbank ; and
D. Chalmers Watson, M.B., F.R.C.P.Edin.

In the following record two cases are described which seem
to make some contribution to the question of the relation
between insanity and lesions of the viscera. Dr. Wilson is
responsible for the clinical record and Dr. Chalmers Watson for
the pathological section of the work and for the remarks.

Miss Sixteen , age on admission , 25 ; admitted December 6 th , 1901;
duration of illness about six weeks; diagnosis , mania following
erysipelas , following malnutrition; termination , death Feb¬
ruary 25 th, 1902.

Summary of the course of the insanity .—1901.—November 1st,
subacute mania. November 14th, apparent recovery in con¬
valescent home. November 30th, relapse. December 6th,

Digitized by v^.ooQLe

492

CLINICAL NOTES AND CASES.

[July,

admission to asylum in subacute mania. December 15th,
apparent recovery, the patient calm and sensible. December
23rd, relapse. December 30th, menstruation.

1902.—January 4th, remission of acute symptoms and
apparent incidence of convalescence. January 6th to 8th, acute
mania, with delirium and some fever (99 0 —ioo° F). January
10th, remission of acute symptoms. January 15th etseq., acute
mania with delirium and fever (99 0 —102° F.). January 19th
to 20th, menstruation. January 25th, improvement, but still
slight fever (99°F.). January 25th to February 25th, gradual
decline and prostration, restlessness, paretic and atrophic sym¬
ptoms. February 25th, death.

Miss Sixteen came of a north-country stock; her parents
migrated from Orkney to Edinburgh, and they and their family
were strong and energetic; there is no history of insanity on
either the father’s or mother’s side. There is, however, some
peculiarity amounting almost to eccentricity, and the patient,
two brothers, and a sister, as well as the father, were of an
unusual personality—people of a pronounced character, whose
views and ways often differed from those of their neighbours.
Miss Sixteen herself was perhaps the most pronounced—under¬
sized, spare, fair in complexion, but with great energy and
determination; as a child, reserved and thoughtful, but when
she did speak she often expressed wise and mature views of
things, and was generally intelligent and capable. In girlhood
she was studious and earnest, fond of music, a devout girl, free
of all frivolities. In adolescence she evinced an independent
spirit that surprised and overcame her parents; she judged
everything for herself and chose her own way; those who
admired her called her resolute; others called her obstinate.
Of her own accord she took a post as clerk ; of her own accord
she gave up a good post and became a mental nurse, persisted
for some years, earned her certificate, then, refusing to be
advised by her parents, went in for fever nursing, which she
followed for four and a half years. This characteristic is worth
consideration, though it is the fashion at present to ignore the
personality of patients. During Miss Sixteen’s illness, when
nursing and tonic treatment were vital, her resistiveness was a
very important factor in preventing recovery. It was useless,
even when she was calm and quiet, to try to induce the patient
to do anything she wished not to do, especially in the matters

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

493

I 903 -]

of diet and of rest; and when she was excited the violence of
her struggles in resisting the feeding-tube, the catheter, or the
enema took much from the value of treatment.

There was no emotional factor of importance in the etiology
of the insanity. In the early stages she brooded much over the
untimely end of a free-thinking lawyer whose offer of marriage
she had refused, but there is no evidence that the subject had
previously worried her; on the contrary, she expressed herself
as being assured of God’s approval in this matter.

The history of Miss Sixteen’s health is instructive. Until she
took to nursing she was freer from illness than most girls.
Though spare, she was strong; though not highly coloured, she
never required treatment for anaemia. Menstruation was some¬
what irregular and troublesome, but did not occasion illness or
lay her aside from work. When she took to nursing, however,
her appetite and digestion began to fail. This was particularly
the case in the last two years, when she was fever nursing;
very often she continued to work on a starvation diet, having no
relish for her meals except when she was off duty for the day.
Soon after she took to the work she suffered an attack of scarlet
fever, from which, however, she seemed to make a complete
recovery. During this period she was also under treatment for
rheumatism. At the last she was put on special duty with a
virulent case of erysipelas, and at the end of it she herself
incurred the disease. For a young woman of twenty-five Miss
Sixteen’s experience was certainly exhausting—life as a clerk,
with long hours; over two years mental nursing; over four years
fever nursing, during the last of which she disliked her food;
then a severe attack of erysipelas. As the fever and delirium
passed off Miss Sixteen was left prostrate, and became excited,
fanciful, and sleepless. Having been called in consultation, and
in the opinion that improved bodily health would be accom¬
panied by a return to mental soundness, we advised removal to
a convalescent home in the country. There was immediate and
rapid improvement in the home, and Miss Sixteen seemed quite
well until one day one of her companions did something to dis¬
please her, and the patient, insisting upon having her own way,
refused to be guided, began to be troublesome, and relapsed.
Then she was taken to her father’s house, where she ate as much
or as little as she pleased, and otherwise resisted management;
so that when she was brought to the asylum in an ambulance

Digitized by ^.ooQle

494

CLINICAL NOTES AND CASES.

[July,

on December 6th, 1901, she was worse than ever—emaciated,
pale, prostrate, with a very feeble pulse, dry skin and hair and
tongue, cold feet and hands, and in constant and talkative rest¬
lessness. For several hours her life seemed in danger.

The notes in this case were unusually voluminous. The
following seem to be essential:

December 10th, 1901 (fourth day).—Patient has been given as much
as 5 j> t. i. d., of Pot. Bromid., and has done very well with it. Her mania,
which is now simple—mostly talking,—has subsided. She is eating a
great deal, and she is stronger.

December 19th.—Miss Sixteen is fatter, quieter, and stronger, by
complete rest in bed, simple diet—nearly all custard,—senna mixture,
and bromide.

December 23rd.—Miss Sixteen is beginning to be excited. The
bromide seems to lose its effect, and she is constantly talkative.

December 27th.—The patient is refusing food; conscious and
rational efforts are diminishing.

December 30th.—Patient is wandering steadily farther from sane
influence. She is refusing food still. She is menstruating.

January 4th, 1902.—Patient seems to be recovering now. Her
attack has been practically one of acute delirious mania, though with
no noteworthy rise of temperature. She has twice passed urine in bed
(probably a motor symptom here). Her conversation has been
rambling; she did not know where she was; imagined herself to be
up; said or asked the same things again and again, and was very per¬
sistent in refusing food and in refusing to move. The treatment during
this crisis, as it has been—the patient very weak, the pulse extremely
shabby, the eyes squinting, the mouth covered with sordes, the tongue
dry, brown, and cracking,—the treatment has been by rest and rectal
feeding, with strychnine and strophanthus when she could be persuaded
to swallow, and an occasional sulphonal suppository.

January 6th, 1902.—This patient has relapsed and is very ill. She
has screamed nearly all last night and the previous night, and the heart
is flagging.

January 7th, 1902.—Last night the patient was less noisy, but only
because she is weaker. She screamed as if in agony—a sudden yell
as if startled by a shooting pain (pleurisy, meningitis, or peritonitis),—
and the least touch seemed sore, as if there were neuritis all over.
To-day her temperature is 99 0 F., though her extremities are cold. There
is no doubt, I think, about the neuritis. I cannot discover any pleurisy
or peritonitis. The patient’s breath is very bad—the odour suggestive
of the decay of approaching death. About 1 a.m. the patient was con¬
stantly noisy, and I passed an oesophageal tube (the pulse practically
gone in the process) and administered 5 ij Hyp. Emuls. (Parald.,
Bromidia, and Pot. Brom.) in hot water; also some hot milk, after
which she slept. At 4 a.m., as she seemed weaker and was wakeful, I
injected strophanthus and strychnine into the buttock, and she rallied
and slept until about 8 a.m.

Digitized by v^.ooQLe

1903 -]

CLINICAL NOTES AND CASES.

495

January 8th.—This morning the patient, having passed much urine
in bed, collapsed after the exertion of changing. Dr. Duncan found
her at 9.30 semi-comatose ; pulse about 150 and shabby; respirations
about 45 and very shallow. Brandy, strophanthus, and strychnine were
administered per rectum . She has now (12 noon) rallied.

January 9th.—Patient calmed somewhat during the night and slept.
The respirations came down to about 36, the pulse to 118. At 9.30
the patient again “ fainted,” and was restored by strophanthus and strych¬
nine. Throughout the day Miss Sixteen screamed loudly at times,
but took some food. At 10 p.m. she “fainted” again. Parald. 3iij
was injected per rectum ,, and by 11.30 the patient was quiet and stronger,
and said she would sleep.

January 10th.—Patient had a much better night. She was disturbed
early by mucus and a little blood in the throat (note this again after
tube which was passed yesterday evening), but slept when nurse cleared
throat by finger. During the day the patient swallowed a considerable
quantity of food.

9.30 p.m.—Strength steadily increasing. She laughed a great deal
during our interview; knew me quite well, and took an interest in what
went on.

January nth.—Patient had a good night. Passed a pale, liquid stool,
not so offensive as yesterday. Took food freely from her nurse this
morning, milk in the forenoon, and a cupful of veal soup later.

January 1 ith to 15 th.—Temperature subnormal; patient in all respects
better, but very weak. She is having salol.

January 22nd.—Patient has suffered another relapse. The tempera¬
ture has been higher this time, though never more than 102° F. As a
result of a bruise from the edge of the bed-pan between the converging
folds of the buttocks, a sore has begun over the sacrum—at first a
blackening patch the size of a sixpence, but obviously about to slough.
The delirium was deeper and mord constant than formerly, but quieter,
with less excitement.

January 26th, 1902.—Patient has been menstruating these past days.
The temperature is down. She is quieter, but very aphasic and meta-
phasic. When her attention is not caught her mind wanders. She
passes urine incontinently. The slough is about the size of half a
crown, to the depth of a quarter of an inch, with much burrowing
under the skin all round, but healing well. The pulse is constantly
no—120.

January 29th, 1902.—The stools (always pale), which were formerly
very offensive, are so no longer. The sore is doing well. She was
raised to-day, and could stand a little. In trying to walk the right leg
swung across the left at each step, and was much more ataxic than the
left. Confusion is considerable, and there is distinct aphasia, also im¬
paired articulation. The right arm and hand are not disproportionately
affected. The strabismus and the ptosis, which were worse on the left
side, have now nearly gone.

January 30th.—This morning she seems to me stronger and clearer
than she has been. She has hallucinations, however; squeals as if in
pain, but denies pain ; and it seemed to me to-day that one of her
squeals was occasioned by some vision, probably of an unpleasant, or at

Digitized by

Google

CLINICAL NOTES AND CASES.

496

[July,

least startling nature. She has begun to be resistive. Salol was
stopped three days ago.

February 16th, 1902.—There has been an alarming fall in tem¬
perature. The digitalis and occasional ergot are continued. The
patient is obviously weakening. Diarrhoea has set in. Salol is resumed.
All water is boiled, and nothing irritating or easily decomposed is given.
The stomach is irritable. The back seems to be healing. One cannot
carry' out treatment, but must be guided by the patient’s whims, which
are quite inconsequent.

February 23rd.—Miss Sixteen’s temperature has been down beyond
the reach of the clinical thermometer (see Chart). She is on a water-
bed, and that has been practically filled twice daily with almost boiling
water. Coffee and other hot drinks have been administered, but the
temperature will not come up. The incontinence is persistent, and the
diarrhoea; the menstruation has ceased.

February 25th, 1902.—At about 12.30 p.m. to-day Miss Sixteen
died. The diarrhoea had diminished with chalk. At the end her heart
failed rather rapidly. Since this patient came to the house there have
been more than the normal number of whitlows and pustular eruptions,
and one rather severe (locally) case of erysipelas.

Miss Seventeen , admitted November nth , 1902, cet . 39. Acute
Mania following many previous attacks ; rapid progress of the
disease , and speedy death on December jth, 1902.

Miss Seventeen’s case so closely resembles that of Miss
Sixteen in essential features that it is unnecessary to enter fully
into details. In this case the patient had not suffered bodily
illness immediately before her attack of mania, but she had
passed through several mental attacks.

Miss Seventeen was poorly developed and ill-nourished,
anxious-minded, and somewhat exacting all her life; but very
gentle, and devoted to the service of other people. She had not
suffered grave bodily illness, but she was a victim of habitual
constipation, with occasional attacks of diarrhoea. She was
thirty-nine years of age, and during the last twenty years of her
life she suffered many attacks of mental derangement, nine of
them so severe as to require asylum treatment. She had re¬
peatedly been suicidal; even in the intervals between her acute
attacks she was discovered to be in possession of poison ; and
on more than one occasion her life was despaired of because of
exhaustion following acute mania.

She was admitted to Mavisbank on November nth, 1902, weak and
emaciated, restless, incoherent, and sleepless, with a poor, irritable
pulse and exaggerated reflexes, and very constipated, but not suffering

Digitized by ^.ooQle

Digitized by v^.ooQLe

Digitized by

CLINICAL NOTES AND CASES.

497

1903 .]

a violent mania. For the first week there was marked improvement;
then a relapse followed, and on December 5th Miss Seventeen was
in acute mania, with furred tongue, foul breath, marked constipation,
and suppression of urine, dry hair and skin, almost no appetite, and a
rapid, weak pulse. Her temperature was subnormal, but variable. The
blood-count revealed nothing unusual; the last film taken (about ten
hours before death) showed wide-spread bacterial infection. She had
delusions of pregnancy and hallucinations of sight and of hearing, but
soon became incoherent. This condition developed rapidly into
muttering delirium, with collapse, and on December 7th Miss Seven¬
teen died.

Post-mortem Appearances .

Summary .—Dilatation of stomach and duodenum, enlarge¬
ment and caseation of mesenteric glands, chronic gastro¬
intestinal catarrh, localised pulmonary areas of pneumococcal
infection with fibroid changes around, sclerosis of the bony
system with profound alterations in the bone-marrow, enlarge¬
ment of the thyroid gland, brain cortex congested, and chroma¬
tolysis in the nerve-cells.

Post-mortem examination on Miss Sixteen. —This was made forty-eight
hours after death. The body was markedly emaciated. On exposing
the viscera the stomach was found to be enlarged and displaced down¬
wards, its lower border being i£ inches below the umbilicus. The
mesenteric glands were enlarged, and two of them were caseous. A
general examination of the thoracic cavity showed fine adhesions over
the upper part of both lungs, especially the right; there were no indica¬
tions of recent pleurisy. The alimentary tract was removed en bloc , and
washed through first with water and then writh 5 per cent, formalin.
The whole tube was then moderately distended with the formalin
solution and secured above and below, its general examination being
made on the following day.

Abdominal viscera .—The stomach was much dilated. Its transverse
diameter at its broadest part was 12 inches; the great curvature
measured 21^ inches, and the small curvature 8 inches. The duodenum
was also dilated, its transverse diameter w r hen opened being 5 inches.
The mucous membrane lining the stomach and intestine was in a state
of chronic catarrh, this being most evident in the lowest part of the
ileum, stomach, duodenum, and ascending part of the colon. The
jejunum and upper part of the ileum appeared fairly normal. The
catarrhal condition was most pronounced in the lowest 12 inches of
the ileum, the point of maximum intensity being 4 inches from the
ileo-caecal valve, where minute ulcerations were visible to the unaided
eye. There was no evidence of tuberculous disease. The liver showed
some fatty change, also congestion. The spleen was normal in size,
but of softer consistence than in health. The supra-renal glands were
markedly congested. The kidneys showed no gross change. The
pelvic viscera appeared healthy.

Digitized by v^.ooQLe

498

CLINICAL NOTES AND CASES.

[July.

Thoracic viscera , etc .—The heart was unusually small in size. The
cavities, valves, and heart muscle showed no abnormality. The lungs
were cedematous and congested at the bases. The bronchi showed
evidence of acute and chronic congestion. At the periphery of both
lungs just underneath the pleura there was a number of small areas of
consolidation, of fairly firm consistence and a white colour, the lung
tissue around being specially congested. Some of these areas were
enclosed by a dense band of fully formed fibrous tissue. There was
no indication of tuberculous disease. The thyroid gland was unusually
large, but otherwise presented a normal appearance. An examination of
a complete vertical section of a femur showed the marrow to be
abnormally red, with areas of gelatinous change throughout. A piece
of rib was taken for histological examination.

Microscopic examination .—An examination of the brain, kindly made
for us in both cases by Dr. Ford Robertson, showed the chromatolytic
changes characteristic of acute disturbance of nutrition. The distinct
histological changes present in the viscera of Miss Sixteen will now be
described. The pieces of stomach and intestine examined were em¬
bedded in paraffin. Figs. 3, 4, and 5 illustrate the condition of the
mucous membrane of the cardiac, middle, and pyloric ends of the
stomach respectively. These should be compared with Fig. 1, which
illustrates a fairly normal mucous membrane, which is seen to consist
of long rows of tubular secreting glands, the irregularity on the surface
of this section representing unavoidable post-mortem changes. A study
of Figs. 3, 4, and 5 shows an atrophy of the mucous membrane, also a
disappearance to a great extent of its glandular elements, which are
replaced by large numbers of small round-cells; also a thickening of the
submucous coat. The reader will observe that all trace of glands has
disappeared in the section illustrated in Fig. 3, and the surface of the
mucous membrane is here covered with a thick layer of tenacious
mucus. The mucous membrane of the duodenum showed similar
changes. The jejunum and upper part of the ileum, which revealed
no distinct change to the unaided eye, showed pathological changes of
a less advanced character. The results of the examination of these
parts confirmed us in our belief that any opinion as to the integrity of
the intestinal tract based only on naked-eye appearances is valueless.
As previously indicated, pathological changes were most manifest in
the lower end of the ileum. Fig. 7 represents a section of the mucous
and submucous coat of the ileum, nine inches above the ileo-caecal
valve. There is a considerable degree of fibrous thickening of the
submucous coat, many of the vessels of which are enormously dilated.
The mucous membrane is in a condition of marked atrophy. The
normal appearance and arrangement of the villi have entirely dis¬
appeared, the villi for the most part being represented by little masses
of granulation tissue or a more fully formed fibroid tissue. In other
parts of the ileum the cellular proliferations and other evidences of
catarrh were very pronounced (Fig. 8). This change was most marked
in and around Peyer’s patches, but was diffusely present. A similar
pathological change was present in the ascending colon, represented
in Fig. 9, which shows profound changes in the mucous and sub¬
mucous coats.

Digitized by

Google

I903-] CLINICAL NOTES AND CASES. 499

Microscopic examination of the peripheral lung lesion previously
described showed the areas to be composed of great numbers of small
round-cells, with few catarrhal cells. Suitable staining revealed large
numbers of FraenkePs diplococci in these areas. Fig. io shows a low
power of the affected part of the lung. Note that the areas are enclosed
by a thick band of fibrous tissue. The other viscera showed no distinct
histological lesions, with the exception of the bone-marrow, spleen, and
the thyroid gland. Unfortunately it is impossible to submit a report
on the histological appearances of the rib, as it was found impossible to
properly decalcify the section, and as a result paraffin sections could
not be obtained. In sections prepared in celloidin the cellular elements
had to a great extent disappeared. The great difficulty encountered in
decalcifying the section is significant as indicating an important change
in the constitution of the bone. The histological appearances of the
spleen were those of increase in the number of hyaline leucocytes and
marked proliferation of endothelial cells. Reference was previously
made to the existence of an enlargement of the thyroid gland. Micro¬
scopic examination showed that the spaces were abnormally large, and
the great cellularity of their walls seemed to be considerably in excess
of what could be accounted for by mere tangential section of the organ;
the appearances represented an early stage of cystic enlargement of the
gland.

Summary .—Dilatation of stomach with pronounced atrophy
of its coats, chronic intestinal catarrh, marked deposit of pig¬
ment in spleen and liver, slight interstitial changes in the
kidneys, chronic disease of the bladder, sclerosis of the bony
system with profound alterations in the bone-marrow, brain
cortex congested, and chromatolysis in the nerve-cells.

Post-mortem examination of Miss Seventeen (conducted within eight
hours of death).— Summary .—The body was markedly emaciated. The
stomach was slightly dilated. The mucous membrane of the alimentary
tract was in a condition similar to that described in the previous case.
Unlike that case, however, the point of maximum intensity of disease
was the stomach, the wall of which over a large area was in a state of
extreme atrophy. This is represented in Fig. 2, which shows great
attenuation of the stomach wall, with disappearance of the mucous
membrane. The liver showed marked venous congestion, slight cellular
infiltration in the portal tracts, and an unusual degree of pigmentary
change in the liver-cells. The kidneys showed congestion, with early
interstitial changes. The spleen also showed congestion, with a great
amount of pigment deposit. The bladder wall was much thickened,
and on microscopic examination very marked changes were present in
all the coats. The epithelial lining had disappeared, the mucous mem¬
brane being represented by a thick band of organised granulation tissue
(see Fig. 11); the submucous tissue was greatly increased, and showed
pronounced thickening of the walls of the blood-vessels (< q . v,); the
muscular coat was much thickened, the thickening being in part due to

Digitized by v^.ooQLe

500 CLINICAL NOTES AND CASES. [July,

proliferation of the muscle-fibres, and in part to extensive overgrowth
of fibrous tissue. The naked-eye appearances of the bone-marrow
were similar to those described in the other ca^e; as formerly, great
difficulty was encountered in decalcifying the section of rib.

Remarks .—The points to which we wish to draw special
attention are (i) the situations of the lesions found at the
post-mortem examinations ; (2) the nature of these pathological
changes; and (3) the advisability of further observations on
the pathology of acute insanity being conducted along the lines
indicated.

1. The situation of the lesions .—In the case of Miss Sixteen
very pronounced pathological changes were present in the
gastro-intestinal and respiratory tracts, although clinically
there were no distinct indications of the existence of such
lesions. The parts of the alimentary tract which showed the
most striking changes were the stomach, duodenum, the lowest
part of the ileum, and the ascending colon. In the respiratory
tract the lesions existed at the peripheral part of the lungs,
just underneath the pleura, and also in the large and small
bronchi. Special attention should also be directed to the
changes described in the bone-marrow. In the case of Miss
Seventeen the gastro-intestinal tract was also the seat of pro¬
found morbid changes. Here, again, we have to record that the
clinical symptoms failed to indicate the severity of these lesions.
An examination of the respiratory tract in this subject did not
reveal any defined lesions such as those recorded and illustrated
in the case of Miss Sixteen, but the large and small bronchi
showed changes similar to those described. Investigation of
the utero-vaginal tract revealed the presence of a small,
pedunculated, submucous polypus just within the cervix uteri.
The size and position of this small tumour precluded its dis¬
covery by the ordinary methods of clinical examination.
Even the passage of a uterine sound would in all probability
have failed to reveal any abnormality. These points are im¬
portant as indicating the facility with which a possible source
of irritation may easily be overlooked. The changes in the
bone-marrow were similar to those recorded of the previous
case. A special feature of this case was the pronounced
thickening of the wall of the bladder; this will be further
referred to.

2. The nature of the lesions present .—If we except the small

Digitized by v^.ooQLe

JOURNAL OF MENTAL SCIENCE, JULY, 1903— Plate I.

Fig. 1.—Mucous membrane of normal stomach, to show the thickness and
normal appearance. The irregularity on the surface is unavoidable post-nurrtem
change (cf. PI. I, fig. 2, PI. II, figs. 3 and 4, and PI. Ill, fig. 5). x 50.

Fig. 2. —Section of the entire thickness of the stomach wall of Miss Seventeen
The mucous membrane has practically disappeared, and the other coats are con
siderably atrophied, x 50.

Digitized by VjOOQlC

To illustrate Drs. O R. Wilson and D. Cii \LME.'<s Watson's —

Digitized by

JOURNAL OF MENTAL SCIENCE, JULY, 1903.— Plate II.

Fig. 3. —Cardiac end of stomach of Miss Sixteen. Shows a, marked atrophy
of the mucous membrane; b, disappearance of the glands; c, great cellular infil¬
tration ; d, prominent thickening of submucous coat; e, a layer of mucus is seen
on the surface. x 50.

Fig. 4. — Middle of stomach. Changes similar to those in Fig. 3. x 50.
To illustrate Drs. G. R. Wilson and D. CiH^mIi&^W at son's paper.

paper

JJI .. J c..,

Digitized by

journal of mental science, july, ipoj.-Plate hi.

Digitized by

JOURNAL OF MENTAL SCIENCE, JULY, 1903.— Plate IV.

Fig. 7. — Ileum ; extreme atrophy of mucous membrane. The villi are represented
by small areas of granulation tissue, or more fully formed fibrous tissue. Note
the thickening of the submucous coat, with great engorgement of its vessels, x 50.

Fig. 8. —Ileum. Payer's patch. To show great increase of small round-cells, x 50.

rs. G. R. Wilson an 5 D. (?h.\lmers Watson s paper.

To illustrate Drs.

Digitized by

JOURNAL OF MENTAL SCIENCE, JULY, 1903.— Plate V.

Fig. 10.—Lung. Note underneath the pleura the areas of small-cell infiltration
described in the text; also the dense bands of fibrous tissue at their periphery.

Digitized by Google

To illustrate Drs. G. R. Wilson and D. Chalmers Watson’s paper.

Digitized by v^.ooQLe

JOURNAL OP MENTAL SCIENCE, JULV, 1903.—Plate VI

Fig. 12. —Outer part of bladder wall (Miss Seventeen >. Illustration shows
(a) great increase of connective tissue in the subserous coat; 1 b\ marked hyper¬
trophy of the muscle-fibres, groups of which are surrounded bv[<r) dense bands
of fully formed fibrous tissue. ( x 50.) ^rOOQie

To illustrate Drs. G. R. Wilson and D. Chalmers Watson's paper.

Fig. 11.—Mucous and submucous coats of the bladder (Miss Seventeen). Note
that the mucous membrane is represented by a thick layer of organising granula¬
tion tissue; the submucous connective tissue is much increased. Note the large
vessel with much thickened wall. ( x 50.)

Digitized by

1903-]

CLINICAL NOTES AND CASES.

SOI

fibroid polypus, the nature of the existing lesions admits of a
general description. The lesions in the alimentary, respiratory,
and urinary tracts were those of more or less destruction and
disappearance of the proper tissue elements of the organs
involved, their place being taken by large numbers of leuco¬
cytes, small round connective-tissue cells, and fully formed
fibrous tissue, the general appearances being characteristic of
local reactions to bacterial infection. Fig. io illustrates the
size and position of these foci in the lung. Suitable staining
revealed the presence in these areas of large numbers of
Fraenkel’s diplococci. The fibroid changes around these
areas clearly indicated the long-standing nature of the lung
lesion. (The reader will have observed that the symptoms
of mental derangement only appeared four and a half months
before death.) The lesions in the bronchi were those of acute
and chronic congestion. While these must not be ignored, we
do not lay special stress on them, as their naked-eye and histo¬
logical features indicated that they were largely of the nature
of a terminal change. It was otherwise with the lesions in the
gastro-intestinal tract. The changes were manifestly those of
chronic irritation, which we may presume to be synonymous
with chronic bacterial infection. These changes may be very
roughly classified into two groups—a, an atrophic ; b, a hyper¬
trophic. An extreme illustration of the former is seen in Fig.
2, which represents a complete section of the stomach wall,
and in Fig. 7, a section of the lower end of the ileum. Figs. 3,
4, and 5 are less advanced illustrations of the same morbid
process in the cardiac, middle, and pyloric end of the stomach
respectively. The hypertrophic phase, which is probably an
earlier stage of the process, is depicted in Fig. 8. While this
cellular infiltration is most marked in and around Peyer’s
patches, it is by no means confined to these areas. The marked
degree of thickening of the submucous coat and the fibrous
state of the villi showed that the pathological process was of
long duration. The lesion in the bladder in the case of Miss
Seventeen was an extensive small-cell infiltration of the mucous
and submucous coats, with atrophy of the mucous membrane
and great overgrowth of fibrous ‘tissue through the hyper¬
trophied muscular coat. The lesions illustrated were obviously
of long standing. The changes in the bone-marrow and spleen
were characteristic of the reaction of these organs to a
xlix. 3 s

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

502

[July,

general systemic infection. We believe that the changes in the
former tissue are specially worthy of careful study.

3. The advisability of further observations on the pathology of acute
insanity being conducted along the lines indicated .—It is not our
intention to form any conclusion from this record re the
etiology of acute insanity. What we desire to emphasise is
that a study of the history and clinical features of these cases,
in the light of the post-mortem evidence, suggests the necessity
of further observations on the pathology of acute insanity being
conducted along the lines indicated in this paper. The
investigations must be of a general nature and reasonably
complete. All possible sources of malnutrition of the nervous
system must be investigated, and special attention must be
devoted to a study of the natural means of defence in the
organism, and to the manner in which these react to bacterial
and other untoward influences. Temperature alterations,
whether of a febrile or subnormal character, should be studied.
Information as to the total quantity of urine passed per diem ,
and the character of the alvine discharges, if obtainable, will
be of the utmost service. Additional information of great value
will be gained by a frequent examination of the blood as already
carried out by Lewis Bruce. Careful regard must also be had to
the individual variations in the powers of resistance, a study of
which is essential to an explanation of the phenomena of disease.

These remarks are not to be taken as minimising the import¬
ance of a study of the hereditary factor in disease of the brain.
This must ever occupy a paramount place, and we wish to
clearly indicate that the lines of investigation to which we
refer are supplementary to that study and in no sense antago¬
nistic to it. In conclusion we would summarise the situations
of lesions the existence of which, in our opinion, is worthy of a
closer study.

a. The oro-gastro-intestinal mucous membrane .—The foregoing
records show that clinical features may be slight or absent, and
yet a condition have existed capable of profoundly interfering
with the nutrition of the brain. The recent researches of
Lorraine Smith ( l ) and Tennant on the presence of bacteria in
the alimentary tract of animals in health and disease are of
great interest in this connection.

b. The respiratory tract .—The examination must include the
whole respiratory mucous membrane, including the naso-

Digitized by

Google

I 9 ° 3 -]

CLINICAL NOTES AND CASES.

503

pharynx. The importance of deafness in some cases of
insanity is recognised; this deafness, in our opinion, is in the
great majority of cases dependent on a very chronic infection
from the nose and naso-pharynx. Hence the importance of
studying the complete clinical picture of disease as it exists
outside the nervous system.

c. The utero-vaginal mucous membrane .—This does not call for
elaboration. We need only cite cases of so-called puerperal
insanity as indicating the importance of this site in some cases
of acute disease; it is possible that it may be important in
some cases of chronic malnutrition of the nervous system.

d. The urinary tract , as in the case of Miss Seventeen de¬
scribed.

e. The skin .—It will suffice to refer to the mental symptoms
met with in some cases of erysipelas, and further remind the
reader of the diagnosis of the case of Miss Sixteen as one of
mania following erysipelas, as indicating the importance of a
study of the skin.

While attention should be directed to these situations as the
main sources of chronic infection, it is equally essential to
investigate the manner of reaction of the tissues to such chronic
change. This involves the detailed study of the blood, tempe¬
rature, pulse, and other changes during life; and later, if
opportunity arises, a careful investigation of the bone-marrow
and other leucocyte-forming tissues.( a )

In conclusion we may be allowed to indicate that we are
aware that structural changes similar to those described may,
and sometimes do, exist to some extent in subjects unaffected
by acute mental derangement. But the recognition of this
fact in no way minimises the probable importance of these
lesions as sources of malnutrition of the brain in the cases
involved. It rather emphasises the great importance of the
closer study of the individual factor in disease , and leads to a
clear appreciation of the fact that, with the possible exception
of a small number of diseases of a specific nature, no two
subjects react alike to the same pathological conditions.

( l ) “ On the Growth of Bacteria in the Intestine,” Brit. Med. Journ. t December
27th, 1902.—( 2 ) “The Reactions of the Bone-marrow and other Leucocyte-forming
Tissues in Infections,” Trans. Path . Soc. of London, vol. liii, 1902.

Digitized by v^.ooQLe

504

CLINICAL NOTES AND CASES.

[July.

Malignant CEdema in a Case of Melancholia; rapid
fatal termination. By R. D. Hotchkis, M.D., Assistant
Physician, Glasgow Royal Asylum.

The following case is thought worthy of publication, not
because there is anything unique in its history and progress,
but because it illustrates the low vitality to which a melancholic
patient can be reduced, and the consequent easy prey he falls
to any acute infective process. More than usual interest is
now attached to these cases, because of the prevalent views
of the toxic origin of insanity ; and the influence which different
poisons exert on one another demands careful study.

A. M. S—, aet. 59, single, a commission merchant, was admitted into
the Glasgow Royal Asylum on April 5 th, 1902.

Past history .—He had a previous attack about twenty years ago,
evidently slight, from which he recovered. Otherwise he has been
healthy. There is no known hereditary predisposition.

Present illness .—For at least a year he has suffered from digestive
troubles which impaired his health, and he also had some business
worries. Mental depression came on about nine months ago. Treat¬
ment chiefly for his dyspepsia was tried in a “Home,” but he got
worse, refused his food, which so reduced him that he had to be
removed to an asylum.

Present condition .—He is thin, spare, and emaciated, with hollow,
gaunt features, which are rendered more striking by his sad and
melancholic expression. No organic disease can be made out except
that his arteries are slightly thicker than normal, and his urine contains
a faint trace of albumen.

His mental condition is one of deep depression; his thoughts centre
entirely on himself, and his chief delusion is that his stomach is oigani-
cally diseased. On subjects not connected with himself he talks
rationally, and his memory seems good.

Ireatment andprogress .—He was at first kept in bed and was spoon-fed
every few hours, a proceeding which he resisted, but which ensured
him getting abundant nourishment. Paraldehyde was occasionally
given at night, and acted fairly well.

A distinct improvement soon set in, and continued uninterrupted till
he was discharged recovered on July 4th. He got comparatively stout
and cheerful, and the last mental symptom to disappear was the delusion
that poison was put into his food.

A few weeks after leaving here he relapsed, and continued more or
less depressed till his readmission as a voluntary patient on February
17th of this year.

His bodily condition is considerably reduced and is practically the
same as on his former admission, with the exception that his urine con¬
tains more albumen. Mentally he is much depressed, and has the same
hypochondriacal delusions about himself.

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

505

February 27 th.—His condition during the ten days since admission
has varied much; sometimes for one day he will be acutely depressed,
when he refuses to speak, will not keep his clothes on or take his food,
but rolls about on the floor with his face between his hands and groan¬
ing audibly. The next day he will be calm, though still depressed,
talking rationally, apologetic for his behaviour the day before, and much
distressed on account of it, and yet affirming, with evident sincerity, that
he could not help it He had to be fed once with the stomach-tube.
Paraldehyde is given at night with good results, which he himself
acknowledges.

March 3rd.—Yesterday about one o’clock he fell through slipping on
the polished floor, and sustained a superficial cut about half an inch in
length over the right eyebrow, which was immediately washed with
carbolic acid 1 in 40. This morning, in addition to ecchymosis, there is
more swelling than would be expected, and the wound looks unhealthy.
He will keep no dressing on it, but does not complain of pain or
uneasiness. There are some signs of prostration, his pulse being
feeble and his extremities somewhat cold.

4th.—Since yesterday the swelling about the wound has steadily
increased, and now his whole face is enormously swollen, the scalp
and neck also being involved. There is some sloughing of the epi¬
dermis over the right upper eyelid, due to its vitality being impaired by
the ecchymosis, but in other places the skin is of a darkish brown tint,
and there is no hardness or marked tenseness. The parts pit on
pressure, and some serum oozes from the wound. There is some
frothy expectoration and slight increase in respiration, showing involve¬
ment of the respiratory tract.

His general condition is one of great prostration—rapid pulse which
at times can hardly be felt, cold extremities, and subnormal temperature.
With a view to ascertain whether incisions would afford relief, Sir Hector
Cameron was consulted, but he did not advise any operative measures.
The treatment adopted was free stimulation, but the prostration in¬
creased, and he died the same evening.

Although the mental depression never left him, he remained conscious
and clear in mind up till the end, e.g., recognised and conversed with
his relations, inquired after his friends, and showed no loss of memory
or mental weakness.

The death was notified to the Procurator-Fiscal, and by his order the
post-mortem was done by Prof. Glaister.

The face was much discoloured, and the oedema involved not only
the face and scalp, but the whole of the neck and the pharynx and
larynx. The glottis was still patent. The skull-cap was somewhat
thickened. The pia arachnoid was thickened, chiefly over the parietal
region, and had some milky patches, but it was not adherent to the
convolutions. The cerebro-spinal fluid was much increased and filled
the ventricles, and the brain substance itself was oedematous. The
basal arteries were atheromatous. Both lungs were oedematous; the
heart normal, but there was some atheroma of the aorta. The capsules
of both kidneys were slightly adherent, but otherwise the kidneys were
normal, as were also the other abdominal organs.

Digitized by v^.ooQLe

506 clinical notes AND CASES. [July,

Remarks .—The above case showed the ordinary symptoms of
melancholia, with delusions referred chiefly to the digestive
organs. While in a reduced bodily state the patient is attacked
through a slight accident by an acute infective poison, and
succumbs without apparent resistance.

As regards the name of this acute infective disease, the
clinical symptoms point to one of the varieties of erysipelas,
viz., oedematous erysipelas or malignant oedema, this latter
term being especially apposite. There are some unusual features
in the clinical symptoms, one being the rapid course of the
disease—fifty-five hours only from the production of the wound
to the end; and of this some twelve hours might be allowed for
the period of incubation, as no swelling or untoward sign was
noticed till after the lapse of that time. It might be urged
that death was due to asphyxia, but, though oedema of the
glottis ensued, it was only partial, as was shown clinically and
also at the post-mortem.

In all forms of erysipelas a rise of temperature is almost
always present, but in this case the temperature was subnormal
throughout, and the symptoms of collapse were among the
first to appear. One explanation might be that the dose of the
poison was so great, and the organism so feeble and non-
resistive, that collapse ensued before the temperature had time
to rise. All text-books describe a high temperature with rapid
onset as one of the chief symptoms, but experience has shown
that in acute diseases in the insane most symptoms may be
modified.

The oedema, which was extensive, not only caused the soft
parts to be enormously swollen, but involved the brain and its
surroundings. Much has been written on the subject of intra¬
cranial pressure. According to one view the effusion produces
clinical symptoms of brain-pressure; the theory opposed to that
being that the brain is compressible, and therefore no patho¬
logical pressure can be exerted by the cerebro-spinal fluid,
which fluid can escape easily and readily from the cranial cavity.
The present case supports the latter view, for, although the
cerebral oedema was extreme, there were no clinical symptoms
of pressure, the patient’s mind being clear, except for the
depression, up till at least ten minutes before his death. He
recognised his relatives, was conscious of his surroundings,
nor did he show or feel any drowsiness; and he expressed the

Digitized by v^.ooQLe

1903 ]

CLINICAL NOTES AND CASES.

SO 7

wish that his usual sleeping draught (paraldehyde) would be
given him that night. Had any pressure at all been exerted on
the nerve-cells there would have been some symptoms, however
slight; but none could be detected.

Notes on Three Cases of Insanity Toxic in Origin . By

Eric M. Thomson, M.A., M.B., Ch.B., Assistant Medical
Officer, James Murray’s Royal Asylum, Perth.

Case 2552.—A married female, aet. 32, was admitted June 18th, 1902,
suffering from acute exotoxic mania of three weeks’ duration.

Family history .—Her parents were first cousins. She was the seventh
of a family of nine, the other members being healthy. Her maternal
uncle at one time had had an evanescent attack of depression after some
love disappointment; a cousin was insane. She had two healthy
children ; she had a miscarriage in 1901.

History of case .—In May, 1902, she had removed to a dirty house,
where there had been a case of typhoid. She personally undertook the
cleaning of the house, and shortly afterwards contracted pains in her
joints, with raised temperature, and an intensely itching erythema. She
was treated symptomatically. In a week or so her mental condition
showed unsatisfactory signs ; at night she would weep without apparent
reason, and was unreasonably suspicious of her relatives. Three weeks
after the occurrence of the physical symptoms she became acutely
maniacal, and, after a futile attempt to manage her at home, she was
brought to the asylum. On admission she was acutely excited and
subject to hallucinations of sight, hearing, and touch,—“ beasts ” were
running over her skin, and these she vainly tried to catch with her
fingers, uttering expressions of horror all the time; she heard voices,
and heard and saw “ water rushing down the walls.” She also declared
that she saw soldiers marching about her room, but that they disappeared
on her approaching them. She was very irritable during convalescence,
and her fleeting delusions returned in the evenings for some weeks.
Her physical condition was unsatisfactory: temperature 99*4°; pulse
108; tongue dry and brown. Her pupils were dilated, and reacted
sluggishly to light. Urine scanty, with a trace of sugar. On her scalp
was a diffuse eruption of sebaceous cysts, which were very hard and
immobile, about the size of a pea, and numbered thirty in all; they had
developed during the few days prior to admission. At first there was
some doubt regarding their nature, but this was demonstrated, and at
the same time a new mode of treatment was suggested, by the patient
rubbing down with her finger one of the cysts on her forehead, burst¬
ing the sac, and diffusing its contents into the surrounding tissue. She
was treated by rest in bed, various mild hypnotics and tonics, with

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

508

[July,

stimulants. Wet packs gave satisfactory results during the high ex¬
citement.

Her recovery’ was, save for a slight relapse, uneventful. She was dis¬
charged after three months’ residence, and soon recovered in home care.

Case 2554.—An unmarried female, set. 67, was admitted July 5th,
1902, suffering from acute, excited, abstinent, autotoxic melancholia.

Family history. —Father died paralysed; mother died of phthisis.
She was the eldest of a family of ten; one sister was hysterical, the
others healthy. A maternal uncle and aunt died of apoplexy. No
insanity was known in three generations.

Personal history .—About six years before admission she suffered from
myxcedema, but this had disappeared under treatment. She had been a
clever, accomplished woman, but had no great staying power for work,
and was at times, when displeased, petulant and hysterical.

History of case. —Twenty-five days before admission she had in public,
without any apparent cause, a violent hysterical fit, this being the first
sign of her mental breakdown. There followed upon this a gradually
deepening depression, accompanied by loss of appetite and general
malaise . She went to her sister’s house a week later, and was then very’
constipated, the usual remedies failing to act. Some days later she
began to refuse food, and was brought to the asylum.

On admission she was depressed and had visceral delusions,—said
that she had no stomach, and that she was the greatest of criminals. Her
physical condition was unsatisfactory, but no definite lesion could be made
out. She refused food. During the next few days her bowels were moved
by a dose of calomel followed by castor oil. Forcible feeding was found
necessary’. She remained very constipated, and was seen by the family
physician in consultation, but no gross abdominal trouble could be
discovered. For a short time there was a hard tumour showing just
above the pubes, but it disappeared as rapidly as it became evident. It
was not an enlarged bladder, but rather pointed to rapid malignant
growth. Her bowels were moved by means of enemata, and a large
quantity of faeces, containing hard scybalous masses, was evacuated.
Diarrhoea then began, and for some days she passed, per rectum , small
quantities of blood of a bright red colour. Her abdomen became
tympanitic, and a slight fulness could be made out in the left flank.
She was again seen in consultation, but her condition was too low to
admit of surgical interference. She died a month after admission.

Necropsy. —Left leg markedly cedematous, and the left inguinal glands
slightly enlarged. The abdomen was swollen and tympanitic. The
small intestine was dilated throughout its entire length; the large intes¬
tine was unequally distended, the ascending colon, hepatic flexure, and
descending colon being dilated; while just below the dilated portion the
bowel was of normal calibre and contained hard scybalous masses,
which, on removing the bowel and flushing it with water, were found to
almost entirely occlude the lumen of the canal. There was extreme
congestion of the mucous membrane in the position of the scybalous
masses referred to. The walls of the intestine were thickened and
catarrhal. A detailed examination of the intestines was made by Dr.
Ford Robertson, who reported evidence of severe chronic catarrhal

Digitized by v^.ooQLe

1903]

CLINICAL NOTES AND CASES.

509

changes in the mucous membrane of the stomach and intestines, there
being much thinning of the mucous membrane, thickening of the sub¬
mucosa, and fibroid changes in the muscular tissues, these all pointing
to a local irritation of long standing.

Case 2259. —An unmarried female, set. 58, admitted August nth,
1902, suffering from acute excited autotoxic melancholia.

Family history .—She was the second of a family of three; her two
brothers were alive and well. A paternal uncle was alcoholic, but lived
to old age. No insanity was known in three generations of the family.

Personal history. —She had had an attack of herpes zoster eighteen
months before admission, but had suffered from no other noteworthy
disease. She had been an industrious woman, of a cheerful disposition.

History of case .—Her illness had been of seven weeks* duration, and
had begun with “stomach trouble,’* loss of flesh, and constipation.
Occasionally she had frightful dreams, but was mostly sleepless. She
worried herself unduly about trifles, and gradually depression followed,
accompanied by delusions of unworthiness and poverty.

On admission she was acutely melancholic. Her bodily condition
was bad ; her urine contained a large amount of pus and some hyaline
casts, and was acid in reaction. A thorough examination of her
abdomen was impossible owing to her resistive condition, while she
herself would furnish no clue to her subjective symptoms. During her
residence she continued excited and depressed; she became abstinent and
had to be fed forcibly. Her urine did not improve under medicinal (urotro-
pine, etc.) treatment and surgical applications, and she was examined
by Dr. R. Stirling under an anaesthetic. The mucous membrane of the
bladder was found to be thickened and rugose. It contained no
calculus; urine scanty, highly phosphatic, alkaline, with pus and blood.
A diagnosis of probable malignant disease of the bladder, with possible
implication of the kidney, was made. Irrigation of the bladder, con¬
tinued for some time, had the effect of rendering the urine less offensive,
but her general condition did not improve. She died four months after
admission.

Necropsy. —Several minute calculi were found in the bladder; the
mucous membrane of the bladder w r as much thickened. A phosphatic
calculus was found in the pelvis of the left kidney, almost entirely
blocking the left ureter. Dr. Ford Robertson reported as follows :—
“ The kidney was found to contain several minute cysts and one fairly
large one, about one third of an inch across, multilocular, situated in
the cortex, and filled with a thick red fluid. Microscopic examination
show’s that the kidney is cirrhotic. The large cyst appears to be a
retention cyst. There are numerous emboli of micrococci throughout
the kidney. The vessels show numerous emboli composed of micro¬
cocci.”

Remarks .—These cases each possess interesting individual
features, while collectively they deserve notice because of the
very evident toxic element in their etiology. Case 2552 shows

Digitized by CjOOQle

5io

CLINICAL NOTES AND CASES.

[July,

a remarkable connection between the sensory hallucinations
and the cutaneous disturbances, and well illustrates the neces¬
sity of the integrity of the three essential factors for normal
mental action, (*) namely, normal cortical neurons, suitable
nutritional conditions, and normal sensory impulses. Here the
last two factors were disordered ; the nutritional basis, for the
time altered, so disordered the cortical neurons as to cause
them to interpret the disordered sensory stimuli received from
the skin, not as feelings of discomfort or pain, but as feelings
relating to the various hallucinations. The spontaneous dis¬
appearance of the sebaceous cysts is also remarkable, while the
patient’s treatment of them, though radical, is certainly sug¬
gestive.

Case 2554 illustrates a common variety of intestinal auto¬
intoxication. Unfortunately no definite information regarding
the usual state of the patient’s bowels, prior to her mental
attack, was available; but in view of the pathological report
the inference is sufficiently clear that a catarrh of the intestines
had existed some time before the occurrence of the mental
symptoms, and that this catarrh was in all probability
causative.

Case 2559 similarly is of toxic origin, the toxicity arising in
this case from the suppuration resulting from a renal calculus,
and along with Case 2554 we U illustrates the difficulty of
abdominal diagnosis in the insane.

Collectively, these cases are interesting because of their toxic
origin, and as illustrating the occurrence of physical symptoms
prior to mental symptoms.

On examining the admission schedules of these patients I
find that the “supposed cause” in the first and third cases is so
obscure as to warrant a candid admission of “unknown,”
while in the other case it is stated as “senility.” It is to be
regretted that, too often, reliance is placed upon this kind of
statement on the statutory schedule, filled up, as it usually is,
in carelessness or ignorance, where usually a prominent sym¬
ptom, such as alcoholism, is noted as causative, and too often
the physiological element is overlooked because of the promi¬
nence of the psychological.

The report of these cases is partly inspired by a remark in
the Journal for April of the current year anent the recording
of cases; one thing is certain, that the case-books of asylums

Digitized by v^.ooQLe

1 9 ° 3 -]

CLINICAL NOTES AND CASES.

511

contain much valuable information which, if collected and
tabulated, would go far to place the study of the etiology of
insanity on a sounder basis and free it from a great deal of
superstition and mysticism.

(*) Dr. Ford Robertson, British Medical Journal t October 26th, 1901.

A Case of Cerebral Tumour complicated with Alcoholic
ConfusionalInsanity. By H. E. Ridewood, M.B.Lond.,
M.R.C.S., Assistant Medical Officer, Claybury Asylum.
With remarks by Dr. Robert Jones, M.D., M.R.C.P.Lond.,
Medical Superintendent.

The patient, A. H. D—, aet. 38, was admitted to Claybury
Asylum on April nth, 1903.

The only important points in her family history were that
her grandfather died in an asylum, and that an uncle died
“ out of his mind.”

The following is her previous history :—She was never insane
before the present attack; she had scarlet fever at sixteen years,
and diphtheria at twenty-four. She never had rheumatic fever,
chorea, gout, influenza, nor fits of any kind. There is no
statement as to venereal disease. By her first husband she had
one child that died ; she then became a Salvation Army nurse.
She married again, and had one child that lived a year and died
of convulsions ; then she had a series of six miscarriages.

Two years ago her sleep first became fitful; since then she
has been continually leaving home for weeks at a time and
sleeping in the open in sheds and outhouses. In disposition she
was “ sometimes cheerful, at others spiteful.” Latterly she con¬
tracted habits of intemperance in drink, and would take nothing
but gin from morning till night. She would have it at any cost,
while she became more and more restless and sleepless.

She was admitted in a wasted and feeble condition ; her height was
5 feet 5i inches, and weight 6 st. 12^ lbs. She could not walk without
help, and could hardly stand alone.

Physical examination revealed nothing abnormal in the heart’s action
save that it was slow; the heart-sounds were clear, the apex-beat was
not displaced, and there were no signs of cardiac dilatation. There

Digitized by CjOOQle

512 CLINICAL NOTES AND CASES. [July,

was a pulse of 50, which was small, regular, and of fair tension. Over
the apex of the right lung there was deficient resonance to percussion
and diminished vesicular murmur on auscultation, without any adven¬
titious sounds; otherwise the lungs appeared healthy. No abnormality
was detected in any of the viscera. The urine had a specific gravity of
1020, was acid, contained no albumen or sugar. Deposit of mucus
and phosphates present. No malformations were present, but the
palate was high and narrow. There was general muscular enfeeblement,
with wasting, but without any local limb paralysis. The grip was a
little stronger in the right hand than the left, while she could not feed
herself properly from sheer loss of power. There was marked paresis
of the facial muscles on the right side. The orbicularis palpebrarum
was affected with the rest, since the closed eye was readily opened with
the finger. There was also paresis of the levator palpebrae superioris,
producing marked ptosis of the right eyelid, through the thin lax texture
of which the cornea, when totally covered, could be seen pointing in an
upward and outward direction. The expression was more or less
vacant owing to the drooping of the right eyelid and flattening of the
natural lines of the same side of the face, while her downcast eyes were
only occasionally raised, with apparent effort, when she spoke. When
she voluntarily raised her lids to look at any object, the eyes converged
naturally, and she counted the fingers and distant objects correctly, and
said she never saw double. No paralysis of any of the muscles of the
eyeball was detected, and no nystagmus was present. The right eye
seemed more prominent than the left, but this, I believe, was more
virtual than real proptosis. The tongue was protruded tremulously in
the middle line, and there was some tremor of both sides of the lips.
Mastication and swallowing were performed satisfactorily. There was
no tenderness of the calf muscles. Co-ordination, as tested by touching
the nose or finger with the eyes shut, was poor, but could be accounted
for to a large extent by lack of attention and muscular weakness. No
error of cutaneous or muscle sensibility was detected on any part of
the body. Sight was impaired, especially in a dim light. No other
affection of the special senses was discovered. The knee-jerks were
both equally exaggerated. Ankle-clonus and the plantar reflex were
neither of them present on either side. The other cutaneous and
organic reflexes were apparently healthy, and there was no affection of
the sphincters. The right pupil was dilated to about three quarters of
the full dilation, while the left was only about half the diameter of the
right. Both reacted sluggishly to light, and rather better to accom¬
modation. The outline was regular in both eyes. Speech was slow,
but without any slurring or elision of syllables.

On admission she was restless, continuously moving about in bed,
and talking to imaginary people. When interrogated she rambled,
stopping abruptly in the middle of one topic to start another. She had
no idea of where she was, but thought she was at home, and recognised
the people around as her friends. She could give no coherent account
of her recent life, stating, however, that she had not been able to sleep
for the last month, and had been taking drugs and sometimes spirits to
procure sleep. She also owned that she had been frequently intoxi¬
cated. Her memory for remote events was equally defective; she

Digiti ' y v^.ooQLe

1903-1

CLINICAL NOTES AND CASES.

5 i3

could not be sure how many children she had had. She had auditory
and visual hallucinations; she pointed to a part of her bed, where she
saw her child sitting, she said, and used to hold conversation with her.
She said she had various articles in bed with her, which she tried to
produce unsuccessfully.

A fortnight later, on April 24th, she was still in the same state of
extreme mental confusion. Every morning, although she had not left
her bed, she described how she had been out on some journey, errand,
or excursion. One morning she described how, after getting her
husband’s breakfast, she went for a walk “ under the water ” on the
river bed down to the stony sea bottom, where she found her husband’s
yacht of fifty tons, which she promptly manned, and sailed to France
accompanied only by her child.

On three separate mornings she described under-water journeys in
which she felt the pressure and motion of the water about her. More
often she said she went for a walk or went shopping. She could not even
remember then whether she had had her dinner or not. Frequently
one saw her waving her hand about in her endeavour to arrange
imaginary objects which she could not catch hold of, such as trying to
put a fictitious dish-cover on a plate. The only physical change was
that the ptosis was more marked and the patient more feeble.

No satisfactory examination of the optic papillae could be made
owing to a steaminess of the cornea with a breach of epithelium in the
centre. Vessels could be seen which, if traced along, led to no disc
that could be recognised as such, owing to the reflection. There was
no white reflex to be got anywhere, however, which a normal disc
would certainly give, so that, on the whole, the presence of papillitis
was highly probable. The pulse was now 80, fair tension.

By May 1st the patient w’as unable to hold her head up, and com¬
plained of pain in the back of the neck. If she sat up in bed the head
fell right backwards nearly between the shoulder-blades. There was
no loss of power in the extensor muscles of the neck, since the head
never fell forwards even if bent forwards. The pupils were about the
same size as before, but were now quite fixed. She became much
slower in replying to questions, and would hardly speak at all, appearing
quite dazed.

May 8th.—There was more loss of power of the flexors of the neck,
without much extensor weakness; the general feebleness was in¬
creasing, and the patient more stuporose. The knee-jerks were still
exaggerated.

15th.—She rapidly became unconscious, with stertorous breathing;
comeal reflex just present, to be lost later on, and the knee-jerks
obtained with difficulty. The pulse stroke was good, the tension fair,
and the rate 65. The coma gradually increased, and the left pupil
became much smaller, almost pin-point, while the right remained
about the same size as before. She died in coma on May 18th.

There was never any vomiting, headache, or fits throughout the
whole course. The temperature varied from 97 0 to 98° till May 17th,
when during the coma the temperature remained at ioo°. The pulse
remained about the normal rate, though slow on admission, slowing
down again during the coma.

Digitized by v^.ooQLe

514 CLINICAL NOTES AND CASES. [July*

The autopsy revealed a tumour arising by a peduncle from the right
side of the sella turcica, apparently from the dura mater, and invading
the temporo-sphenoidal lobe of the brain. When the brain was
removed it appeared in the angle between the basal surface of the
temporal lobe, the pons Varolii, and the crusta, pressing on the two
lafter and deflecting the third nerve. The right temporal lobe looked
larger than the left, and the tumour seemed to grow deeply into its
interior. The surface of the vault showed close packing of the convo¬
lutions, with flattening of their usually rounded margins, due to the
increased intra-cranial pressure. There was no cerebro-spinal fluid seen
above the tentorium, but some was present beneath it. The optic
nerves on section were redder than normal, so that optic neuritis was
present. The nature of the tumour is probably sarcomatous. The
brain is being hardened for examination and description.

Remarks by Dr. Robert Jones .—This case shows the difficulties
which encompass the diagnosis of cerebral tumour. Firstly,
there was neither headache nor convulsions, and some doubt
existed as to optic neuritis. Mentally the patient presented
the symptoms characteristic of alcoholic dementia—the param¬
nesia so frequently noticed in these cases, when the patients
make imaginary journeys, are forgetful of their surroundings,
and endeavour to fit the past into the present. In the case
under review the patient called the nurses and others around
her by names she thought she knew them by before admission.
There was a definite history of drink, extending over two or
three years, and the symptoms of the latter possibly obscured
those caused by the intra-cranial growth, which, except for
pressure on the nerves of the right eye and right side of the
face, were probably more functional than local, and caused by
intra-cranial pressure. It has often been asked if there are
any constant psychic symptoms common to all cerebral
tumours. The answer to this must be in the negative, as the
symptoms depend upon the localisation of the growth, and
whether it be intra-cranial or cortical; also upon its size, its
nature, and the rapidity of its growth. Observers who have
recorded a number of cases of cerebral tumour (and a valuable
summary of these has lately been compiled by Vigouroux)
state that mental or intellectual troubles are noted in about
one half of all cases, delirium in about one out of twelve,
and insanity very rarely. In the clinical experience of this
asylum (excluding haemorrhages, softenings, cysts, aneurysms,
etc.) there are records of about twenty-four cases of cerebral
tumour in over 9000 admissions, about 3 per cent, in each of

Digitized by v^.ooQLe

1903-1

CLINICAL NOTES AND CASES.

SIS

the sexes, a little more in males and a little less in females.
These cases fcannot be said to have had any one special
mental symptom, or set of symptoms, unless a dull, heavy
somnolence was characteristic of them. It has been stated
by some that the growths encroaching upon the frontal lobes
are accompanied by marked psychic symptoms—that a
special form of “reasoning insanity” is associated with neo¬
plasms of this region; but others consider the frontal lobes
to be “tolerant and silent” in regard to symptoms.

Brault and Loeper insist upon dementia as a symptom, and
they describe a psycho-paralytic form of cerebral tumour where
psychic troubles predominate and appear first. The dementia
has been described as a slowness of ideas, a laziness, a cloudy
state of mind with diminished power of attention, loss of power
in regard to intellectual effort and concentration, and a slow
response—the patient often falling into a veritable stupor imme¬
diately after replying. Brissaud has especially referred to this
stupor, stating that the patient does not speak or answer, does
not leave his bed or chair, does not eat; his habits are defective,
and only when his name is loudly called does he emerge from
his lethargy—and relapses again. The loss of memory has been
especially noted, proper names being the first to go; recent facts
are not remembered; but conduct, he states, remains normal
and without disorder.

In cases admitted into asylums actions are necessarily dis¬
ordered, and mentally there is a marked quantitative difference
in the intellectual faculties; the dementia is often total, and
there is complete indifference to surroundings, and in these
cases the patients are not conscious of their situation, have no
reflective life, no ideas, and they are unable to speak or act
for themselves.

Ball described “ irritability” as a special feature of cerebral
tumour, and that this feature enabled a diagnosis to be made
between cerebral tumour and cerebral softening. In the latter
dementia appeared with tears and laughter rather than in the
changed character and irritability of tumours.

Dupr6 and Devaux described a psycho-puerilism as of much
diagnostic importance, there being an infantile intonation and
an impatient, if not an obstinate indifference. Brissaud, as
already referred to, states as his experience that the intellect
goes and memory goes, but character is unaltered, and that

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

516

[July.

there is a simple return to childhood without the vivacity and
curiosity of the latter. Some have described impulses as
characteristic of cerebral tumours, also an “ambulatory
automatism.” In cases admitted into asylums, as stated, there
is more or less complete dementia, but may be neither sickness
nor headache, at times no convulsions, and but little assistance
can be obtained from the patient. When Broca’s area is
affected there may be the same speech difficulties as in general
paralysis, and cases are not infrequently diagnosed as general
paralysis of the insane, especially when, in the course of
the disease, the convulsive seizures are general and the
dementia profound. Cerebral tumours have to be distinguished
from senile dementia, softening, epilepsy, neurasthenia, lead
poisoning, and uraemia, as in these the mental and physical
symptoms are not dissimilar. To sum up, in regard to troubles
of the intellect, changes in the emotions and volition, there are
not any of these which are characteristic of the presence of
cerebral tumours, or are diagnostic of their locality.

What is the cause of the torpor ? Possibly the intra-cranial
pressure; for the torpor is relieved by surgical operations, such
as trepanning or lumbar puncture. This probably accounts for
the relief of symptoms in some cases of general paralysis.
Possibly toxic causes give rise to the convulsive symptoms, as
also to the delusions and torpor referred to, the toxins being
caused by dissociation of nerve elements surrounding the
tumour and during its growth, being then absorbed and causing
fever, headache, delirium, and convulsions analogous to the
auto-intoxication of uraemia or cholin poisoning of dementia
paralytica.

An Obscure Case of Aneurysm . By Robert Pugh,
M.D., B.Ch.Edin., Assistant Medical Officer, Claybury
Asylum.

A. B—, aet. 37, married, labourer. Admitted to Claybury
Asylum September 22nd, 1893, suffering from general paralysis.
No family history obtained.

Certificate .—His lips are tremulous, speech slow and hesi¬
tating, and the labials are not pronounced. Says a sack of

Digitized by v^.ooQLe

1903]

CLINICAL NOTES AND CASES.

517

flour fell on his shoulders from a height of fifty feet; says he
was at the London Hospital this morning; thinks he is now in
Bromley.

Physical condition .—Is fairly well nourished, has well-marked
signs of syphilis. Fraenum absent. Scar to left and below the
orifice of the urethra. Inguinal glands “shotty.” Tongue
furred and finely tremulous. Heart and lungs healthy. Pupils
unequal, left dilated, right contracted to pin-point, light reflexes
absent. Knee-jerks exaggerated. Plantar reflexes very marked.
Muscular movements tremulous and inco-ordinate. Gait
unsteady. Speech slurred and inarticulate.

Mental condition. —He is dull and confused, power of atten¬
tion much impaired, mental reaction slow, takes a long time to
answer simple questions; rambling and incoherent in his
remarks; memory much impaired for recent, remote, and per¬
manent events. Does not know where he is, nor how long he
has been here ; has no knowledge of time.

Progress of Case .

June 21st, 1894.—He is very tremulous, demented, and paretic. He
takes no interest in his surroundings, and has no knowledge of time or
place. Bodily health fair.

July 10th, 1901.—He is very shaky and lost. Speech is slurred.
Says he has ^7 5,000,000. Pupils contracted; light reflexes absent.
Left knee-jerk absent. Bodily health fair.

April 27th, 1903.—Mentally he is in a state of gross dementia. He
is absolutely lost to his surroundings. Bodily health feeble. Muscular
movements tremulous and very in co-ordinate. Pupils dilated; light
reflexes absent Knee-jerks absent Heart’s action feeble, and the
sounds in all areas clear.

May 15th (at 6.30 p.m.).—Patient was sitting up in bed, coughing
and labouring under dyspnoea; the cough was resonant and brassy; the
dyspnoea lasted for a little time, but responded to treatment

Next morning at 5 a.m. he died suddenly.

Autopsy .

Is poorly nourished. Has well-marked signs of syphilis. Fraenum
absent. Scar to left and below the orifice of the urethra. Inguinal
glands shotty.

Dura mater .—Thickened, excess of subdural fluid. Pia arachnoid:
much fronto-parietal opacity and thickening; strips with difficulty,
especially over parietal regions. There is a considerable excess of sub¬
arachnoid fluid. The vessels at the base are atheromatous, and the
sinuses are empty.

Encephalon .—1147 grammes ; right hemisphere 483, left hemisphere
475, cerebellum and pons 160. There is much wasting, chiefly in the

XLIX. 36

Digitized by v^.ooQLe

518

OCCASIONAL NOTES.

[July.

pre-frontal region, which is obscured by oedema. The lateral ventricles
are dilated and very granular ; the fourth ventricle is also very granular.

Pupils : right, 5 mm.; left, 6 mm.

Thorax .—Right pleura is firmly adherent at apex, posterior border,
and to diaphragm. The left pleura is slightly adherent at the apex and
the posterior border. The bronchial glands are cedematous and fibrous.
The bronchi contain blood. Right lung weighs 680 grammes; the
upper lobe is somewhat congested and fibrous. Left lung weighs 570
grammes; the upper lobe is oedematous; the lower lobe is pneumonic,
of a lobar type, and presents a marble appearance owing to presence
of blood. The pericardium is natural. The heart is wasted; the
ventricles are natural. On opening the trachea an irregular, ragged,
ulcerated area the size of a shilling is seen, just at the beginning of the
right bronchus. Several rings in this neighbourhood are necrosed.
The trachea, larynx, and the bronchi—more especially the left—contain
much recent blood-clot, which has practically flooded the lungs. The
opening leads forward into an irregular, false aneurysmal sac, which
lies below the arch of the aorta and passes forward, upward, and to the
right. A portion of the sac projects to the right of the pulmonary
artery. The original opening of the aneurysm from the aorta is im¬
mediately adjacent to and below the orifice of the left subclavian
artery. The portion of the aneurysm commencing from this opening
is denser and older than the remainder. The whole thing is the size of
a large orange, and contains much laminated and granular blood-clot.
The aorta is very dilated and atheromatous.

Abdomen .—Liver 1620 grammes, dense, fatty, small, nutmeg type.
Spleen 130 grammes, pulpy. Kidneys, right 120 grammes; left 115.
Capsule strips readily. Cortex 4—6 mm., density increased. Renal
arteries natural. Abdominal aorta atheromatous. The stomach and
intestines contain numerous blood-clots.

Cause of death .—Rupture into the trachea of an aneurysm of the
aojrta.

The case is one of great interest, as it showed the entire
absence of the physical signs and the pressure symptoms point¬
ing to an aneurysm. The patient had been in bed for some time,
and the presence of an aneurysm was not thought of until the
day before he died, when he developed the “ brassy ” cough and
his attack of dyspnoea.

Occasional Notes.

Alcoholic Insanity.

The report of a special committee to the Glasgow Parish
Lunacy Board shows that in the year ending May 15th, 1902,

Digitized by v^.ooQLe

OCCASIONAL NOTES.

519

1903.]

no less than 259 cases of mental disorder of alcoholic origin had
been admitted to the two asylums and the observation wards,
one third (33 per cent.) of the whole admissions of the year
being directly due to alcoholic excess.

This enormous amount of mental disorder does not by any
means exhaust the share of alcohol in the causation of insanity.
In many cases alcoholic habits, which have ceased, have given
a predisposition which later in life leads to mental break-down
from other exciting causes; and the children of drunkards yield
a considerable contingent to our asylum admissions.

Civilisation is credited with producing an increased amount
of insanity, but it is the vices accompanying civilisation that
are really to blame; if alcoholic abuse and the spread of
syphilis were checked, civilised communities would probably
compare very favourably with the most uncivilised peoples in
this respect.

This report shows that a large proportion of these alcoholic
cases were earning good wages; that in fact they voluntarily
reduced themselves to pauperism. This surely is an offence
against society that should be duly punished, but what punish¬
ment will be effectively deterrent to an individual to whom
neither pauperism nor insanity has power to appeal ? Such an
individual must be irresponsible, and should be dealt with
accordingly.

Treatment, and not punishment, is required by those who have
recovered from an attack of alcoholic insanity. The case of
every such person should be medically investigated and re¬
ported on to a magistrate, who should have the power of
relegating the individual to a home for inebriates for any period
not exceeding three years.

Punishment should, however, be meted out to the particeps
criminis —to those who have aided, abetted, and profited by
the offence against society; and these are the proprietors of
the drink-shops. It would be vain to attempt to assess the
amount of criminality in any given case, and it must, therefore,
be settled in the sum total arising in a given community.
This would best be done by levying a special rate on the public-
houses of a district to defray the expenses of the maintenance of
all alcoholic insane patients in the asylums or inebriate homes,
and of their families in the poor-houses. Such a rate would be
quite justifiable in face of the enormous profits made from

Digitized by v^.ooQLe

520

OCCASIONAL NOTES.

[July,

drink, and the huge increase in value of any house to which a
licence is granted, for which the community at present gets no
return whatever.

Such special rating of public-houses would probably more
than anything else tend to stimulate the proprietors to make
their profits from the real needs of the people for refreshment
rather than by encouraging and fostering the drink habit,
which is now their most profitable way of obtaining business.

It may be argued that all cases of alcoholic insanity do not
arise from drinking at public-houses, and this is true; but on
the other hand the excessive drinking which their methods of
business foster produces much ill-health and poverty apart
from insanity, and, as we have pointed out, causes also much
insanity which is not ranked as alcoholic.

If the public-houses of the country were specially rated to
the extent of a third of the cost of all pauper insanity, they
would still be treated with undue leniency. We trust that
Glasgow, which is so forward in dealing with lunacy matters,
will act as a pioneer in putting some check on the licence for
evil of the licensed victuallers.

Voluntary Boarders in County and Borough Asylums .

The extension of the voluntary boarder system to the county
and borough asylums has long been felt to be a necessity by
all who are interested in promoting the early treatment of
the insane. It is, moreover, only just that a provision of the
law which is found to be good for the well-to-do classes should
be extended to the poor. Dr. Ernest White has done good
service in again giving prominence to this great need of the
poor, in the recent discussion on the treatment of incipient
insanity.

That voluntary boarding was not extended to the so-called
pauper institutions in the late Lunacy Law was probably due to
the fear that many paupers might prefer to be treated as quasi -
lunatics in asylums rather than as paupers in workhouses;
this would be very likely to be the case, and constitutes a valid
objection. The difficulty, however, is so easily to be overcome
that it should not be a bar to the adoption of such an important
and valuable method of treatment.

Digitized by

Google

r 9°3-]

OCCASIONAL NOTES.

S2I

A medical certificate to the effect that the applicant was
capable of making the request for treatment, and was in need
of it, countersigned by a magistrate, should be sufficient to
protect the procedure from abuse.

The poor, much more than the well-to-do, suffer from the
want of appropriate means of treatment in the early stages of
mental ill-health preceding the stage of certifiable insanity,
and are consequently much more in need of voluntary boarding.

The Parliamentary Committee of the Association, which is
doing such good work in bringing to the attention of the Lord
Chancellor the various legislative reforms that are so much
needed, may be trusted to urge this amongst the foremost of
the possible improvements in the treatment of mental disease.

The Inadequate Lunacy Commission .

Lunacy legislation in the present Parliament is again con¬
spicuous by its absence, but before this reaches the eyes of our
readers there will probably have been some discussion in the
House on the insufficient number of medical men on the
Lunacy Commission.

The proofs of this insufficiency are so well known to the
members of this specialty, and have been so often urged, that no
repetition of them is needed here; but interest must be felt in
regard to the effect on the House of Commons of a statement
of the facts of the case.

The Parliament that hears with comparative indifference of
the destruction of £150,000 worth of tinned food, and of the
distribution amongst the population of fifteen thousand blankets
(possibly infectious), is not likely to be greatly perturbed by
being informed that the welfare of a hundred thousand insane
patients is being neglected.

A cynic would say that the insane have no votes and conse¬
quently cannot expect consideration, but the truth probably
lies in the fact that Parliament is more interested in things
which concern party rather than the State. National health is
as yet a question that is not within the range of practical
politics, and lunacy matters must, therefore, for the present,
remain in their condition of muddle.

Digitized by v^.ooQLe

522

OCCASIONAL NOTES.

[July,

Superannuation Allowances in Scottish District and Parochial

Asylums .

That officers and servants of the Scottish district and
parochial asylums should be utterly shut out from all super¬
annuation allowances is an almost incredible anomaly. Public
servants throughout Great Britain are generally provided for in
this way, and very few of them can claim it on the ground of
having duties that are in any respect so anxious, responsible, or
dangerous. Asylum workers should be the first and not the
last to be thus provided for.

The discussion on this subject at the Glasgow Divisional
Meeting in March, and the memorial addressed to Lord Balfour
by the Parliamentary Committee, will, we hope, draw the atten¬
tion of the responsible authorities to this glaring injustice.

The injustice to the asylum workers, however great, is
probably the least of the evil, for the inmates of these asylums
must suffer indirectly from the difficulty of obtaining and
retaining a satisfactory staff. This has been frequently pointed
out in the annual reports of the Scottish Commissioners, but
hitherto without the result of even a Parliamentary pro¬
position.

Legislation, it is well to remember, is not carried either by
justice or necessity, but by the numbers, noise, and persistence
of the advocates. We are not numerous, are not hysterical
enough to yell effectively, and so must rely on patient per¬
sistence. The Association should never cease from its efforts in
persuading the Houses of Parliament to redress this grievance.

The Department for Mental Diseases at the Albany Hospital.

The report of the first year’s work of the pavilion (F) for
mental diseases at the Albany Hospital is now to hand, and
appears to offer every encouragement for the extension of the
hospital treatment of mental diseases.

One hundred and seventy-three cases were admitted during the
year, of whom 57 recovered, 53 improved, 43 did not improve,
6 died, and 14 remained at the end of the year. Of the improved
and unimproved, 41 were transferred to the State Hospitals for
the Insane, and of these, 20 were transferred in the first week,

Digitized by v^.ooQLe

OCCASIONAL NOTES.

523

1903]

and 4 between two and four months. Dr. Mosher says that the
length of time patients should remain is still undetermined, and
thinks that no definite rule can be established.

Dr. Mosher also remarks that the pavilion has demonstrated
that mental patients of all classes may be received on voluntary
request, and that only “ a small minority resent the confinement
and cannot be held.**

Women nurses have been entrusted with the care of both
men and women, an arrangement that is reported to have
worked satisfactorily.

The experiment has been so successful that it is to be con¬
tinued, and we urgently hope that similar additions may soon
be made to British hospitals.

The Winsley Sanatorium for Consumptives .

The laying of the foundation stone of the Winsley Sanatorium
for Consumptives was an opportunity for the expression, by
those connected with, it of their recognition of the valuable
services of a member of our Association, Dr. Lionel Weatherly.

The sanatorium is the result of a combined charitable effort
of the counties of Gloucester, Wiltshire, and Somerset, and
when complete is expected to supply sixty beds.

The Western Daily Press , in commenting on the opening
ceremony, speaks of Dr. Weatherly as having been the “ in¬
spiring genius of the movement,” and it is satisfactory to
remember that this is said of the Chairman of the Tuberculosis
Committee appointed by the Medico-Psychological Association.

A New Journal ’

We have received notice from Cambridge that there is a
project for starting an English journal devoted to psychology.
The great increase in the number of workers in this depart¬
ment of science has overburdened the pages of Mind, and it is
believed that there is now scope for a journal which will permit
of the publication of important papers in regard to analytic,
genetic, comparative, and experimental observations. The
recent founding of new laboratories and the establishment of

Digitized by v^.ooQLe

OCCASIONAL NOTES.

524

[July,

the Psychological Society justify the expectation of a largely
increased volume of work.

The scope of the new journal is limited to the publication of
original articles and critical discussions on psychological
problems. It is proposed to issue a volume of some 500 pages
annually, in parts as may be found convenient, and the sub¬
scription is fixed at 15s. prepaid. The names of those who
sign the prospectus are: W. McDougall, C. S. Myers,
W. H. R. Rivers, A. F. Shand, and J. Ward, to whom com¬
munications should be addressed. They expect that the first
part will be ready in October next, but in the meantime desire
to know how many subscribers will aid in the scheme, and
how many will join in a guarantee fund, which is necessary in
order to induce the University Press to undertake the printing
and publishing.

We trust that this new venture will command the support it
deserves, especially among those whose work lies in asylums;
for the investigation of normal psychology is a necessary pre¬
liminary to the elucidation of psychiatry—an inquiry too long
neglected, and as yet only partially appreciated.

The Family Care of the Insane .

At the International Congress, held at Antwerp last Sep¬
tember, the proceedings of which were reported in the last
number of this Journal, it was resolved that the Congress of
1904 should be held in Edinburgh. A Scottish Committee
was elected, and Sir John Sibbald is now arranging to convene
a preliminary meeting. It is to be hoped that it will be fully
attended by representatives of the various State-supported and
charitable agencies for the relief of the poor, every variety of-
home help, and that measures will be adopted to secure the
success of the Congress, which has aroused so great an interest
and formulated such important propositions.

Where shall I send my Patient ?

The “ Association of Medical Men receiving Resident
Patients ” has issued a Guide for Medical Practitioners and a Book

Digitized by v^.ooQLe

1903 .] OCCASIONAL NOTES. 525

of Reference to the Health Resorts and Institutions for Patients of
Great Britain . It is printed by Mr. E. J. Frampton, at Bourne¬
mouth, and sets forth the information indicated on the title-
page at considerable length.

Beginning with a short resume of the procedure in cases of
insanity, a list of asylums is given, arranged according to the
counties in which they are placed. Ireland is represented by
three, and Scotland by one institution for the insane, so that
the compilers’ remark that the first issue is not so complete as
was desired must be held as fully justified. They might consult
the Medical Directory with advantage. Then comes a list of a
few convalescent homes, institutions for the blind, and for the
deaf and dumb. The compilers find room for a few remarks on
ophthalmia neonatorum, and indicate that medical treatment is
a preventative of blindness, thus guiding the medical prac¬
titioners of the country into safe ground. A list of medical men
receiving resident patients, giving all particulars except the
names, will be useful to those who have found it difficult to
obtain such information otherwise. A number of hydropathic
establishments and nursing institutions find a place in the book,
and a chapter on health resorts gives a brief account of various
localities from the medical point of view. Lastly, a list of
selected hotels at health resorts has been inserted, which may
be of service to those who possess neither Bradshaw nor
Baedeker. We suggest that the hotels of the country should be
left to advertise themselves, and that the space occupied by
details of county asylums which can only receive the State-
supported patients in their own districts, and by snippets of
unnecessary medical commonplace, should be devoted to an
extension of the information as to establishments w T here
paying patients are received. The book has been well indexed,
so that the contents are readily accessible.

An Australian Scandal .

The Lancet of last year gave details of a great wrong com¬
mitted in Melbourne, a wrong whereby our respected colleague,
Dr. Beattie Smith, has been grossly injured. The result is that
he is no longer in the service of the State of Victoria, but after

Digitized by v^.ooQLe

526

OCCASIONAL NOTES.

[July,

twenty years of notable work in the asylums of that country,
within a short step of reaching the highest place, he is cast
adrift without pension or compensation. The political record
of Victoria is debased still further by this last example of shame¬
less misgovernment. Dr. Beattie Smith has had to give place
to an assistant medical officer, who, if the allegations against
him reported in the Lancet (*) are to be trusted, was utterly
unfit for the post. The “ Minister ” at the head of the depart¬
ment, however, acted in spite of the Inspector’s protest. The
callous indecency of the incident, as related by the Australian
correspondent of the Laticet, passes belief, were it not that it
is of a piece with what has gone before. We trust that the
Council of the Association will carefully consider the whole
question raised by this act of Victorian maladministration,
for it not only affects one of our members, but vitally touches
the interests of the insane in those important asylums at the
Antipodes.

(*) See “ Notes and News.”

The International Medical Congress at Madrid\

The fourteenth International Medical Congress is now a
thing of the past. About 7000 members attended it, exclusive
of the wives and families accompanying them. For some
unknown reason the Madrid authorities included in the
Congress not only doctors, but dentists, veterinarians, and
pharmacists as well. This was too large a number of persons
for the authorities to manage, and consequently a good deal of
confusion prevailed. The Spaniard is a polite, courteous
gentleman, but his business capacity is decidedly wanting.
Moreover, the results of that fatal word mahana (to-morrow)
were everywhere in evidence, and arrangements which should
have been made weeks before were only just concluded when
the Congress opened. An account of the proceedings of the
neurological section appears on another page. From it it will
be seen that the Association had honours conferred on it by
the election of three of its members to the position of Honorary
Presidents. The difficulty of understanding what was said by
the Spaniards, however, led many men to forsake the Congress

Digitized by ^.ooQle

REVIEWS.

527

1903.]

and explore Madrid, or go on excursions to the Escurial and
Toledo. The reports and papers were too numerous for the
time allotted to them, and only about a third of the sixty-six
communications were read. On another occasion it will be
better to limit their number and allow all of them to be read.
Only one resolution was passed by the neurological section—a
resolution calling on the Press not to report crimes, in order to
avoid the contagion of crime. It is doubtful, however, whether
the editors of the Press in any country will consent to omit
the most sensational part of the contents of their paper; but
that too much prominence is given to the life of the criminal
in prison and to accounts of his life-history, in some papers,
there is no doubt, and the consequence is that weak-minded
individuals commit some homicidal or other criminal act.

As regards the Congress itself, it was an unwieldy affair and
lacked several of the characteristics of a scientific meeting.

Part II—Reviews.

Report on Dieting of Pauper Lunatics in Asylums and Lunatic Wards
of Poorhouses in Scotland\ By Dr. J. C. Dunlop. (Supplement to
the Forty-third Annual Report of the Commissioners in Lunacy for
Scotland .) 1902. Price $\d.

In this supplement of their Forty third Annual Report we have one
more illustration of the very vital interest which is evinced by the
Scottish Lunacy Board in all that concerns the real welfare of those
dependent members of society who come under their cognizance. The
very valuable indications afforded by the report, if acted upon, as they
undoubtedly will be, can only result in rectifying very apparent
anomalies of diet scales—anomalies which one is glad to find are not so
much in the direction of niggardliness as in the direction of wasteful and
irrational expenditure in certain kinds of diet at the expense of other
and essential items of food.

Dr. Dunlop takes as a standard of an all-round dietary for pauper
lunatics one that has an energy value of 3300 large calories for males,
and of 2650 for females, and, judged by this, the result in the aggregate
serves to show that so far as males are concerned the physiological idea
which underlies common sense in the matter of food is not very far
wrong, though there are numerous very anomalous departures from the
standard in individual institutions.

Digitized by v^.ooQLe

528

REVIEWS.

[July,

In the thirty-nine institutions over which the inquiry extends the
average energy value of the male diet works out at 3335 calories, or 35
above the standard, and this is quite in keeping with the average weight
of the working male patient, which works out at 1 £ lbs. in excess of
the standard. The standard for females is everywhere far in excess of
that laid down, working out at 2893, or 243 above the average.

The following shows the departure from the standard average energy
value of the ordinary diet, and the departure from the standard weight,
in the four different classes of institutions in which pauper lunatics are
accommodated :

5 Royal Asylums

Energy value
in calories.

. - 28

Weight
in lbs.
+ 2£

16 District Asylums .

»• + 7

— 2

3 Parochial Asylums

• -153

— 2$

15 Poor-houses

. +125

- i

One is faced with apparent contradiction. In the Royal asylums the
average weight of the working patient is above the standard, and yet, in
general, the dietary is below the average energy value ; and on the other
hand, taking the average of the fifteen poor-houses, the energy value is
greatly in excess of the standard, yet the average weight fails to come
up to standard. There is one point -which is not dealt with specially in
this report, and which has, no doubt, an important bearing on the sub¬
ject of the effective value of the diet, and that is the manner of its
preparation. There can be very little doubt as to the comparative
quality of the cooking in Royal asylums and in poor-houses, and this may
to a considerable extent serve to explain the apparent discrepancy
between the energy value and average weight in these two classes of
institutions.

There is another aspect of the subject which might profitably have
been included in this inquiry, and which, we think, would assist in
arriving at some idea of the comparative efficiency of the dietary in the
various institutions, and as an indication either of parsimoniousness or
extravagance in the matter of food. Due regard being had to the pro¬
portion of staff among the total boarded, the cost of provisions per
patient forms an approximate guide to the value of the dietary. Of the
sixteen district asylums, in which 13 per cent, of those boarded belong
to the staff, and in which the average energy value of the male diet is
3307 calories, the cost of provisions per patient per year being
;&io is. iod. y those in which the cost is low are, as a rule, characterised
by a low energy value, and by an average weight of male working
patient which is below the standard. There is one, for instance, in
which the staff numbers 15 per cent, of the total boarded, and the cost
of whose provisions is £9 1 is. $d., and this is found to be associated
with an energy value 323 calories below standard, and with a weight of
male patient 12 lbs. below standard. In four district asylums, on
the other hand, an average excess of patients weight of 4^ lbs. is
found in association with a cost for provisions of £10 6s. 7 id. t and a
dietary energy value 212 calories above standard. To this general rule
there are noteworthy exceptions,, for which there must be some explana-

Digitized by v^.ooQLe

I 9°3-]

REVIEWS.

529

tion, and which are no doubt capable of remedy. An example of this is
to be found in the case of one asylum whose cost for provisions, viz.,
£11 13J. 7 d., is the highest among district asylums, and the energy
value of whose diet is the second highest, being 445 calories above
standard, and yet the average working male patient’s weight is found to
be below standard to the extent of 4 lbs. It is not without
significance that this asylum’s meat bill, like that of one of its neigh¬
bours, reveals the fact that practically a quarter of the meat in the
dietary is of the sort called tinned.

Such a thing as uniformity in dietary in asylums is for obvious
reasons impossible and undesirable, but it may be confidently affirmed
that the committees of asylums and other authorities are anxious and
desirous to deal in a spirit of reasonableness with the dependent insane
committed to their care. It can hardly admit of doubt that, broadly
speaking, the inmates of those institutions in England and Ireland
which correspond to the district asylums of Scotland are dieted in no
less parsimonious fashion. The close approximation of the item in the
maintenance account which comes under the heading of provisions in
the three divisions of the United Kingdom affords proof of this. Still,
anomalies will be found to exist, just as is displayed in this inquiry,
and it is in the adjusting of such that this report will prove of
inestimable practical utility. It will, of course, be of greatest value to
the Scottish institutions, each of whose dietaries is criticised in¬
dividually, but, making allowance for differences in the matter of local
habit, the suggestions for the proper and sufficient dieting of pauper
lunatics offered by Dr. Dunlop will be a very real help towards the
framing of diet scales which will meet all reasonable requirements. All
authorities, and their dependent charges everywhere, are under a deep
debt of obligation to the Scottish Commissioners, who once more have
proved by their energy that in their consideration for the well-being 01
the insane poor they are second to none.

Recherches Cliniques et Thlrapeutiques sur r£pilepsie, rHysteric, et
ridiotie. Par Bourneville, avec la collaboration de MM.
Ambard, J. Boyer, Crouzon, L. Morel, Paul-Boncour, Philippe et
Oberthur. \Clinical and Therapeutical Researches on Epilepsy,
Hysteria, and Idiocy .] By Bourneville. Vol. xxii. Paris : aux
Bureaux du Progrls Medical, and F£lix Alcan. Large 8vo, pp.
236 ; 16 plates and 14 illustrations in text.

This instructive report (for the year 1901) of the Children’s Department
of the Bic£tre and of the Fondation Valine (in connection with it) gives
the usual information as to the classification of inmates and their “medico-
pedagogic” treatment. It would seem that of 166 pupils frequenting
the senior school, 13 have been able to gain the “certificat d’&udes ”
or leaving certificate required in the case of ordinary elementary school
children. Stress is rightly placed upon the improvement of speech
and pronunciation—often very imperfect with imbeciles,—and no less
than twenty of the teaching staff have had the advantage of training in

Digitized by v^.ooQLe

530

REVIEWS.

[July,

the methods used at the National Institution for Deaf Mutes. Much
attention is given to the cultivation of music and singing, and some
observations of the instructor (M. Sutter) are quoted to show that the
teaching of music is not thrown away even upon those who are partially
deaf, one of whom became a fair pianist, the vibrations being con¬
ducted by means of a rod from the instrument to the frontal bone of
the performer ! Gymnastics and dancing are also held in high esteem.
Cases of marked educational improvement are cited in detail, and
Dr. Bourneville judiciously remarks that he impresses constantly on
his school staff that their pupils are also patients, and as such require
to be treated with long-suffering consideration.

The manual and industrial training of the more capable inmates
continues to be carried on with much vigour, and it is claimed that
the labour of the 124 working patients (including probably also that of
the instructors) is worth for the year nearly 30,000 francs. The
printing office would seem to be the most profitable department,
bringing in 7223 francs with only eight workers; and next to that
brush-making, bringing in over 5000. Dr. Bourneville contends that a
larger share of the profits should be spent in improvements, and in
this view we fully sympathise.

The statistics show that on the 1st of January, 1901, there were at
the Bicetre 437 male patients, and at the Fondation Valine 213 female
patients, 52 of the latter being epileptic. There were 20 deaths at the
former institution and 16 at the latter during the year 1901. One case
of suicide (a lad of 16) is recorded at the Bicetre; and tuberculous
disease is assigned as the cause of death in five of the twenty cases,
though it probably existed in other cases returned as pulmonary disease.
Two cases of general tuberculosis are amongst the assigned causes of
death at Fondation Vallee, but here again there are a large number
of broncho-pneumonias, etc. There does not seem to have been any
prevalent epidemic at the Bicetre, though whooping-cough and chicken-
pox occurred at the Fondation Valine; and we may remark that the
death-rate appears high as compared with that now generally current in
idiot institutions in this country.

Section III of the report is devoted to the advocacy of the creation
of special classes in connection with the elementary schools of Paris for
backward and feeble-minded children not requiring “ hospitalisation.”
Dr. Bourneville fortifies his position by printing interesting reports of
the progress of special schools established in Germany, England,
Belgium, and Denmark, and again urges his views upon the educational
authorities. We trust his praiseworthy insistence may lead to a speedy
practical result.

In the second portion of the volume we find several well-classified
schemes for use by assistants in obtaining particulars of family history
and noting peculiarities and general condition of patients. We note
that the morning and evening temperatures of all new admissions are
taken for five days, as an aid in detecting infectious disease, actual or
incubating.

Various careful studies on such subjects as the treatment of vertiginous
epilepsy by bromide of camphor, moral idiocy, the osseous conditions
attending infantile hemiplegia, adolescent insanity, etc., in which Dr.

Digitized by

Google

REVIEWS.

531

I903-]

Boumeville has been aided by his “ internes,” close a volume which
fully sustains the reputation of its predecessors. It may interest some
of our readers if we quote a notice which appears on the cover that
M. Boumeville is at the disposal of doctors and others interested in
the treatment of abnormal children, at the Bicetre on Saturday mornings
(at 9.30 precisely ) to show them his clinique and demonstrate the
methods of instruction in vogue. G. E. Shuttle\\;orth.

Ueber das Pathologische bei Nietzsche. By P. J. Mobius. Wiesbaden :

Bergmann, 1902. Octavo, pp. 106.

The Dawn of Day. By F. Nietzsche. Translated by Johanna Volz.

London : Fisher Unwin, 1903. Octavo, pp. 387. Price 8 s. 6 d.

In one of the latest volumes of the Grenzfragen des Nerven - und
Seelen-lebens , Dr. Mobius has written a careful study of Nietzsche from
the pathological point of view, and if taken, as the author himself would
wish it to be taken, in conjunction with the study of Nietzsche’s works,
and with the admirable biography by his sister, it may be regarded as
furnishing an almost indispensable contribution to the proper under¬
standing of Nietzsche. A writer like Nietzsche easily leads those who
discuss him into extremes : on the one hand his admirers reverentially
accept all his utterances without discrimination, and are most impressed
by his most extravagant sayings; on the other hand, the alienist (or, at all
events, an author like Nordau, masquerading as an alienist) is tempted
to go too far in the opposite direction and to find insanity everywhere.
Dr. Mobius’s position—though he is not always a reliable guide—is
on the present occasion critical and discriminating. He is quite
aware that in dealing with Nietzsche we are concerned with a very great
writer and a thinker of all but the highest order; he points out, also,
that even when his work became definitely morbid it was still not
without real artistic and philosophic value. But at the same time he
quite definitely realises the pathological element, and in this study, by
the analysis of Nietzsche’s works, and also of his life,—many of the
facts being here published for the first time,—he presents us with as
clear a picture of Nietzsche’s mental condition as we can at present hope
for. It may be said at once that the biography does not bring before
us the material necessary to obtain a complete picture of Nietzsche’s
mental state—partly, no doubt, because it is not yet complete, and
partly because the writer, being at the lay point of view, has uninten¬
tionally omitted many significant facts which would have helped to
make clearer an interesting and somewhat unusual case of general
paralysis. Thus it would appear that the heredity is not so absolutely
sound as the present reviewer, in a detailed study of Nietzsche pub¬
lished some years ago, had been led by the biography to believe. The
father died of a cerebral tumour, and while we cannot reasonably regard
this as an unfavourable hereditary influence, it has to be added that
Nietzsche’s violent migraine and his extreme myopia were inherited
from the father’s side, and that the father’s sisters are described as
hysterical and eccentric. On the side of the mother, also, though she

Digitized by v^.ooQLe

532

REVIEWS.

[July.

herself was sound and healthy, there would now appear to be mental
abnormality ; one sister is said to have committed suicide, and another
fell into a state of melancholy, if not insanity. Nietzsche's sister, like
her brother, suffers from migraine as well as myopia, and the only other
child died at the age of two in convulsions.

Dr. Mobius has been able to bring together various details concern¬
ing Niejzsche's physical characteristics. There were no marked
stigmata of degenerescence. The circumference of the head (57 cm.)
is small, considering that he was moderately tall, and while the frontal
region was finely developed the occipital region would appear to be
defective. Except as regards sight, all the bodily functions were
healthy, as is, indeed, shown by the fact that the physical machine
worked on undisturbed for so many years after the mental faculties
were in abeyance. It has sometimes been said that Nietzsche’s sense
of smell was unusually keen; this is a mistake. Like many other
people, he was no lover of bad odours, but there is not the slightest
reason to suppose that this was associated with any unusual degree of
olfactory sensibility. It may be added that he never smoked, and
avoided alcohol. Like many people who do not smoke, he was fond of
sweet things. The sexual impulse was certainly weak, while Nietzsche's
friendships were very warm ; but the possibility of sexual inversion
may be absolutely excluded. The sexual instinct was not entirely
absent; Nietzsche visited prostitutes from time to time, but there was
nothing that could be called love ever involved, and no definite
liaisons . Dr. Mobius makes no reference, positive or negative, to any
specific infection, and it is possible that this omission is significant, in
view of a statement in the preface to the effect that a certain amount
of reticence has seemed desirable. Nietzsche's original condition, it is
concluded, may be regarded as neurotic, or as showing a slight degree
of degenerescence.

The second part of the study is devoted to the evolution of the
disease. The migraine is dealt with fully; at one time it was associ¬
ated with choroiditis, and Dr. Mobius holds that the inherited migraine
was made more severe by the onset of general paralysis. It is in the
year 1882, in Zarathustra , or, to be more precise, in the fourth book
of the previous work, Frohliche Wissenschaft , that we may first trace the
definite indications of the influence of disease. Before that date
Nietzsche had published many books, and while a critical student of
these books would be inclined to say that the writer was a highly sensi¬
tive and probably neurotic subject, no trace of insanity could reasonably
be found in them. But in 1882 Nietzsche was for a time overtaken by
the typical euphoria of the general paralytic. In a state of marked
exaltation and intense mental activity he wrote for some months at great
speed, and the result appears in Zarathustra ,, a book written in a prose-
poetic form, which is at once a work of unquestionable genius, and
at the same time largely the outcome of insanity. Works of this kind
are much fewer than some have supposed. The masterpiece of our
English poet Smart is an example on a smaller scale.

Dr. Mobius traces as carefully as the data enable him the irregular
course of the disease from this period onwards. In the winter of
1887-8 occurred a second period of acute exaltation and tremendous

Digitized by v^.ooQLe

1 9°3-]

REVIEWS.

533

literary activity. All Nietzsche’s later writings date from this period.
This was, however, the final flaring up of mental activity before extinc¬
tion. At the beginning of January, 1889, Brandes, the well-known Danish
critic, received from Turin an enigmatic note in a large handwriting,
unstamped and incorrectly addressed, signed “ The Crucified One.” On
the day on which that letter was probably posted Nietzsche was found
helpless in the street, imperfectly conscious of his surroundings. Friends
arrived, and he was taken home to Germany. Gleams of memory came
to him from time to time, but he was seldom able to recognise friends,
and never became completely aware of his condition or his environment.
He died in 1900, so that, as will be seen, the disease ran a course of at
least nineteen years.

When we turn to Nietzsche’s works, as Dr. Mobius truly remarks, we
find many pearls there, though they are not all pearls. It is in the
volumes written during the years before the Zarathustra outburst that
we find the finest and deepest work, mostly written in the form of
pensees, At this time his thought still ranged freely; he had not yet
distorted it by the constant repetition of that counsel of perfection,
“ Become hard ! ” by which sensitive souls seek to protect themselves
against the arrows of fate. The Dawn of Day , which has now at last
been published in English by Mr. Fisher Unwin, belongs to this period,
and though it is less instructive from the point of view of morbid psy¬
chology than Zarathustra , it will enable the reader to understand some¬
thing of Nietzsche at his best and sanest, and to realise what it is that
has made Nietzsche so potent an influence in European thought to-day.
The translations s careful, though by no means brilliant; the qualities
of a great stylist can never be rendered in a foreign tongue.

Havelock Ellis.

La Logiquc Morbide. I DAnalyse Mentale. By N. Vaschide and
C. Vurpas. Paris : Soci£t£ d’£ditions Scientifiques et Litteraires,
1903. Octavo, pp. 268. Price 4 f.

Apart from the question as to its precise value, this volume is of
some interest as a “ sign of the times.” It illustrates very significantly
the manner in which the scientific study of normal psychology and the
scientific study of morbid psychology are leading to an approximation,—
it might almost be said a fusion,—of the two branches of study. The
book issues from the Villejuif Asylum (where Dr. Toulouse has done
much to accentuate this tendency), and is the work of the chief assistant
of the laboratory of experimental psychology in the asylum, aided by
one of the assistant physicians ; while a preface is furnished by Professor
Ribot, who may perhaps be described, in the words of the dedication of
the volume, as “the first who has attempted an analysis of the
mechanism of morbid psychology.”

Dr. Vaschide, to whom the chief part in this work evidently belongs,
is one of those young Roumanians who in recent years have shown the
energy of their youthful nationality by coming to the front in various
branches of biological science. The bibliography of his experimental

XLIX. 37

Digitized by

Google

534

REVIEWS.

[July,

contributions to normal and morbid psychology during the past seven
years occupies some ten pages, and this ambitious, almost feverish
activity for work is shown by the scale on which this study of “ morbid
logic ” is planned, for when completed it will occupy four volumes. Dr.
Vaschide was led up to it by an earlier study of mental activity in sleep.

In the short preface, which many readers will find the most valuable
part of the work, Professor Ribot sets forth the fundamental ideas which
underlie the conceptions here developed. Logic, he states, is a
province of psychology; it cannot be regarded as a detached and
abstract study, for there is no such thing as “pure thought.” The
“ mental analysis ” here exclusively studied is a sort of psychological
rumination obstinately fixed on all the details of the subjects internal
or external life, and even in its weakest form constituting a step towards
the abnormal,—the first stage in a morbid evolution,—although when
intelligently directed it enters largely into the work of the poet, the
artist, and the man of science. This “mental analysis” forms the
subject of the present volume, while the succeeding volumes will be
devoted to the morbid syllogism, morbid emotion, and morbid in¬
tellectual creation.

The plan of the volume is simple. Apart from introductory and
concluding chapters, it is entirely occupied by the full and careful exami¬
nation of four cases,—three from the asylum, the other met with in
society,—which cover, as the authors believe, the four different kinds of
morbid mental analysis. The first case is one of somatic introspection ,
in which the subject, a woman, concentrates her attention on her own
physical mechanism, elaborately watches and detects the minute details
of her own anatomical conformation and physiological processes, and
embodies her discoveries into a system of delusions; the discoveries
may be quite correct, but are wrongly interpreted, as when the subject
in this case discovered for the first time her pubic bone and regarded
it as a new growth, tending to prove that a general solidification of the
tissues was going on. The second case is one of mental introspection, in
which the subject, instead of living in wholesome ignorance of his
mental processes, is perpetually scrutinising his most trifling thoughts
and impulses, thinking them over again, questioning them, doubting
them, feeling remorse for them, until personality is lost in the contem¬
plation of itself; this subject also was a woman. The third case repre¬
sents morbid extrospection , in which the subject’s attention is directed
in the same exaggerated fashion on the details of outward events, and
the most trifling signs and incidents are interpreted as possessing
significance ; this case shows the manner in which a woman gradually
persuades herself that a man is in love with her, and that she is really
affianced to him. The last case is one of morbid analysis of the cosmic
environment; it is the case of a wealthy young man, apparently an
average man of the world, who, as the result of an illness following a
wound received in a duel, changed all his habits, became devoted to
solitude and metaphysical questions, and especially absorbed in
astronomy, spending his income on complex astronomical instruments
which he was unable to manipulate, and astronomical literature he was
unable to understand. There was no definite insanity, no definite
delusions; yet the man’s whole nature was changed, and his whole

Digitized by

Google

REVIEWS.

1903 .]

535

mental field filled with a shifting phantasmagoria of confused meta¬
physical and astronomical notions.

While there is much that is instructive and suggestive in the way in
which these typical cases are worked out, the chief value of the book
seems to lie in its general attitude and spirit, the twofold method of
approaching its subject, and the absence of any attempt to exaggerate
either the normal element or the morbid element in the mental
processes investigated. Havelock Ellis.

LAssociation des Idles. By Dr. E. Claparede. Paris: Doin, 1903.

Octavo, pp. 426. Price 4 f.

The latest volume of Dr. Toulouse’s International Library of Experi¬
mental Psychology is one of the best so far issued. While the volumes
have all come from competent hands, the reader occasionally feels that
the book was written, rather hastily, to order. Dr. Claparede, who is a
privat-docent at the University of Geneva, and editor of the Swiss
Archives de Psychologies has executed a most careful and thorough
study of his subject, marked not only by fulness of knowledge, but by
its critical and impartial spirit. He has the advantage, moreover,—
very necessary in the case of a subject which largely owes its existence
to a succession of great English thinkers,—of possessing an excellent
knowledge of English and American psychological literature.

Association, as the author recognises, by no means covers the whole
mental field, but has, as it were, to be dissected out. The author, who
assumes throughout the parallelism of psychic and physical phenomena,
considers that in dealing with association we are concerned with “ a law
of cerebral simultaneity ” which may be thus stated :—“ When the cere¬
bral processes take place simultaneously such a relation is established
between them that when one is re-excited the excitation tends to be
propagated to the other.”

In the first and much the larger part of the volume we are presented
with a summary of all that is known of this associational mechanism of
the psychological machine, and Dr. Claparede emphasises the imper¬
fection of our knowledge, and our ignorance of the underlying causes
of the forms of association. The pages devoted to a discussion of
Flechsig’s “associational centres,” which attracted so much attention
some years ago, are fairly typical of his method. After pointing out
that it is now generally recognised that the structural characters on
which Flechsig relied are by no means so fundamental as Flechsig
asserted, he proceeds to show that even if one could accept Flechsig’s
schematic arrangements at his own valuation the gain for psychology
would be small; it would assist clinical study, but would not aid
psychological comprehension; so far from explaining association, it is
probable, the author acutely remarks, that it was the existence of certain
notions regarding association which influenced Flechsig’s schematisa-
tion. A specially interesting chapter in this first part of the book is
that on the speed of association, with its summary of the methods and
results of psychometrical work. Here and elsewhere due attention is
given to the influence of toxic and pathological considerations.

Digitized by v^.ooQLe

536 REVIEWS. [July,

In the latter part of the book Dr. Clapar&de discusses the importance
of association and the exact part it plays in mental life. It is an
important factor, but it is one factor on)y; the experimental investiga¬
tions of the past twenty years have shown that mental phenomena are
far more complex than we had previously imagined, and it is no longer
possible to regard the broad and simple principles of Mill, Bain, and
Spencer—helpful as they once were—as all-sufficing. Here and
throughout the author’s attitude is judicial, and he shows no undue
partiality to any particular school of thought.

The volume is furnished with indices and a useful bibliography.

Havelock Ellis.

L'Hypnotisme et la Suggestion . By P. Grasset. Biblioth&que Inter¬
national de Psychologie Exp^rimentale. Paris: Doin, 1903.
Octavo, pp. 534. Price 4 f.

Professor Grasset makes no attempt to add to the facts of hypnotism;
he has only one case of any interest to bring forward. He considers,
however, that the facts are already so numerous and so conclusive that
we are noyr less in need of facts than of a “ psychological analysis ” of
hypnotism. This he furnishes by applying to hypnotism his favourite
schematisation of the “ O centres ” and the “ polygonal centres.” The
“ O centres ” are the higher psychic centres; the “ polygonal centres ”
are the lower psychic or upper automatic centres. It is the polygonal
centres, Professor Grasset insists, that are alone affected in hypnotism ;
and he zealously applies his scheme at every available point. It sounds
a little bizarre, but seems to work out fairly well.

Whether or not, however, we accept the author’s favourite scheme of
the psychic centres, this discussion of hypnotism and suggestion is
certainly, on the whole, thoroughly judicious, and marked by its reason¬
able, common-sense attitude and avoidance of all extreme positions.
The reader is somewhat unfavourably impressed at the outset by the
obvious fact that Professor Grasset’s knowledge of the literature of his
subject is confined to French authors. He tells us, indeed, that
hypnotism is a “ completely French ” subject (only excepting Braid).
He is thus shut out from any sound historical view of his subject, and
has, moreover, no first-hand knowledge of so masterly a discussion of
the problems of hypnotism as we owe to Moil—a discussion with which
he would be fairly in sympathy. But as the original and translated
literature of hypnotism in French is fairly considerable, and as it is
undoubtedly true that the most significant movements in the modem
development of hypnotism have taken place in France, Professor
Grasset’s general attitude towards the questions he is discovering is
affected less than might be anticipated, and even his references to
foreign workers are fair and correct so far as they go.

The author’s general attitude may easily be defined. He recognises
that it is to Charcot that we owe the scientific recognition of hypnotism,
but he also recognises that Charcot was mistaken in generalising from
his own individual cases. He follows Bemheim and the Nancy school

Digitized by

Google

1903.]

REVIEWS.

537

in regarding hypnotism as a much simpler process than Charcot sup¬
posed, characterised mainly by suggestibility; but as against Bemheim
he agrees with Janet in sharply distinguishing the suggestibility of
hypnotism from the ordinary suggestibility which more or less marks all
human beings in ordinary life : the one phenomenon is pathological, or
at all events extra physiological; the other is physiological. While, how¬
ever, suggestibility is the main characteristic of hypnosis, there remains a
small residue of somatic and not suggested characteristics, which justify
Charcot’s description; these characteristics are, however, much more
varied and much less important than Charcot believed.

There is a good and fairly comprehensive chapter on hypnotism from
the therapeutical point of view. The attitude is favourable, though not
enthusiastic. Like most practical observers, he considers that hypnotism
is useful in hysteria, of very little value in neurasthenia, difficult to
apply and unreliable in insanity (since it only affects the polygonal and
not the O centres), sometimes of use in alcoholism and morphinomania.

Havelock Ellis.

Reports of the Cambridge Anthropological Expedition to Torres Straits .
[Vol. II, Physiology and Psychology , Part II.] Cambridge: Univer¬
sity Press, 1903. P. 141 to p. 223, 4to. Price 7 s.

This new instalment of the Reports of the Cambridge expedition
contains sections on hearing, smell, taste, and reaction times, for all of
which Dr. C. S. Myers is responsible; and sections on cutaneous sensa¬
tions, muscular sense, and variations of blood-pressure, for which Mr.
W. McDougall is responsible. It may be said that the work recorded
here fully confirms the impression produced by the first part, and it is
a great satisfaction to find English workers carrying on so admirably
and recording so clearly work of a character which has hitherto been
carried out,—so far as it has been carried out at all,—by American,
German, French, or Italian investigators. In a scientific expedition
such as this,—to the other side of the world, in a strange environment
and among a people new to most of the investigators,—it was inevitable
that at many points the most practicable methods and the most satis¬
factory instrumental devices could not always be known beforehand;
much of the time was necessarily spent in discovering the best available
procedures, and it is all the more remarkable that so many definite and
apparently reliable results have been obtained. The observations
made were at most points checked by similar observations made either
on members of the expedition or on a group of Aberdeen people after
the return of the expedition.

Dr. Myers tested auditory acuteness by Politzer’s Hdrmesser, Runne’s
clock, and a device of his own, and came to the conclusion that the
general auditory acuity of the inhabitants of the islands of Torres
Straits is inferior to that of Europeans. He attributes this in some
measure to pathological conditions produced by diving, but not alto¬
gether, since a similar though less marked deficiency was found among
the children. The upper limit of hearing, as tested by Galton’s whistle,

Digitized by v^.ooQLe

538

REVIEWS.

[July.

was found to be practically the same as among Aberdonians, the
advantage, if any, being possessed by the latter. The smallest per¬
ceptible tone difference was also found to be somewhat greater than
among the Aberdeen people, whether adults or children were com¬
pared, though all the natives could readily distinguish an interval less
than a tone.

The investigation of the sense of smell here recorded is of consider¬
able interest, both on account of the olfactory acuity commonly
attributed to the lower races, and of the very serious, intelligent, and
interested manner in which the natives actually went through the
examination, which was conducted by the usual method of graduated
solutions, Zwaardemaker’s olfactometer (as might have been anticipated)
not proving practicable for such an inquiry. Japanese camphor, as
being both stable and familiar to the islanders, was the chief odorous
substance employed. The main difficulty encountered was that at
Torres Straits everything, even the water, seemed to have a smell.
The conclusion reached is that the average olfactory acuity is slightly
higher in Torres Straits than in Aberdeenshire, “a smaller proportion
of the islanders having obtuse and a greater number having hyperacute
smell-power.” The acuity of the children in both communities seemed
slightly higher than that of the adults. Dr. Myers considers, however,
that the main difference between the native and the European is not so
much his greater olfactory acuity as the fact that the native is much
more interested in smells, and studies them more carefully. Hence it
is mainly by careful attention and practice that he is able to dis¬
criminate and remember closely similar odours. The comparisons
made by the natives of the various odours presented to them were found
to be very ready and apt; they frequently compared them to odours
with which they had a real chemical relationship. The likes and dis¬
likes of the natives for the various odours were much the same as
obtain among Europeans.

The results in regard to taste were less remarkable. There was a
general liking for sweet substances and a marked dislike for bitter.
There was no distinctive word for bitter.

Mr. McDougall reached notable results in investigating cutaneous
sensations. He found that the power of tactile discrimination of the
natives at Torres Straits was about double that of Englishmen. This
delicate tactile discrimination is considered to be a racial characteristic,
for it was not found at Sarawak. The power of tactile discrimination
was not accompanied by unusual accuracy of tactile localisation. It is
interesting to observe also that neither was it accompanied by great
sensibility to pain, as tested by Cattell’s algometer. It was found,
indeed, that the susceptibility of the natives to pain was hardly half as
great as that of Englishmen.

In discrimination of small differences of weight the natives were
found rather superior to Englishmen, although such tests were quite
new to them. In the size-weight illusion (the estimation of the weight
of tins having same size but different weights) the natives were much
more astray than the English, and the native women more so than the
native men. Mr. McDougall seems to think that the Miiller-Schumann
explanation of this illusion destroys its value as a test of suggestibility.

Digitized by v^.ooQLe

REVIEWS.

539

1903-]

There seems a little confusion here. The fact that an illusion is normal
leaves the question of suggestibility unaffected. If you are travelling in
a slow train which is passed by an express train moving in the same
direction you have the illusion of travelling backwards. The illusion is
normal; but the question of suggestibility still comes in if your judg¬
ment yields to the illusion. The size-weight illusion is certainly normal;
even the blind experience it in some degree (as Rice has shown); but
the fact that it is explicable leaves quite unaffected the question of the
subject’s suggestibility, which is simply concerned with the measure in
which his intelligence yields to his sensations.

The experiments on blood-pressure in relation to mental activity led
to little result, as is not surprising in view of the difficulty and complexity
of the matter.

The reaction-time results (although only a simple registering appara¬
tus had been included in the outfit of the expedition) were more
interesting, and it was found unexpectedly easy to explain to the
islanders the general bearing of reaction-time experiments. The average
auditory reaction of the young Torres Straits islanders was found to be
not appreciably different from that of the Englishman, but his visual
reaction was distinctly longer. The Sarawak native reacted more
quickly than the Englishman, both to auditory and visual stimuli. Dr.
Myers discusses these results in relation to the observations made by
others, and while not reaching any final conclusion is inclined to believe
that there are real racial differences in reaction time.

Havelock Ellis.

Harvard Psychological Studies. Vol. I. Edited by Hugo Munster-
burg. New York : Macmillan and Co. Large 8vo, pp. 654.
Price 4 dollars.

This volume (which also constitutes the fourth of the Psychological
Review Monograph Supplements) presents sixteen experimental investi¬
gations carried out under Professor Miinsterburg’s supervision in the
Harvard Psychological Laboratory. They deal mainly with problems
of perception, memory, aesthetic feeling, and animal psychology, the
last being a department of psychology to which special attention is
devoted at Harvard, the methods adopted being so far as possible those
usually applied in human psychology. Among the specific subjects
explored were tactual illusions, the relation of eye-movement to after¬
images, the control of memory images, rhythm and rhyme, the existence
of symmetry in primitive and civilised art, the instincts, habits, and
reactions of the frog. It would be difficult to summarise these studies
briefly; we may content ourselves with noting the comment of Professor
Miinsterburg that (as must, of course, often happen in pioneering in¬
vestigations) the various authors are sometimes in contradiction with each
other, and not seldom in contradiction with his own views and con¬
clusions.

The concluding paper, in which Professor Miinsterburg gives a brief
summary of his own views as to the position of psychology in the system

Digitized by v^.ooQLe

540

REVIEWS.

[July,

of knowledge, should not, however, be passed without notice. As he
has already explained at length in several books, this distinguished
psychologist is opposed both to the association theory of the English
school and the apperception theory of Wundt as a completely satisfactory
expression of the facts. The former is one-sided and barren, the latter
illogical. He desires to make a synthesis of both which shall have the
defects of neither, developing a psycho-physical theory which shall con¬
sider the central process in its dependence not only on the sensory but
also on the motor excitement, thus attaching specially great importance
to the centrifugal processes of mental life. This he calls the action
theory. In the present study he considers the position generally
assigned to psychology in the system of knowledge, and finds that,
though usually a very important position, it remains vague. He con¬
siders that this is due to the fact that there are really two different kinds
of psychology—the psychology of phenomenalism which explains, and
the psychology of voluntarism which interprets. He holds by the
first, but does not believe that on this account the propositions of
voluntarism are wrong in its interpretative account of real life and of
immediate experience; “ on the contrary, voluntarism is right in
every respect except in believing itself to be psychology.” From the
voluntaristic point of view we can obtain a more direct account of man’s
real life than psychology can hope to give. It is not psychology, though
“ it is the voluntaristic man whose purpose creates knowledge and thus
creates the phenomenalistic aspect of man himself.” These two aspects
of inner life are not, however, ultimately independent and exclusive, the
subjective purposes of real life demanding the labours of objective
psychology, so that the last word is not dualistic but monistic. The
difference is only one of logical purpose and treatment, of point of view.
These remarks lead up to a scheme of the sciences, under this double
aspect, presented in an elaborate table. Havelock Ellis.

On the Physiological Feebleness of Women [ Ueber den physiologischen

Schwachsinn des Weibes ]. Von Dr. P. J. Mobius. Halle, 1903.

Octavo, pp. 123. Price 1 mark 50 pf.

No one need be surprised to learn that those who differ from Dr.
Mobius on this vexed question have tried to fasten upon him the
reproach that he is an enemy to women. It has been so customary in
society, as well as in light literature, to give the fair sex compliments
and to avoid unpleasant truths, that all sincerity is lost in speaking, and
to many persons even in thinking. It should, however, be borne in
mind that those who wish to change the time-honoured relations
between men and women have no right to wax angry because they get
a plain answer to a question which they themselves have provoked.
The pamphlet has now passed into the fifth edition. At the request of
his publishers the author has reprinted the adverse criticisms which
have appeared; and if these are all, he is fortunate, for there is no serious
attempt to meet his arguments. The only critique on this side which is
worth reading is one in the Berlin Zukunfi ; by Friede F. von Bulow.

Digitized by

Google

REVIEWS.

1903 ]

541

This lady argues that the doctor’s fears are visionary, that the desire in
women of having a husband and children, especially children, is
naturally so strong that it will always lead them to satisfy it, and that
learned and professional women will never bear more than a small pro¬
portion to the others.

Yes, nature will come in winner in the end; but people may fight
against nature with much injury both to health and morals. The pro¬
gramme let out by some of the advocates of the “ emancipation ” of
women seems a dangerous one, both to society and to the State, and
none the less dangerous that it is pushed on step by step, so that the
unthinking are ready to imagine that it is ill-natured to refuse a conces¬
sion which is sure to be followed by a new demand. In a matter with
so many aspects, and where so many considerations, passions, and
affections enter, the controversy may be carried on for any time. The
intellect alone is rarely allowed to decide, and people may not be
reasoned out of what they were never reasoned into. Nothing is more
difficult than to rouse ordinary men to the danger of distant con¬
sequences, and when they are unwilling to see them it becomes
impossible. The desire to invade men’s functions and occupations, and
the proposals that whatever men do women should be allowed to do
also (save serving in the army and navy), provokes the inquiry whether
women’s faculties are of the kind to fit them for the tasks to which they
aspire. Those who take an unfavourable view of their claims point out
how little women have accomplished in all branches of knowledge, in
literature, in art, and in music ; while the “ Feministen,” as Mobius calls
them, argue that hitherto they have been kept in bondage and sub¬
jection by the selfishness of men, and so deprived of proper oppor¬
tunities of distinguishing themselves. To those who wish some reading
to prompt their convictions on this subject we can recommend Dr.
Mobius’s treatise. He possesses a gift, rare in Germany, of putting his
meaning into plain, easy, and forcible language; he has a good
command of the facts, and has, we think, taken the range of the subject.
What may be of special interest to the readers of this Journal are his
observations upon the comparative weights of the male and female
brain.

He remarks that there is a difficulty in appreciating the comparative
weights of the male and female brain as given by Bischoff, for one with
a small brain might have more mental activity than one with a larger,
because the smaller might have a larger proportion of those parts most
important to mental life. But Riidinger has shown that in new-born
infants the whole group of convolutions enclosed by the Sylvian fissure
is simpler and with fewer bends in the female infant than with the
male, and that the island of Reil, in all its measurements, is bigger, more
convex, and more complicated in the male than in the female infant.
He has shown that in the adult the third frontal gyrus is smaller and
simpler in the woman, especially that portion which lies next the median
gyrus. From his table it appears that these differences are considerable.
Riidinger has further shown that in the female brain the whole middle
gyri of the parietal lobe and the inner upper bridging convolution are
much less developed in men of low mental power. He found similar
configuration of the parietal lobe, while in men of good intellect the large

Digitized by v^.ooQLe

542

REVIEWS.

Duly,

development of the parietal lobe presented quite another type. From
this it is shown that parts of the brain of great importance to mental
life, the convolutions of the frontal and parietal areas, are less developed
in women than in men, and that this difference already exists at birth.
As man and woman have the same convolutions, but of different
sizes, both have the same mental properties; the difference is a ques¬
tion of degree.

Mobius finds these data confirmed by his measurements of heads.
A circumference of 57 cm. and upwards is generally met with in men
of good mental power; below this standard the capacity is mostly inferior;
while in women one meets with heads of 57 cm. and 56 cm. circum¬
ference, and often heads as low as 52 cm. and 51 cm. He does not
wish to hinder women studying medicine, though he would not en¬
courage it.

Mobius thus appeals to medical men:—It is of much importance
that physicians should gain a clear conception of the female brain and
mental character, so as to know its weaknesses, and that they should do
all that lies in their power, in the interest of the human race, to resist
the unnatural efforts of the feminists. The health of the people is
endangered by the perversity of the new woman. Nature is a stem
mistress, and threatens the breach of her rules with severe penalties.
She has decreed that the woman should be a mother, and if she seeks
to lead a life apart it is the worse for her. William W. Ireland.

Ueber die IVirkung der Castration [On the Effects of Castration\ Von
Dr. P. J. MObius. Halle, 1903. Price 2 marks.

After a learned historical introduction, Dr. Mdbius goes on to
examine the effects of castration on men, women, and on the lower
animals. As might be expected, these are more marked if the mutila¬
tion occur at an early age. The alterations observed affect not only
the breasts and genital organs, but also the glands, the fatty tissues, the
muscular system, and the bones. As the larynx does not widen,
eunuchs retain their boys’ voices; hence some eunuchs have gained
notoriety as public singers. The mental powers are diminished, though
some eunuchs have shown ability and even courage. In the wars with the
Goths the eunuch Narses was thought a worthy successor to Belisarius.
In Eastern courts, the eunuchs have often much influence, and several
are mentioned in history. The sentiment of love is not always extinct
in these mutilated beings. Operations such as the removal of the
ovaries, undertaken in the hope of ending erotic delusions, have not
been justified by the results arrived at. It has been proposed in
America to castrate male imbeciles who have shown marked erotic
propensities, and in some instances this has been done.

Altogether this little treatise is written with the authors usual ability
and thoroughness. He has availed himself of every source of informa¬
tion, so that it forms the most complete work on the subject.

William W. Ireland.

Digitized by v^.ooQLe

1903-]

REVIEWS.

543

The Story of my Life. By Helen Keller. With her Letters (1887
—1901) and a Supplementary Account of her Education , including
Passages from the Reports and Letters of her Teacher, Anne
Mansfield Sullivan. By John Albert Macy. Illustrated. New
York: Doubleday, 1903. Crown octavo, pp. 441. Price 7 s. 6 d.

This book describes another great triumph of the teaching art
achieved in the United States. The first of these was Laura Bridgman.
It was Dr. Howe, of Boston, who conceived and carried out the task of
teaching Laura, a child eight years old, who had lost her sight at the
age of two years. Many accounts of this case have been published in
books and periodicals, and there is a separate Life of Laura Bridgman
by Lamson. Not so well known is Oliver Caswell, blind and deaf from
infancy, who was also educated at the Perkins Institution for the Deaf
and Dumb at Boston.

Helen Keller was born in Alabama in 1880. She lost her sight and
hearing when eighteen months old. Before this she had been a
forward child, could walk well and speak a little. The impressions of
sight and sound seemed never to have been quite effaced; but she
ceased to speak. As the effects of the illness passed away she could
find her way about the house, used to fold clothes, and creep about
looking for guinea-fowls’ eggs in the long grass. She felt everything
with her hands, and began to make signs. A shake of the head meant
“ No,” and a nod “ Yes.” A pull meant “ Come,” and a push “ Go.”
“ Was it bread that I wanted ? ” she tells us. “ Then I would imitate the
acts of cutting the slices and buttering them.” She even practised a
few mischievous tricks, such as locking her mother in the pantry, and
when no one understood what she wanted would get into fits of fury,
scratching and kicking. At last her father took her to the Perkins
Institution at Boston, when a special teacher was procured for her.
At that time Helen was nearly seven years old. From this date we
have two parallel narratives—Helen’s account of her own recollections
and the awakening of her intellect, and the teacher’s descriptions of
her methods and the progress of her pupil. They support and illustrate
one another; but the teacher’s account seems to be the most valuable.
Helen Keller’s own narrative bears marks of the polish of another hand.
There are many passages indicating a writer who could both see and
hear. Some of these may be merely the reproduction of phrases which
she has taken from her reading, as when she speaks of the lustrous
shell of the nautilus, which at night sails on the blue sea. It would not
occur to a blind person that the sea is not blue at night. This explana¬
tion, however, does not hold good with all the passages. Helen’s
letters seem to be presented unchanged, and it is interesting to trace
the gradual elaboration both of thought and style from the first rude
efforts.

The conjunction was favourable of a most skilful teacher and a pupil
naturally intelligent. Anne Sullivan evidently possesses an original
mind and sound judgment, with unwearied patience and a warm and
loving heart. Her greatest difficulty in bringing the light of knowledge
into the shrouded mind of her little pupil was to get her to apprehend
that there were symbols for her sensations and thoughts by which she could

Digitized by

Google

544

REVIEWS.

[July,

have communication with other persons. She failed to associate the signs
for milk, confused between the liquid, the vessel which held it, and the
act of drinking. “ We went out,” writes Miss Sullivan, “ and I made
Helen hold her mug under the spout while I pumped, and then, as the
cold water gushed forth filling the mug, I spelled w-a-t-e-r in Helen’s
free hand. Helen thus describes the first apprehension of the symbol:—
“ I stood still, my whole attention fixed upon the motions of her fingers.
Suddenly I felt a misty consciousness as of something forgotten, a thrill
of returning thought, and somehow the mystery of language was revealed
to me. I knew then that w-a-t-e-r meant the wonderful cool something
that was flowing over my hand. That living word awakened my soul,
gave it light, hope, joy, set it free. There were barriers still, it is true,
but barriers that could in time be swept away.”

All the way back Helen was highly excited, and learned the name of
every object she touched, so that in a few hours she had added thirty
new words to her vocabulary. With this key the portals of knowledge
were successively opened. She was taught finger signs, then to read
embossed type, to write the braille characters and ordinary writing, and
to use the typewriter; finally by muscular adjustments to use her vocal
apparatus, and to follow words by putting her hands on the mouth and
throat of the speaker. Her devoted teacher went with her everywhere,
and by finger alphabet kept her informed of everything around. She
got lessons in plant and animal life, and in the events of the day and in
the history of the world. Helen eagerly read such books as were in
embossed type, and was taught German, French, Latin, and Greek. It
should be borne in mind that this girl only knows words as combinations
of letters or through the sense of muscular adjustments; hence it seems
that the enormous expenditure of mental energy required to teach her
four foreign languages might have been much better utilised in conveying
to her real knowledge. We do not, therefore, read with unlimited satis¬
faction about her passing the preliminary examination in Greek and
Latin, German and French, for Radcliffe College, and think that she was
wisely advised not to go on studying for a degree at Harvard University.
But in this age it is difficult to resist the craze for examining and being
examined, and Helen was spurred on by the desire to keep pace with
other girls. She also passed in geometry and algebra, though for these
studies she had little taste. These achievements show under what
great difficulties the human mind can successfully work. It is pleasing
to observe how much this girl so cruelly stricken by disease enjoyed life
through the few avenues left. She delights in rowing, riding, toboggan¬
ing, bathing, and swimming. She feels the vibrations communicated
by a musical instrument like the piano. The sense of smell, though of
little use in conveying knowledge, affords her much pleasure ; she loves
the odour of the pinewoods and the perfume of the flowers. Surrounded
with sympathetic friends, she has been guarded from many of the cares
and troubles of life, and only knows of the evils of the world by what
reports are allowed to reach her. By long attention and practice and
interpretation Helen is exquisitely sensitive to every agitation and thrill
in her companions. Miss Sullivan tells us that when she was being
examined by the aurist in Cincinnati '‘all present were astonished when
she appeared not only to hear a whistle, but also an ordinary tone of

Digitized by v^.ooQLe

1903-]

ANTHROPOLOGY.

545

voice. She would turn her head, smile, and act as though she had
heard what was said. I was then standing beside her, holding her hand.
Thinking that she was receiving impressions from me, I put her hands
upon the table and withdrew to the opposite side of the room. The
aurists then tried their experiments with quite different results. Helen
remained motionless through them all.” As regards the question of a
sixth sense which some people have ascribed to Helen Keller, Miss
Sullivan observes, “ The existence of a special sense is not evident to
her or to any one that knows her. Miss Keller is distinctly not a singular
proof of occult and mysterious theories, and any attempt to explain her
in that way fails to reckon with her normality. She is no more mysterious
and complex than any other person. All that she is, all that she has
done, can be explained directly, except such things in every human
being as never can be explained.”

The editor, Mr. Macy, deserves much credit for the arrangement and
treatment of the subject. The illustrations are tastefully designed and
well executed. Altogether this is a work not only valuable to the
psychologist, but likely to be very pleasing to the intelligent general
reader. William W. Ireland.

Part III—Epitome of Current Literature.

i. Anthropology.

Polydactylism and Epilepsy [Polydactylia ed epilessid\. (Arch, dipsichiat .,
vol. xx Hi, fa sc. 6, 1902.) Lai.

The author describes two cases of polydactylism, one occurring in
an adult epileptic, the other in a baby with hereditary taint of that
neurosis.

The patient in the first case was a heredo-alcoholic, whose fits began
in his twenty-sixth year after a heavy drinking bout. The accessory
digit, consisting of two phalanges with a nail, was present on either
hand, but not on the feet. It was articulated to the ulnar margin of
the little finger. The same anomaly was said to have existed in the
patient's father. The patient presented numerous stigmata of de¬
generation.

In the second case the supernumerary digit, which consisted of a
single phalanx bearing a nail, was only present on the right hand; it
was articulated to the radial side of the first phalanx of the thumb.
No other physical anomalies were present; and no case of polydactylism
was known to have occurred in the family. The only hereditary taint
was epilepsy and mental debility in a maternal aunt.

In neither case were the patient's parents of near kin.

The author considers that his cases go to show a connection between
polydactylism and epilepsy through a common origin in degeneration.

W. C. Sullivan.

Digitized by ^.ooQle

546 EPITOME. [July,

Anatomical Note on a Case of Deformity of the Right Upper Extremity
in an Insane Patient [Nota anatomica sopra un caso di deformitd
air arto superiore destro osservata in un frenastenico\ (Arch, di
Psichiat., vol . xxiii,fasc. 6.) Pianetta.

In vol. xxi of the Archivio (1900) the author published a note on
some cases of morphological anomalies of the extremities in the insane;
and in the present paper he records the result of an autopsy on one of
these patients—an hereditary degenerate with partial syndactylism of
the right hand. Several anomalies were found in the bones of the
hand and in the muscles of the forearm. The osseous abnormalities
were most notable in the second phalanges ; in two fingers (index and
middle) that phalanx was absent; in the ring and little fingers it w r as
rudimentary, and in the latter it was partially blended with the ungual
phalanx. The ungual phalanges of the index and middle fingers were
united, and bore a single nail. The os magnum and unciform bone
were blended. The rest of the hand skeleton was normal. The
muscles of the hand and forearm were all somewhat atrophic. Their
most important anomalies were the absence of the extensor indicis and
of the tendon of the flexor sublimis digitorum to the little finger, and a
reversal of the ordinary arrangement of the flexor tendons, the deep
flexor being perforated by the tendons of the superficial muscle.

W. C. Sullivan.

The Physiological Stigmata of Degeneration [Les stigmates physiologiques
de la degenerescence]. (Gaz. des Hdp., Feb., 1903.) Mayet '.

The author divides the stigmata of degeneration into four classes—
anatomical, physiological, psychological, and sociological. The first
group he discussed in an earlier paper contributed to the same journal,
and the third and fourth groups he proposes to deal with later on.
The present paper is devoted to the physiological group, and is, as the
author expressly points out, a simple catalogue of the several functional
disorders which, for good, bad, or indifferent reasons, various observers
have brought into the wide net of “ d£g£n£rescence.” It is needless to
add that the catalogue is a long one, seeing that some authors claim for
the degenerate a monopoly of tubercular diseases and of post-nasal
adenoids ; and one expansionist even goes so far as to insist that every
departure from the left occipito-anterior presentation in childbirth is to
be accounted a stigma. The paper is followed by a useful list of the
literature on the subject. W. C. Sullivan.

a. Physiological Psychology.

The Psychology of the Dying [Contribution d la Psychologie des
Mourants ]. (Rev. Phil., Dec., 1902.) Pi/ron, H.

In various cases, the author has noted at the moment of death a
coenaesthesic sensation—doubtless associated with arrest of motor,
respiratory, and circulatory functions—which is not without interest
The cases here described were mostly tuberculous, and included
individuals of both sexes, and of atheistic as well as religious beliefs.

Digitized by v^.ooQLe

1903]

PHYSIOLOGICAL PSYCHOLOGY.

547

In all the cases, the last sensation to which expression was given was
one of flying, of moving upwards. In some cases death was peaceful, in
others painful. In one case a girl died clasping the iron bars of the
bed, in horror of being borne upwards.

What is the cause of this sensation ? Pieron, no doubt rightly, asso¬
ciates it with the similar sensation of rising and floating commonly
experienced in dreams, and with that feeling of moving upwards and
resting on the air which is sometimes experienced by persons in the
ecstatic state, and which in the lives of St. Ida of Louvain, and many
other saints, is treated as a real phenomenon.

The explanation is evidently quite simple. In an ecstatic person in
whom this sensation occurred, Janet found anaesthesia of the sole of the
foot. Bergson has suggested that in dreams of flying there is numbness
and arrest of circulation due to pressure on the parts supporting the'
weight of the body. We must, Pieron argues, apply the same explana¬
tion to the sensations of flying experienced at the moment of death.

Havelock Ellis.

Right-handedness and Left-handedness . ( Joum. A nth. Inst., July — Dec.,
1902.) Cunningham, D.J.

This subject was chosen by Professor Cunningham for the third
Huxley Memorial Lecture of the Anthropological Institute. He deals
with it in a thorough manner and with wide knowledge of the extensive
literature. He regards right-handedness as an organic acquirement of
early man, due to natural selection. There is no good reason to show
that monkeys are right-handed, and evidence obtained from Dr. Taylor,
at the Darenth Asylum, showed that microcephalic idiots tend to be
ambidextrous (five right-handed, four ambidextrous, one left-handed)
The functional pre-eminence of the brain is the cause, and not the
result, of right-handedness. Left-handedness may be regarded as due
“probably to a transposition of the two cerebral hemispheres in the
same way that transposition, either partial or complete, of the thoracic
and abdominal viscera occurs.” It is noteworthy that there is a large
proportion of left-handedness in those showing transposition of the
viscera.

Professor Cunningham rejects the explanation resting on the sup¬
posed better blood-supply of the left hemisphere, finding that facts are
against it. Nor is it true that the left hemisphere is either heavier or
more convoluted than the right. Professor Cunningham himself hoped
to find an explanation in a comparison of the motor centres for the arm
in the two hemispheres, but finds that in man, and even to some extent
in the ape, this area is more exuberant on the right side. He concludes
that the attempt to discover a structural basis for the functional
superiority of the left cerebrum is at present baffled, but that one must
still believe that such structural basis exists. Havelock Ellis.

Internal Autoscopy [DAutoscopie Interne]. (Rev. PhilJan., 1903.)

Sollier, P.

Autoscopy is an abnormal power of observing and representing the
anatomical and functional state of the subject’s own internal organs. If

Digitized by v^.ooQLe

548

EPITOME.

[July.

the representation is external, in a hallucinatory form, it is termed external
autoscopy; if the observation is direct, it is termed internal autoscopy.
The phenomenon, which occurs most clearly in the hypnotic state, is
analogous, Sollier suggests, to the power shown in premonitory dreams,
by which the disturbance of internal organs becomes definitely clear to
sleeping consciousness before it is perceived by waking consciousness.
Autoscopy was vaguely known to the ancient magnetisers; more
recently attention was called to it by Fer£ ; it has been most thoroughly
studied by Sollier and Comar.

Sollier considers that the phenomenon is most definitely observed in
hysterical patients, who in the hypnotic state attain a conscious know¬
ledge of organs which in the subject’s ordinary state are anaesthetic.
SolUer’s own theory on hysteria is well known; he looks upon it as a
fundamental disturbance of the cerebral cortex which may be regarded
as a sort of sleep, varying from a simple diminution of the cortical
centres to their complete arrest.; this state is translated into varying
conditions of the body and viscera—vaso-motor, trophic, sensorial,
motor, etc. Partial or complete recovery from this somatic sleep is
attained in various ways, and notably in the hypnotic state. This is
the theory which Sollier seeks to apply to the explanation of the
phenomena of autoscopy.

A typical case is furnished by a country girl, a patient of Comar’s,
without any education, who had formerly been treated for coxalgia; in
a state of hypnosis she gave a fairly accurate description of the joint, in
homely language, as it would appear without organic lesion. The same
patient said, on another occasion, feeling the low'er part of her abdo¬
men, “ It is strange what I have there in the middle; I did not know
I was made like that I have a sort of pear there, with the point
downwards, and with strings from the top on each side turning forwards ;
there are several of them in the folds of a veil, and in one of the folds
there is something like a nut; it’s funny.” The same patient described
the bladder, ureters, and urethra, the stomach with its mucous folds
and glands, and also the heart. Another patient of Comar’s described
with much accuracy and precision her arteries and their bifurcations,
indicating the positions with the point of her finger; and even dis¬
covered by autoscopy, if one may trust the observation, the whole
course of the circulation back to the heart.

Sollier describes in considerable detail three cases of hysteria in
which autoscopy existed. The most important was a girl set. 22, who,
as he had been able to assure himself, was quite ignorant concerning
the structure of the body. This subject could under certain conditions
represent, or, rather, see, her vessels, heart, blood, lungs with bronchi
and pulmonary vesicles, intestines, ovaries (described as like almonds),
tubes, uterus, vagina, muscles, tendons, skeleton, and brain. She
could not only describe the macroscopic appearance, but even (as
regards ovary and brain) the microscopic constitution.

Sollier considers that the cases of hysteria which show autoscopy in
the hypnotic state are comparatively rare; it occurs mainly in very
severe and old-standing cases with visceral disturbances, and appears,
usually quite unexpectedly, when the function of an anaesthetic or
disturbed organ is being re-established. Surprising as the phenomenon

Digitized by ^.ooQle

1903-]

CLINICAL PSYCHIATRY.

549

may be, Sollier thinks it is possibly merely a question of degree between
autoscopy and our usual confused perceptions of internal functions.
Although the subjects frequently use the word “ see ” there is of course
no actual vision ; autoscopy would appear to be a representation
founded on ccenaesthesic sensations originating in the organs. Sollier
admits, however, that the subjects often rightly describe the colours of
organs, and cannot explain this.

Sollier fully discusses the whole question, and meets the obvious
criticisms that may be made. He gives his reasons for believing that
unconscious reminiscence, suggestion, and trickery may be absolutely
excluded. The sincerity of the subjects is also suggested by the method
of description ; neither the scientific nor the common names of organs
are used, and it is only after describing what she sees that the subject
adds, “ That must be such and such an organ.”

Sollier is no great believer in the explanatory force of the word
“ suggestion ” in hypnotic phenomena, and he considers that in auto¬
scopy we may learn to see more clearly what it is that happens in
hypnosis. The hypnotic subject is able to obey an order referring to
the unconscious and involuntary system, not because it is “ suggested,”
but because for the time the unconscious and involuntary part of the
organism has become comparatively conscious and voluntary, and
therefore responds in the same way as under ordinary circumstances
the organs ruled by striated muscle respond. Havelock Ellis.

3. Clinical Psychiatry.

On the Utility of Lumbar Puncture in the Diagnosis of General
Paralysis . {Journ. of Ment. Path. y Oct, — JVov. } 1902.) Joffroy and
Mercier,

In this paper, originally communicated to the Congress of French
Alienists held at Grenoble in 1902, the authors record the result of an
inquiry into the value of cytological examination of the cerebro-spinal
fluid in general paralysis.

A series of punctures in healthy persons and in ordinary insane sub¬
jects showed the number of leucocytes per c.mm. in that fluid to be
usually not more than two. In the general paralytic, on the contrary, it
almost invariably exceeded five. Seventy punctures were made on 48
different patients suffering from that disease; in 17 instances, though no
exact count was made, the number of leucocytes was seen to be exces¬
sive ; in the remaining 53 instances the corpuscles were counted, and
found to be as follows :—In four cases they varied between o and 5 per
c.mm.; in eight cases they numbered between 5 and 10; in thirteen
cases they varied between 10 and 20; in eighteen they varied between
20 and 50 ; in eight they numbered between 50 and 100; in one they
numbered between 100 and 200; and finally, in one case they numbered
204.

Thus 66 out of 70 punctures showed a notable increase of the white
corpuscles. Of the four instances in which the number was under 5 per

XLIX. 38

Digitized by

Google

550

EPITOME.

Duly,

c.mm., three were in cases which their very slow evolution would
rank in a special category, so that there was only one case of un¬
equivocal general paralysis which failed to show hyperleucocytosis.

On the other hand, in five patients not regarded as general paralytics
there was an increase in the number of leucocytes to 5 per c.mm.; one
was a case of syphilitic meningomyelitis with Argyll-Robertson pupils;
the other four were cases of tabes with mental symptoms. Except in
these five instances the authors have failed to find this condition in any
form of mental disease other than general paralysis. In fourteen cases
of alcoholism, for instance, and in ten cases of dementia praecox, the
number of corpuscles never exceeded 2 per c.mm. Several examples
are briefly indicated, showing the decisive value of this sign in doubtful
cases, especially in distinguishing early general paralysis from alcoholism
with exaltation and from mania.

The authors find that the hyperleucocytosis precedes the speech and
pupillary symptoms ; and that it is, in fact, most marked in the initial
period of the affection. They regard it, therefore, as the most constant
sign of general paralysis, and consider that its absence is sufficient to
dismiss the suspicion of that disease. Its positive value is equally high
if other conditions capable of producing it, i. e. t especially syphilitic and
parasyphilitic diseases of the nervous system, can be excluded.

W. C. Sullivan.

Two Cases of Polyneuritic Mental Confusion [Deux cas de confusion
mentale polytievritique\ {Bull, de la Soc. de M/d. Ment. de
Belgique , Feb., 1903.) Crocq.

In 1887 Korsakoff described polyneuritic psychosis as a special
morbid entity, particularly characterised by amnesic disorders. Another
name which he gave to this condition was toxaemic (psychical) cere-
bropathy. He recognised two varieties—one slight, characterised by
amnesia affecting recent events; another severe, with marked amnesia
accompanied by false reminiscences and delusions. This view has since
been severely criticised by Babinski, Chaslin, S^glas, Ballet, etc., who
maintain that practically this psychosis of Korsakoff is only a form of
mental confusion, and in the two conditions one finds identical amnesic
disorders.

The two cases described by Crocq help to elucidate this interesting
question:

1. M. L—, female, aet. 54, alcoholic, after mental worry became
excited, had delusions, and was dirty in her habits for three months.
The muscular atrophy, absent knee-jerks, etc., observed, correspond to
the usual signs of alcoholic paralysis (or peripheral neuritis). Mentally
the characteristics were—loss of identity, amnesia, visual and auditory
hallucinations. She improved markedly.

2. L. D—, female, aet. 68. First under observation January 10th,
1902. She had given way to drink since 1899. The onset of her
illness dated eighteen months ago. The symptoms—pains and weakness
in the legs, tenderness of muscles on pressure, incoherence of speech,
atrophy of legs and arms, then contracture, etc.—all suggest peripheral
(alcoholic, no doubt) neuritis. The knee-jerks were apparently strong,

Digitized by v^.ooQLe

I 9°3-]

CLINICAL PSYCHIATRY.

551

however—no doubt because the anterior crural nerve was not affected.
Mentally the dominant feature was amnesia, especially for recent
events; she had also false reminiscences, but, as proving the relative
integrity of her intellectual faculties, the patient realised that her memory
played her tricks (her condition was analogous in this respect to that of
a patient with motor aphasia), her condition being therefore unlike
senile dementia. Under treatment she improved.

These two cases with decided polyneuritis are, according to Crocq,
typical examples of mental confusion, and militate strongly against
Korsakoff’s view of the autonomy of polyneuritic psychosis.

H. J. Macevoy.

A Case of Septiccemic General Paralysis [ Un cas de paralysie ginlrale
septicemique\ {Bull de la Soc. de Mid . Ment. de Belgique , Peb.,
1903.) Crocq.

B. F—, female, aet. 33, admitted January 18th, 1903. Married in 1896;
in January, 1900, miscarried at the third month and developed severe
streptococcic infection with fever and delirium, which lasted fourteen
days and nearly proved fatal. During her convalescence, one month
after the miscarriage, she had a convulsive seizure with temporary
paralysis of the tongue and right arm (for a few hours). These attacks
recurred at intervals of three days to fourteen days, and were followed
by various transitory paralyses. Her speech became difficult, her ideas
confused. Later she had auditory hallucinations and delusions of per¬
secution, and was sent to St. Jean Asylum on January 19th, 1902. On
October 12th she returned home improved, but weak intellectually.
Five days later she lost consciousness, and on the following day became
maniacal and incoherent, and dirty in her habits; her legs were con¬
tracted ; reflexes exaggerated; light reflex feeble. No history and no
evidence of syphilis could be obtained on careful inquiry and exami¬
nation. ,

Reviewing the etiology of general paralysis, Crocq is of opinion that
the most important factor is a locus minoris resistentice as regards the
brain, *. e., a predisposition; and that numerous occasional or exciting
causes may determine the onset of the disease. Among the latter,
infections and intoxications come first; syphilis heads the list by far,
but other toxic factors must be considered, and among them puerperal
septicaemia. H. J. Macevoy.

New Contribution to the Study of Post-operative Psychoses [.Nouvelle
contribution d Fbtude des psychoses post-oplratoires]. (Arch, de
Neurol ., 1903, No. 87.) Picqui and Briaud.

The authors restrict the denomination of post-operative psychoses to
delusional disorders which occur in the sphere of ideation alone; so
that neurasthenia, for example, following upon an operation, is excluded.
They also exclude delusional states directly due to toxaemia, which are
transitory and differ in their symptoms and treatment—just as puerperal
insanity differs from the transitory puerperal delirium arising from
septicaemia. They admit, however, that the line of demarcation
between these two groups of cases may be hard to draw! Moreover, as

Digitized by v^.ooQLe

55*

EPITOME.

[July,

has been pointed out by Magnan, we may have a febrile or toxaemic
delirium superposed upon a true psychosis. Hereditary predisposition
is a marked feature in post-operative insanity, so much so that one may
deny the possibility of an operation alone causing a psychosis in a
healthy subject; at the same time this is no argument for rejecting this
class of cases. Gynaecological operations are not more likely to cause
post-operative insanity than other operations; the confusion with simple
neurasthenia has led to this opinion. The symptoms of post-operative
insanity are most variable, and have furnished some justification for
denying its existence as a separate form; moreover, in cases where
general paralysis and other well-defined psychoses have supervened (or
appeared to) upon an operation, we must attribute the occurrence to a
mere coincidence. The variation in symptoms, or in the character of
the psychosis, arises from the variability in the mental conformation of
the patient and the varying predisposition—the all-important factor.
The nature of the operation itself is another factor to be considered.
The prognosis varies considerably as well as the treatment.

Notes of nine cases are appended, (i) A woman aet. 36, after
curetting of the uterus, developed melancholia with delusions of nega¬
tion, hallucinations, suicidal tendency. Predisposition (hereditary)
marked; one cousin insane, father alcoholic. (2) A woman aet. 48,
with ideas of suspicion, developed definite delusional insanity of perse¬
cution after an operation for removal of a uterine fibroid. In the third
case a woman developed symptoms simulating those of general
paralysis, etc. The paper, as a whole, is a useful contribution to the
study of post-operative insanity, but does but little to clear up the haze
which obscures the subject. H. J. Macevoy.

4. Treatment of Insanity.

Paraldehyde as a Hypnotic . ( Afonats.f\ Psych, u. Neur ., Dec., 1902.)

Bumke.

This is a serious study of the claims advanced in favour of paral¬
dehyde as a hypnotic since its introduction into medicine in 1882.
The ideal soporific which shall with certainty and without delay secure
an untroubled refreshing sleep, approaching natural sleep as nearly as
possible; the soporific which shall neither lose its efficacy nor accumu¬
late its effects, and which shall, moreover, be easily dispensed and agree¬
able to take;—such a drug, like the philosophers stone, has yet to be
discovered. Among soporifics, however, as things are, paraldehyde
can claim many virtues, and further experience and better knowledge
have only strengthened its position. In the Freiburg Asylum, Dr.
Bumke says that paraldehyde has more than held its ground against
sulphonal, trional, and hedonal, and that it and scopolamin are now
alone employed.

Far too much has been made of the unpleasant taste of paraldehyde,
and of the fact that the patient’s breath smells of the drug. The severer

Digitized by v^,ooQle

1903.]

TREATMENT OF INSANITY.

553

strictures on these counts depend probably on the use of impure
preparations. Dr. Bumke states that, administered in a peppermint
tea strongly sweetened with sugar candy, it is readily taken, and that in
respect of the odour of the breath they have had no inconvenience in
the wards. Administration in enema form has in general not been
found suitable, nor the hypodermic use available, the drug being too
irritating.

Clinical experience has for the most part confirmed the teachings of
the physiological laboratory, according to which the sensitiveness of the
nervous system is in the end of the cerebrum, spinal cord, and medulla
oblongata. Only very large doses affect the last named, and of the
centres herein contained it is the respiratory which succumbs before the
circulatory.

The effective dose in man is on the average not less than 45 minims ;
more than 60 minims will rarely be required; and doses of 75—90
minims gave in Dr. Bumke’s experience good results even in the
severest forms of excitement. Sleep sets in in from three to fifteen
minutes, and is for the most part unaccompanied by symptoms. Descrip¬
tions of vertigo, headache, sense of fulness in the head, thick speech,
thirst, etc., seem to apply only to observations before 1884, and Bumke
considers that they must have been due to impurities, probably to fusel
oils.

The duration of sleep is from five to eight hours.

The experience in Freiburg is strongly against an habituation of the
system to the drug. It was not necessary to raise the dose. With
some exceptions—Albertoni, Berger, Sachs, Daman—this is the general
experience. A sedative action on the brain in addition to the hypnotic
action has been asserted, and probably exists—it is difficult to demon¬
strate. Upon the spinal cord the experimental evidence is definite
that the functions of the grey matter are diminished—whence the reduc¬
tion or abolition of the reflexes. Lethal doses of strychnine have thus
been overcome in animals by paraldehyde, and two cases of tetanus in
man are reported as cured by the same means (Ottavi, Tomasini).
With ordinary dosage it is, however, difficult to show this effect. The
effect upon sensation is likewise difficult of demonstration in man; in
any case it is inconsiderable.

Upon the circulation the action of paraldehyde has been very
thoroughly investigated, and the outcome of very numerous experiments
and most extensive clinical observations has been to establish the
harmlessness of paraldehyde even in eases of disease of the circulatory
apparatus .

Upon the blood there appears to be no evidence of deleterious action
so long as the doses are therapeutic; with enormous toxic doses a
spoiling of the blood, with development of methaemoglobinaemia, has
been noted in animals, in particular in horses. In toxic doses in
animals paraldehyde exerts a paralyzant effect upon the organs of respi¬
ration, but this is never even hinted at in the therapeutic employment
of the drug, not even when the respiratory organs are affected by disease,
e.g.y in emphysema, bronchitis, pneumonia, and phthisis.

Upon the organs of digestion, the drug has very little action, though
many have anticipated an irritant action. Accordingly we may pre-

Digitized by CjOOQle

554

EPITOME.

[July,

scribe it with impunity when this tract is healthy. Only in the severest
forms of disease of the stomach can paraldehyde be regarded as contra¬
indicated.

Upon the kidneys there is no appreciable effect; if anything the
remedy promotes the flow of urine and acts as a sedative to the urinary
mucous tract.

Concerning the toxicology of paraldehyde, no undoubted case of
death from a single dose is on record* though as much as twelve to
thirteen teaspoonfuls and even more have been taken at one dose, /. e .,
twelve to thirteen times the ordinary therapeutic dose. There is mention
in the Brit Med . Journ ., 1890, of death after six to seven teaspoonfuls
of a paraldehyde mixture, but the case was one of enteric fever, and the
proofs are entirely wanting, according to Bumke, that paraldehyde was
the undoubted cause of death.

Mackenzie (Virchow-Hirsch'sJahrb. y 1891, i) records the enormous
dose of 3£ ounces with recovery after very pronounced toxic symptoms—
stupor, insensitiveness of the pupils, lividity, hurried pulse and breathing.

Chronic intoxication may arise if the use of the drug is long persisted
in, but the occurrence is rare, and according to Bumke only ensues
when large doses, /. e., 30 grammes (seven to eight teaspoonfuls), are
taken. The symptoms in these cases resemble the delirium of alcohol.

From the foregoing it follows that we have in paraldehyde a most
valuable hypnotic suitable for all forms of sleeplessness with the excep¬
tion of that caused by severe pain; that in the usual dose of 45—90
minims it rarely produces either by-effects or after-effects ; that it is not
contra-indicated by disease of heart or lungs or kidneys, or even of the
alimentary tract except in very serious disease of the stomach ; Anally
that to its administration there is no real impediment in the way of
taste or smell. (We might add that any difficulties which might occa¬
sionally arise on the last count are at once overcome by ordering the
drug in gelatine capsules.) Harrington Sainsbury.

On the Treatment of Rpilepsy by the Toulouse-Richet Method. ( Psychiat ,
Neurol. Wochenschr ., Feb. 2 8th, 1903.) Halmi and Bargaras .

The authors draw attention to the continuous arising of new remedies
for and new methods of cure in epilepsy, and the as constant dis¬
appointment of our hopes which further trials of the new agents bring.
In particular they make reference to the combined opium and bromide
cure of Flechsig, which later developments and several recorded cases
of death whilst under the treatment have brought into discredit. They
point out that the epileptic seizures may, for various reasons, disappear
for long periods—two to twenty-nine years, as the more recent statements
of Sinkler make clear,—and the futility, therefore, of the attempts to
demonstrate the curative value of drugs by observations extending over
periods of three to four months, or at the most one year. In spite of
these objections, however, they determined to make trial of the Toulouse-
Richet method, so strongly had it been recommended.

As will be remembered, this method consists in the reduction of the
chloride of sodium in the food (by an appropriate diet) during the time
of administration of the bromides; the theory being that under these

Digitized by v^.ooQLe

1 903]

TREATMENT OF INSANITY.

555

conditions the bromide can substitute itself for the chloride of sodium
in the tissues, and hence, by a more intimate contact, influence more
powerfully the cell activities.

Fifteen cases were selected for trial. During a period of ten months
these were subjected to bromide treatment with ordinary diet; during
the two following months the bromide was withdrawn, the diet continu¬
ing unchanged ; tfie Toulouse-Richet method was then pursued during
one month; and then finally the patient reverted to ordinary diet and
bromide for another seven months.

The results of these trials certainly do not prove the value of the
method; they may be described as negative. But then the lines of the
experiments do not appear to us to have been very judiciously laid
down. Why the two months' period of complete withdrawal of the
bromide before commencing the Toulouse-Richet method ? This must
of necessity have disturbed the balance reached during the bromide and
ordinary diet period, with the result that the effect of the hypochlorised
diet of the Toulouse-Richet method did not come in direct juxtaposition
to the ordinary diet period, though this was what we wanted. Then,
too, why the short period of the Toulouse-Richet method ? This is
meaningless. The periods should be of equal duration. Two of the
fifteen cases selected for observation died after the commencement of
the Toulouse-Richet method, but also after this treatment had been
abandoned ; in the one case there had been thirteen days of treatment,
in the other seventeen days. It does not appear at all clear that the
method had anything to do with the death. Somewhat illogically, so it
appears to us, the authors, whilst denying any curative value to the
method, admit that it does develop the action of the bromide ; indeed,
they ascribe the two deaths to this over-action. But unless they are
prepared to deny any therapeutic value to the bromides this admission
asserts all that MM. Toulouse and Richet have claimed, viz., that the
activity of the bromides is heightened by the withdrawal of salt from the
dietary. This is their teaching, and their recommendation is to reduce
the dose of bromide when passing from a full saline dietary to a hypo¬
chlorised diet. Harrington Sainsbury.

Pseudo-epilepsies and the Relief of Some Forms by Thyroid . (foum .

of Nero, and Afent. Dis ., Oct., 1902.) Browning .

The following are some of Dr. Browning's conclusions :

1. “In the young there occurs a class of cases characterised by re¬
current attacks of heterogeneous type, and that may conveniently be
called pseudo-epilepsy.”

Our comment is that to give a name to anything so nondescript as
his class of cases would be most unwise.

2. “ This form is curable.”

But we must add it is so nondescript that the fear is that it will never
be diagnosed.

5. “ Troubles of this kind, when due to rachitis, are amenable to
thyroid treatment”

That will be unexpected, inasmuch as thyroid is not a recognised
treatment for rickets.

Digitized by v^.ooQLe

556

EPITOME.

[July,

These three from among his seven conclusions we may quote. They
are not at all satisfying ; but, indeed, the whole paper appears to us most
inconclusive. Harrington Sainsburv.

5. Sociology.

Juvenile Murderers and Homicides \Ueber jugendliche Morder und
Todtschldger\ (Arch, f Kriminalanthropologie, Bd. xi.) Baer.

This paper is one of the most notable contributions of recent years
to the anthropological and psychological study of the juvenile criminal.
It is based on careful observation of a series of twenty-two youthful
assassins who were under the author’s care for considerable periods of
time in the Plotzensee Prison at Berlin. Full notes are given of each
case, comprising a history of the crime, the personal and family ante¬
cedents of the criminal, his physical and mental condition, with
anthropometric details, and, in most of the observations, with good
photographs of the individual at different ages. The main facts brought
out by the inquiry are then summarised, and their bearing on various
problems of criminology is discussed with that union of thoroughness
of method and breadth of view which invariably distinguishes Dr.
Baer’s work A paper of this scope and character cannot, of course, be
adequately treated within the limits of a short notice, and the present
rksume does not aim at more than indicating a few of its salient
points.

Of the twenty-two murderers, three were aged 14 to 15 years, three
15 to 16, eight 16 to 17, and eight 17 to 18. Only six of the cases
were crimes of passion—revenge, jealousy of comrade’s success, etc.
In three others the motive was to gain a change from reformatory to
prison; and in the remaining thirteen the object was robbery. In
nearly all the instances the crime was of a very revolting brutality, so
that the series may be fairly taken to represent juvenile delinquency at
its worst. It becomes, therefore, a question of interest whether these
criminals presented the anatomical characters supposed by the Italian
school to be distinctive of the “ reo nato ,” and more particularly of
the assassin type. The author’s answer is unhesitatingly in the negative :
—“ Neither in the general formation of the skull, nor in that of the
face and the rest of the skeleton, could any peculiar characters be
detected showing a specific deviation from the normal condition of
development of individuals of the same age, belonging to the same
race and social class.” In many of the cases, no doubt, physical stig¬
mata of degeneracy were present, but they were not different in kind,
degree, or combination from those met with in the non-criminal de¬
generate.

In these youths, as in all classes of criminals, intellectual and affective
anomalies were frequent and well marked. In ten instances the mental
condition was one of pronounced defect; and at least five of the other
cases had episodic attacks of depression with suicidal impulses. Two
of the prisoners became insane after some years’ imprisonment; and in

Digitized by v^.ooQLe

SOCIOLOGY.

557

1903.]

this connection Dr. Baer points out that the psychoses which develop
about puberty, though they may not present definite intellectual sym¬
ptoms before the seventeenth or eighteenth year of age, often induce
disorders of conduct several years earlier.

Absence of moral feeling was noted in nearly all the cases, but, as
the author remarks, it is not always easy to say how much of this defect
is due to congenital feebleness of brain and how much to the influence
of bad training. And a somewhat similar reservation, he adds, has to
be made in regard to many of the physical anomalies met with in such
cases. Very often they are to be viewed not as the expression of a
congenitally defective organisation, but as the result of bad hygienic
conditions during the period of growth.

In common with English and French observers, Dr. Baer notes that
the worst cases of ethical defect, as shown by the brutal character of
the crime and the total absence of remorse, are found in the town-bred
youths. A vicious sexual precocity appears especially to characterise
these young criminals of the big cities.

As regards the effects of treatment and the ultimate prospects in
these cases, Dr. Baer is not optimistic. In only two or three instances
was there any real raising of the intellectual and ethical level. The
only rational treatment, the author holds, is that of the reformatory
for an indeterminate period, preferably in institutions of the farm
colony type. But he considers that in many cases no permanent
results can be looked for from that or any other method; it is, in fact,
necessary to recognise the existence of a class of incorrigible criminal
defectives who are unfit for free life, and must, in the interests of
society, be kept under restraint indefinitely. W. C. Sullivan.

The Mental Examination of Accused Persons \Lex amen mental des
privenus\ {Bull, de la Soc. de Med. Ment. de Belgique , Feb., 1903.)
De Moor.

Dr. de Moor, in his presidential address to the Belgian Society, in
view of the well-known fact that insanity is often overlooked in the
law courts, urges the importance of judges being able to acquire, as at
Heidelberg University, some knowledge of the mental condition of
criminals, and of diseases of the mind generally. Moreover, he would re¬
serve the mental examination of accused persons or prisoners to medical
men with special diplomas. The selection of a lunacy expert should always
be granted to the defence in a trial. In important cases he is in favour
of two experts giving evidence, one of whom should be chosen by the
defence; in case of their disagreement, the magistrate, with the consent
of the defence, could select a third expert, whose decision would be
practically final. In some cases, it is highly desirable that the accused
should be placed under observation in an asylum for a limited period
(the German law fixes this limit to six weeks). Such a sojourn by a
special enactment could be made without prejudice to the accused. In
addition to giving correct information concerning the mental condition
of the accused (detection of simulation, etc.), such a period of observa¬
tion in an asylum would turn out to be of real benefit as regards the
treatment of the really insane. In exceptional cases the six weeks of

Digitized by v^.ooQLe

EPITOME.

558

[July.

observation granted by German law might be extended by permission
of the magistrate upon request of the defence. Dr. de Moor in this
address does not pretend to deal fully with this question, but merely
makes a few suggestions well worth consideration. H. J. Macevoy.

Social Venereology [ V/n/reologie Sociale\ (Le Progrh Medical , April
ii thy 1903.) Clado .

This is a most thoughtful paper, of the greatest interest, on the
question of the prevention of the spread of venereal diseases, and well
worth close study. It is only possible here to give some of the author’s
conclusions and suggestions. A careful examination of evidence (statis¬
tics, etc.) shows that prostitution is the cause of the spread of venereal
diseases; that clandestine prostitution is answerable for quite two
thirds of this ; that in three quarters of the cases a woman prostitutes
herself before her legal majority; that prostitutes are generally recruited
among girls seduced and abandoned; etc. It therefore follows that
the great source of venereal diseases arises from the clandestine prosti¬
tution of young women ; moreover that man is particularly responsible
for its spread. The protection of the young woman against seduction
is of the first importance, and it is especially in this connection that
the prophylaxis of venereal diseases becomes a social question. The
error of those in favour of “ regulations ” is that they have dwelt parti¬
cularly on the fact that the diseased prostitute is immediately much
more dangerous than the diseased man, losing sight of the not less
evident fact that the best means of avoiding the evil would have been
to protect her against the man who contaminated her.

The author divides his work into three parts. The first deals with
the causes of the propagation of venereal diseases, especially prostitu¬
tion ; the second with the prophylaxis of these diseases (protection of
minors, regulation of prostitution, therapeutic organisation) ; the third
with extra-genital inoculation and its prophylaxis.

The majority of prostitutes first fall as minors, through seduction—
most commonly between the age of fifteen and eighteen years, the age
of sexual vulnerability in woman, as the author calls it, and it is against
this that it is especially necessary to direct our efforts. Other causes
contribute secondarily to favour the downfall of the young woman
(faulty education, want of supervision, the licence of the streets, the
ascendency of the employer over his work-girls, the dangers inherent to
the profession, the promiscuity of the poor, etc.); but there is one
factor for which the law alone is responsible, and which concerns the
man : that is the absence of penal measures (the author treats especially
of conditions in France) calculated to cause restraint in his lust. In
France especially we note this apparent contradiction,—that while the
law considers marriage as one of the best social institutions, yet it
accumulates obstacles to its accomplishment; for the rake has in his
favour (a) the certainty of impunity in the seduction of a minor above
the age of thirteen years; ( b ) the interdiction of the research after
paternity ; (c) the numerous obstacles to legal marriage (administrative
formalities, professional difficulties—as in the case of soldiers, obligation
to the consent of parents—for the man if under twenty-five years, for the

Digitized by v^.ooQLe

SOCIOLOGY.

1903]

559

woman under twenty-one); (d) the absence of a law punishing breach
of promise.

After discussing the immediate causes of prostitution as they affect
women (sloth, vanity, want, etc.) and men (celibacy, conjugal conti¬
nence, clandestine polygamy, etc.), Clado considers the accessory
causes which favour venereal contamination—such as alcoholism, want
of knowledge or initiation, the dearth of women, the long duration of
venereal contagion (the latter made worse by defective treatment, fear
of police in certain countries, prevalence of quacks, etc.).

When we approach the subject of anti venereal prophylaxis, the most
urgent desideratum is the protection of young women, especially the
prevention of their first fall. The author considers that there are four
good means of obtaining the desired result—(1) punishment of the
man convicted of seducing a girl below age, by forced marriage, prison,
or a heavy fine; (2) detention up to the age of majority of a minor
who prostitutes herself; (3) punishment of parents who connive at her
fall; (4) punishment of the man who has relations with a minor,
prostitute or not

On the important question of the regulation of prostitution, the
author contributes a mass of useful and weighty information. In Paris,
for example, he shows that the system of consultations as carried on at
the dispensary of the Prefecture is insufficient; that it is inefficient
from the point of view of prophylaxis, and that it is in reality directly and
indirectly dangerous to the public health. The prostitute does all in
her power to avoid police supervision, and for very obvious reasons has
a marked antipathy to the dispensary. “ The system which goes by the
name of regulation,” says our author, “ far from being opposed to the
dissemination of venereal diseases, on the contrary favours it: firstly, be¬
cause the compulsory attendance given to diseased women is insufficient
as regards cure and inefficient as regards contagion; secondly, because
on account of the regulations, clandestine prostitutes, by far the most
numerous, avoid and escape this attendance.” Another conclusion is
that the prostitute, not being responsible for a venereal disease con¬
tracted willingly by a married man, and he alone being directly respon¬
sible for the contamination of his family, the measure of social preser¬
vation should be directed against the culprit,—that is, the man. Society
has no right to imprison a diseased woman.

That the suppression of brothels does not lead to the increase of venereal
diseases the author believes is shown by English experience (statistics
of army, navy, etc., are quoted). The progressive diminution observed,
on the contrary, can only arise from the diminution of the prostitution
of minors, the great source of venereal disease—diminution due to the
heavy penalties against seduction,—or from the liberty allowed to prosti¬
tutes, who, not being in dread of police regulations, go in quest of
suitable treatment; or it must be due to these two causes combined.

On the subject of antivenereal therapeutics the author advocates the
necessity of impressing its importance upon patients; of encouraging
the opportunities of treatment. The treatment of syphilis should be
gratuitous, at any rate to those who wish it; well-organised establish¬
ments should be accessible to all. That the actual organisation for the
treatment of these diseases is almost uniformly bad or deficient is well

Digitized by v^.ooQLe

EPITOME.

560

[July,

known. So great an authority as Fournier says that out-patient hospitals
and dispensaries are perhaps sufficient for the treatment of syphilitic
accidents , but badly equipped for the treatment of syphilis; that the
consultations are irksome, inconvenient, humiliating, odious. And
when we come to the conditions of in-patients, they are generally most
unsatisfactory ; scarcely anything is done to invite the unfortunate
patients to be efficiently treated. Under several headings the author
enumerates the necessary means of ameliorating and reforming the dis¬
pensaries and hospitals devoted to the treatment of venereal diseases—
his views being almost unanimously shared by the distinguished spe¬
cialists who met at the Brussels Congress. In the third part extra¬
genital contamination is discussed with its prophylaxis ; and then follows
a summary of the author’s conclusions on the whole subject.

H. J. Macevoy.

On the Care and Training of Young Idiots and Imbeciles \ZurPJlcge und
Erziehung jugendlicher Idioten und Schwachsinnigen\ {Neurol.
Wochenschr ., Nos. 44, 45, and 46.) Krayatsch.

In three numbers of this weekly, Dr. Krayatsch, Director of the
Asylum at Mauer-Oehling in Lower Austria, shows what has been
already done, and what is farther proposed to be done, in Lower Austria
for young idiots and imbeciles. By the census of 1890 there were
returned, in a population of 2,800,000, 3000 idiots and cretins, of whom
400 were considered to be of a school-attending age. But Professor
von Wagner, in his investigations on cretinism in Styria, has shown that
in the year 1899 there were as many as 284 boys and 184 girls in
institutions for the care and training of weak-minded children in Lower
Austria.

Attempts to care for these feeble-minded children were conducted
with but little spirit till the year 1896, when the institution at Kierling-
Gugging was opened. Since then up to the end of June, 1901, 242
boys and 191 girls have been received.

The author gives the daily arrangement of lessons, and some statistics
of the grades of idiocy, and the mortality.

In the third number he gives the sketch of a plan for a new institution
for the care and education of feeble-minded children in Lower Austria.
A scheme for the erection of a large institution for idiots in Lower
Austria will be introduced into the Landtag by Mr. Steiner, who has
already effected many reforms in the treatment of lunatics.

William W. Ireland.

Digitized by v^.ooQLe

1903]

NOTES AND NEWS.

561

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

The General Meeting was held at the Langham Hotel, Portland Place,
London, W., on Friday, May 15th, 1903. Dr. J. Wiglesworth, the President,
occupied the Chair.

The following members were present:—Drs. J. Wiglesworth, H. H. Newington,
H. F. Kidd, R. C. Stewart, A. N. Boycott, C. Mercier, T. B. Hyslop, C. H.
Bond, W. A. Weatherly, H. G. Hill, J. M. Moody, H. Barnett, A. R. Urquhart,
F. Watson, W. L. Andriezen, W. F. Menzies, H. E. Haynes, G. H. Savage, J. G.
Soutar, G. E. Mould, A. J. Alliott, H. Stilwell, H. F. Winslow, T. O. Wood, M.
Craig, W. Briscoe, H. T. S. Aveline, F. W. Edridge-Green, W. Douglas, G. H.
Johnston, W. R. Dawson, James Chambers, D. Bower, G. E. Shuttleworth, R. J.
Stilwell, G. S. Elliot, J. C. Johnstone, E. B. Whitcombe, J. B. Spence, H. Rayner,

A. Miller, H. A. Benham, D. G. Thomson, J. W. Higginson, and Robert Jones
(Hon. Sec.).

Apologies for non-attendance were received from Drs. A. R. Turnbull, P. A.
Macdonald, and T. Stewart Adair.

Visitors. —Drs. S. Palmer, E. G. Younger, J. Marnan, and Mr. W. Schroder.
The Educational and Rules Committee met in the morning, and a Council
Meeting was held before the General Meeting. The following were present:—
Dr. Wiglesworth (President), H. Hayes Newington, Henry Rayner, Theo.

B. Hyslop, C. K. Hitchcock, E. B. Whitcombe, W. R. Dawson, Rothsay C.
Stewart, H. Gardiner Hill, Charles Mercier, A. R. Urquhart, C. Hubert Bond,
Ernest W. White, Maurice Craig, J. Beveridge Spence, E. Braine-Hartnell,
H. A. Kidd, A. N. Boycott, L. A. Weatherly, J. M. Moody, and Robert Jones.

The following candidates were elected ordinary members:—Bailey, William
Henry, M.B.Lond., M.R.C.S., L.S.A., D.P.H., Featherstone Hall, Southall,
Middlesex (proposed by Drs. R. Percy Smith, F. W. Mott, and Robert Jones);
Eady, George John, M.D.Brux., M.B.Lond., M.R.C.P., M.R.C.S., L.S.A., Juglans
Lodge, Enfield, Middlesex (proposed by Drs. David Ferrier, H. Hayes Newington,
and Robert Jones); Johnstone, Thomas, M.D.(Hon.)Edin., M.R.C.P.Lond.,
Medical Officer of Health, Ukley, Yorks (proposed by Drs. W. Bevan Lewis, W.
Maule Smith, and Jno. Glen Forsyth); Wigan, Charles Arthur, M.D.Durham,
M.R.C.S., L.S.A., Medical Officer, Bristol Training Ship “ Formidable,” Deep-
dene, Portishead, nr. Bristol (proposed by Drs. G. H. Savage, C. T. Ewart, and
Robert Jones.

Communications.

An adjourned discussion took place on two papers that were read before the
previous General Meeting. These papers were :

(1) ” The Care and Treatment of Persons of Unsound Mind in Private Houses
and Nursing Homes,” by Dr. Ernest W. White.

(2) ” Lunacy and the Law,” by Dr. T. Outterson Wood.

Dr. Rayner said he did not hear the papers read, but he had perused them
since in their printed form. The subject was one in which he had long been
interested, and he therefore wished to offer some remarks upon it. There were
two important points for discussion: first, the desirability of having early care of
mental cases ; and the second, that such care should be efficient. So far as the
legalisation of treatment of early mental cases was concerned, he hoped that
matter might be regarded as fairly well settled. When a Lord Chancellor had
introduced the clause which he had into several separate Bills, it was reasonable
to hope that when he tried a third time it would become law. But then there
arose the question of making that privilege efficient. He thought there was great
danger of that privilege being seriously abused unless some limitation were im¬
posed upon its use. In his view, very considerable limitation would be necessary.

Digitized by v^.ooQLe

NOTES AND NEWS,

562

[July,

On what basis that limitation was to be fixed would be a point for discussion. With
regard to the persons to take care of early cases, his experience had been that the
best people were those who had had considerable asylum experience. Perhaps
medical officers who had been for some time in asylums were the very best people
under which such cases could be placed. Next in order were old asylum
officers, not rank-and-file attendants. Beyond those he had found that ladies,
who perhaps had had experience in nursing their own friends and had taken to
the work, had turned out to be about the most efficient. On the other hand, his
experience had been that general nurses were not good for mental cases. Unless
such nurses had, early in their career, taken to mental nursing, they turned out
badly for the latter work ; they were too stereotyped in their habits. He believed
all alienists would agree that nobody without special experience should be per¬
mitted to take care of the most difficult cases now being considered. Such patients
required a greater amount of tact and judgment than was called for in any class
of medical work, and to put them into the hands of ignorant and, what was worse,
prejudiced persons was most deleterious. He had seen men and women pose as
having had experience in mental cases who had really done very serious damage
to patients in a very short time, and perhaps almost permanently jeopardised their
chance of getting well. In other cases he had seen people—qualified nurses of
long standing—who had treated their patients with the utmost care and kindness,
but at the same time with the greatest neglect, to the permanent damage of the
patients. He had seen, in nursing homes, patients who had been kept in back
rooms and allowed to be wet and dirty, and to masturbate to any extent, and yet
who had been treated kindly all the time. Still, they had been very much ne¬
glected. He had seen cases of delusions relegated to bed, where their delusions
became stereotyped and fixed. In fact, in those cases there had been extreme
neglect of a very kind form. Therefore he thought the main point to consider
was how to make treatment of slight mental disorders good ana efficient, to shut
out not only the absolutely incapable, but also people who were likely to treat cases
on wrong lines. That required a great deal of consideration, both as to how the
limits were to be set, and as to who was to set them. He did not know whether
the Commissioners in Lunacy might be inclined to grant licences to people who
should take charge of cases, but his own feeling was that the Medico-Psychologi¬
cal Association, which had done so much in the direction of improving the training
of attendants in asylums, might set itself to work by examination, and perhaps
also by teaching, to furnish the public with a reliable body of people who could
have charge of cases of incipient insanity. He would be very glad if, as a result
of that discussion, some definite proposition of that kind came before the Associa¬
tion.

Dr. Weatherly (Bath) said all were delighted to hear the very lucid papers of
Dr. White and Dr. Wood at the last meeting at Derby, more especially as time
did not permit of the proper and full discussion of the paper brought before the
Society by Sir William Gowers earlier in the session. At that discussion nearly
all the speakers seemed to preface their remarks by saying they knew nothing
about the subject of which they were about to talk. During thirty years he had
worked among the insane, and the first fourteen of them were devoted to a great
extent to the private care of the insane in private dwellings. It would be remem¬
bered by members of that Association that in 1880 he read a paper before them
on the question, which was discussed at two meetings. Later he had the privilege
of publishing that paper as a book, and was honoured by being allowed to
dedicate that book to one whose name was revered by all, the late Earl
of Shaftesbury. His lordship saw that book through the press, and had a great
amount of correspondence with him on the subject. In that book he (Dr.
Weatherly) brought forward a proposition to make the system of single treatment
of the insane a definite legalised system, such as Dr. Rayner had just suggested;
i. e. t to eliminate people who simply took patients into their houses without any
special knowledge of mental disease, or the treatment of it, for so many pounds,
shillings, and pence. He suggested in that paper that suitable people should be
allowed to take one or two cases ; that they should work by licence, not granted
by the Commissioners, but by their petty sessional divisions, as against quarter
sessional divisions, because one recognised that petty sessional officers would
know, more about the people in their small area. He thought it might be of

Digitized by v^.ooQLe

1 9°3-]

NOTES AND NEWS.

563

interest to the meeting to read one of the letters of the late Earl Shaftesbury on
the subject. His lordship said: “ I do not object to the principle—I see the
good results of it in many aspects; but I somewhat doubt the possibility, should
the system be extended to the degree you propose, of exercising such an accurate,
constant, and vigorous inspection as would prevent a recurrence of the horrible
abuses that prevailed in former days. You may judge what I feel on the subject
by the evidence I gave before the House of Commons in 1859, when I stated that
1 were any relative of mine afflicted by insanity, I would place him or her in a
house along with many others, in preference to any retreat for a single patient.’
You will reply, perhaps, that your plan involves the superintending care of a
medical man; nay, but I answer, the very worst cases in my knowledge were those
where medical men had both the sole care and whole profit of the patients
committed to their charge. Nevertheless the wisdom and experience of good
men may invent some mode of discipline and superintendence whereby the scheme
you propose may be rendered as safe as any other. Of course, such a plan as
yours can be intended only for the comparatively rich, inasmuch as the vast mass
of those who can barely afford a guinea a week, or even twice that sum, for care
and treatment, must, of necessity, be excluded. Almost all reformers in lunacy
matters, whether they be lay or professional, are so carried away by the claims of
the patient—a natural and very commendable feeling—that they totally forget the
claims of the public. The patient has every claim to care, comfort, curative
treatment, and his freedom as soon as he is well; but the public have a right, on
their side, to security from danger, annoyance, and the pressure of intolerable
burdens. I do not say these things to discourage inquiry—much will be gained
by frequent discussion,—I am only anxious that nothing should be propounded
hastily. The public are so sensitive on the subject of real or alleged madness,
that they fall into fits of ecstasy at every new scheme that is brought before them.”
Those were the words of one whose name would always be loved by all who were
devoting care and time to the treatment of the insane, however one might disagree
with some of his propositions. What he felt very strongly when Sir William
Gowers read his paper was, that that gentleman apparently wanted it possible to
place people under care and treatment without, apparently, any supervision what¬
ever ; that the relatives might be able, without what he described as the stigma of
certification, to place their patients with Jack, Tom, or Harry to be treated. He
thought Sir William Gowers forgot that a large majority of the patients who were
sent to private houses were not sent with their free will, but against it; they were
practically compelled to go to those places, and therefore were virtually made
prisoners. He (Dr. Weatherly) thought something should be done to legalise the
detention of every person suffering from mental disease and their treatment in
single houses. He was most emphatic on that point. With regard to Dr. White’s
remarks as to the suitable cases for private care, he would not dream of attempting
to state what cases, in his opinion, were suitable for private care. It depended to
a very large extent upon the person under whose care and treatment the patients
were being placed. Looking back he could recollect cases where a widow,
perhaps, and her two daughters had devoted themselves so absolutely and entirely
to the care of the patient placed under them that he did not think that patient
could have been placed anywhere better, though the cases were probably those
which Dr. White might not have thought suitable for private treatment. But he
had also seen cases where single care was most appropriate, but where the patients
had been placed under the care of people who had no idea of managing them.
He thought each case should be taken on its merits. The next question which
should be considered was whether the care and treatment of the insane should be
so wholesalely relegated to anybody, whether they had or had not special know¬
ledge of the care and treatment. He was not simply referring to lay people, but
to medical men themselves. He thought it monstrous that medical men and
judges should stand up and say that ordinary people were quite as capable of
judging of the mental condition as were men who had devoted their whole lives
to the care and treatment of the insane. Surely one who had anything the matter
with his eyes would go to an oculist who had devoted his time to that special
study; and in the case of mental disease it stood to reason that those who had
devoted their lives to such cases must know more about them than the ordinary
man. If in any way a system could be established whereby a medical man engaged

Digitized by v^.ooQLe

564

NOTES AND NEWS.

[July,

in mental work would be able to have a patient under care in a house away
from an institution, whether public or private, it would be a very great help.
Another point which was touched upon by Sir William Gowers, and also by Dr.
White and Dr. Wood, was that of voluntary boarders. He (Dr. Weatherly)
thought the voluntary-boarder system should be very widely extended. It should
undoubtedly be extended to those public asylums which were now doing good
work by taking private patients. He would insist upon such asylums having a
definite department apart, and a definite dietary for those private patients. But
he thought the voluntary-boarder system should be brought into touch with those
asylums. It might be said that he was speaking on behalf of licensed houses
when he said it was a wrong thing in the Act of 1890 to include the voluntary
boarders on the licence. If an institution could get and keep voluntary boarders,
and get them well, while keeping them comfortable, those boarders ought not, in
his opinion, to count on the licence. Many houses would be willing to add to
their buildings, to provide an annexe for voluntary boarders if they were not
included in their licence. And very likely the institutions would do more good
work in curing those people by association, by general discipline, and the morale
of the institution than could be done under single care. He trusted that there
would emanate from that discussion a suggestion that the whole system of
voluntary boarders should be more or less widely extended.

Mr. Briscoe said that Dr. White’s paper was, in his opinion, a remarkable one,
and the question might be regarded as a national one, almost as much so as the
abuse of the practice of bloodletting was in former days. He said it had occurred
to him that a resolution somewhat similar to the following would be a proper one
to adopt in the circumstances:—“ That this Association disapproves the modern
system now being practised with regard to single care and private nursing homes,
and we would suggest to the law authorities some stringent methods with regard
to the better regulation of single care cases, nursing homes, and other places for
persons of unsound mind ; and, in particular, we would lay stress on the important
fact that the caretakers should be specially qualified on the matter, possessing
psychological training and knowledge.” That was only a rough idea, but it was
probably similar to what was in the minds of most of the members.

Dr. Bower said all would agree with that part of SirWilliam Gowers’ paper which
said that something must be done to allow of the treatment of certain cases in
private houses instead of their being sent to asylums, and, as Dr. Hayes Newington
pointed out at the meeting at which Sir William Gowers’ address was delivered,
the Association had taken all the steps it possibly could to get the Scottish
provision inserted into the new Act. On the other hand, he (Dr. Bower) thought
it necessary not to make it absolutely a matter of free trade, the treatment of
lunacy and the boarding out of lunatics, and that some precautions, similar to those
suggested in Dr. White’s and Dr. Wood’s papers, and by Dr. Rayner in his
remarks that evening and also when Sir William Gowers read his paper, were
desirable. He thought all alienists—he certainly did—saw many cases in consul¬
tation which could be treated at their own homes or in private houses. But he
thought those private houses required to be very carefully looked after, and it was
necessary that the homes should be very carefully selected. It happened that
about a fortnight after the reading of Sir William Gowers’ paper he (Dr. Bower)
was looking out for a suitable private house, preferably that of a medical man, to
which he could send a case which had been with him for some time, and which he
thought would do better in a private house. Possibly he was unfortunate in the
houses he went to, but in nearly every case the desire appeared to be to see as
much of the patient’s money and as little of the patient as possible.

Dr. Douglas said he approached the matter under discussion from a standpoint
somewhat different from that of most of those present. He had not approached the
study of mental cases through the portals of an asylum, which in some ways was
possibly a disadvantage, but it gave him a point of view which was of advantage,
namely, that of the general practitioner and physician. Though he had not had
what was commonly called an asylum experience, he had, from his earliest entry
into the profession, taken a special interest in mental cases. He thought it was
almost impossible, except in a very rough way, to generalise on the matter; every
case should be judged on its merits. Doubtless there were many cases under
private care which, if one took them separately, would do better in an asylum;

Digitized by v^,ooQLe

1903]

NOTES AND NEWS.

565

but one had no choice in such a matter. The friends of the patient would not
agree to such a thing nor listen to it. He saw no objection to some form of
certificate showing that there must be some special knowledge (on the part even
of the medical man) of mental cases before he could take up the care of private
patients. There were many medical men who were not suitable persons to have care
of private cases; one had heard the acknowledgments of meaical men that they
knew nothing about the matter, and there was a good deal of evidence to the effect
that they did not. He thought there was no objection to leave the matter to
medical men who could show special knowledge of mental cases. There were
many non-medical people—women, for instance—who might be very suitable
persons to place a patient under; that must be judged by the person and by the
case—there was no other way, so far as he could see. There was every prospect
that when the next Bill became an Act the Scottish clause would be introduced.
A proposal had been made somewhat different from that, that there were persons
who could not be considered as sane who were not able to look after their
property, but who might have freedom to go where they liked and be at liberty
when they liked. He admitted there was something to be said for that, but he
would not give any such case freedom to go where he liked. The point was a very
difficult one, and he ventured to suggest to the special joint committee on the
subject that where there was no parent or elder brother or sister, as the case might
be, some one who could occupy the position in loco parentis , there should be a
guardian who would at least nave certain power and influence over the patient,
and be to a certain extent responsible. A day might come when, either through
a weakened will or strong temptation, those patients might show undoubted signs
of insanity, and the alienist should be prepared to deal with that condition. No-
doubt it was a very difficult thing to put into an Act of Parliament, but he did not
think the difficulty should prove insuperable. He regretted the Committee could
not see their way to frame a clause which would give effect to that idea; he was
not without hope that they would yet do so.

Dr. Savage said he felt some hesitancy in speaking on the present occasion,
because, at the original address by Sir William Gowers, he spoke fairly fully.
Unfortunately he was not present when the two most excellent papers were read
by Dr. Ernest White and Dr. Outterson Wood. He spoke very much from the
same point of view as Sir William Gowers did, though perhaps with a larger
experience and practical knowledge. One came to the point that, do what one
would, one had to face the fact mentioned by Dr. Douglas, that a large proportion
of the friends would not have their relatives certified, and till they could be forced,
by a kind of police action, to certify against their will, something must be done,
and it seemed to him that something should be done in the way of recognising
single homes. There he agreed with the speakers that day, tnat it was of the
utmost importance to have a notification of patients and a kind of notification
of homes. That day he sent out, at the request of a medical man, his 3078th
regular form for applicants who wanted to have patients in their houses.
Therefore there were on his list 3077 people more or less aualified. When
he told his hearers the qualifications of some they would be able to judge. A
parson’s wife wrote to say, “ Unless you can send me a patient to pay jfiooo a
year, and cause no trouble, my husband will have to put down his carriage, as he
has lost heavily on the Exchange.” That was the sole qualification. Another
thing, which he had spoken very feelingly about, was that people thought every
medical man was qualified. Many of the doctors who applied to him had had
some experience of the insane; some had been resident medical officers, but in
many cases their houses were totally unfitted for receiving mental cases; they
were semi-detached in a High Street, with no gardens. Then there was another
important point. He frequently said to a doctor, “ I do not know your wife.”
That was one of the most important things. He had had the following experi¬
ence. He had sent a patient to the house of a doctor who had had training.
His wife drank, and the consequence was that great troubles arose, and in the end
the patient was removed. Because he had allowed the patient to go into single care
the remark was made, " Doctors are no good, we will have a nurse, and run our own
risk; we will take her away.” They did so, and the patient committed suicide.
It was necessary to select the people to have charge of single cases with the
utmost care, and to see that they had had some special training. There was need

XLIX. 39

Digitized by v^.ooQLe

566

NOTES AND NEWS.

[July,

for a permission of some kind; whether it should be permission by magistrates
he could not say. He felt that registration of houses and notification of cases
would, to a great extent, cover the ground. There would be trouble, as every one
recognised, but all felt a tendency towards greater freedom in the treatment of
patients. Every case should be looked upon individually, not only from the
point of view of his disorder, but from that of his relatives and his home. The
next thing he thought members would all agree upon, but about which nothing
had been said that day, was that one felt the Association would urge, as far as it
•could, the increase in the number of Commissioners, for it was absolutely ridicu¬
lous to expect the Commissioners, let them work as hard as they might, to do more
work than they did at present. Therefore if there were to be registration and
notification they would not be able to take it up. He was quite sure that all of
them, especially those who were acquainted with consultations in general practice,
encountered many patients who ought to be certified, but who yet could not comply
with the requirements of the certificate in respect of what could be seen at the
time of the interview. He signed a certificate that day. There were no facts
indicating insanity at the time, but he made an assertion that the man was
.suffering from “ acute mania,” that he was defective in self-control, loquacious,
loud, and turbulent of tongue. That alone was not enough to indicate that the
man was necessarily insane. Still, as he was a dangerous lunatic, unless one took
the bull by the horns and acted in that way, danger to society would arise.
Therefore, besides giving freedom in the treatment of patients, one required
that there should be an extension of certification.

There was one other point, and one which constantly annoyed him. One was
inclined to think that one’s professional brethren intended to be honest in what
they said, but he was sick of hearing the following:—A patient was sent into a
•county asylum or a private asylum as a general paralytic; and the doctor said to
the frienas, if the patient had been put earlier under his care it would have gone
better with him. There were equally hopeless cases of dementia prsecox, which
began with so-called hysteria, and were as certain to end in weak-mindedness as
general paralysis was to end in death; and it was nonsense, and it was wicked, it
was one man throwing a slur on the reputation and honour of another to say, “ If
this patient had been sent to me sooner I could have done more for him.”

Dr. Edridge-Green wished to refer to one point which, at the meeting when
Sir William Gowers’ paper was read, was laid stress upon by those who did not
belong to the specialty, namely, that a person by being certified became a lunatic,
and was thereafter permanently known as such. But there was no doubt that in
this case, as in other things, the very means which the public took to avoid
certification brought about the result they wished to avoid, because in many cases
the public would make their own diagnosis. One heard over and over again,
“Yes, Mr. So-and-so was a raving lunatic in that house,” and the report kept
much more permanently to the man than if he had been sent to a large or small
institution, care being taken to transfer him quietly to it. It was for that reason
that recurrent cases came back repeatedly to asylums, the statement made being
that they found people were making remarks about them.

Dr. Alliott wished to make a few remarks as a general practitioner, who had
been engaged in the personal treatment of mental cases for twenty years, and had
since given up that branch of work. He had heard with a good deal of surprise
that the majority of patients who came under the care of private practitioners
came there against their will, and suffered a sort of imprisonment. Perhaps he
was the exception proving the rule, but he was happy to say that, during his
twenty years’ experience, the patients had come to his house voluntarily. He
had been impressed by Dr. Savage’s question, “ If those border-line cases were not
treated in private houses, where were they to go ? ” The evidence of certifiable
insanity in such cases was to seek, and up to the present he had been unable to
find it. The patients had come willingly, and, as Dr. Savage remarked, he did
not know where else than to such homes they could have gone. In the hope,
frequently justified, that they would get better, the friends were averse to certifica¬
tion. With regard to the stigma which was supposed to rest on the patient and
his friends, and referred to by Dr. Edridge-Green, with whose remark he did not
quite agree, he could not help seeing a very great difference between the person
who had been under certification and the person who had not. Speaking as a

Digitized by v^.ooQLe

NOTES AND NEWS.

S67

* 903 -]

■general practitioner, he could say it made 'a great deal of difference. Dr.
Edridge-Green had referred also to patients being sent away to an asylum,
so as to escape a public branding with lunacy. He did not think the going away
to a private asylum bad that degree of privacy which those connected with such
institutions were apt to imagine. He heard with great regret, at the last meeting,
of the very large number of people who were incompetent to take charge of
private patients. Happily his experience had not been of that sort, and he hoped
such instances were the exception and not the rule. He had only seen kindness,
and some amount of skill, on the part of doctors who had charge of private
patients. It seemed to him that in private care there was an opportunity of
giving personal attention to the cure of the patient, which was not so possible
when there were a number of patients together. Of course in the latter case
patients could get entertainments and dances, which were most excellent; but
he thought some patients were more readily helped where they could receive
individual personal care. He would be the last, from his personal acquaintance
and knowledge of them, to make any criticisms but the most favourable on those
valuable homes, the private asylums, but he thought there were a large number of
patients not suitable to be sent to asylums, and not certifiable, but yet not fit to
take care of themselves. He spoke from that point of view, and because he was
surprised to hear it said that many patients sent under private care were imprisoned,
taken into the house by the back way, and then locked up. He said he was one of
those whose experience was contrary to that.

Dr. Henry Winslow said that the first consideration which alienists ought to
have, and probably did have, was, what was for the good of the patient ? How was
he to be got well, and what was the quickest means of accomplishing that ? Was
that to be done by sending a patient, say for trial, for a certain time to a private
house or private home, or was the patient likely to be benefited more by going to
a public institution where he or she could be thoroughly looked after by expe¬
rienced persons P His own observation and belief was that they could derive a
vast deal more benefit by being placed as early as possible under the care of those
who had had considerable experience in institutions, either private or public, or in
hospitals. It seemed to him almost unreasonable to expect that persons who had
not had considerable experience in the management of insane patients could be
expected to exercise that supervision and that care which were so absolutely
necessary, more especially in the early stages of insanity. There were, no doubt,
cases which were fitted to be taken care of in private houses; he alluded especially
to the chronic cases. He saw no reason whatever why a chronic lunatic should
not be put into a private house. Such patients were capable of some enjoyment
of life, and many of them were quite harmless, and could £0 about with only a
moderate amount of supervision. But to put a case of early insanity, when it was
not quite clear what course it was going to take, into the hands of a general
practitioner, or a person unacquainted with insanity, was, to say the least, a most
hazardous thing to do. He thought all must have been impressed by the very
large number of cases recorded in the daily press, of persons who were taken
suddenly insane and were placed under general practitioners who knew very little
about lunacy. The patients had slipped through their fingers and committed
suicide. Hardly a day passed in which some such incident could not be seen
recorded, and he regarded it as very deplorable. He thought persons who took
•charge of such cases, unless the patients were properly protected, ought to be held
accountable to the law, because nobody was justified in taking charge of an insane
person without exercising the very utmost supervision to prevent any catastrophe
of that kind. He had himself seen cases of a similar kind, where men who were
carrying on large general practices in London—he would not say from careless¬
ness, but from want of proper supervision and proper knowledge and experience
—allowed persons of that kind to get into trouble. The public view was that it
was a misfortune for Mr. So-and-so to have taken his life, but about the last idea
which seemed to occur to the general public was to ask who was to blame for it.
Certainly the person to blame was he who had charge of the patient. The onus
ought not to fall upon the attendants, but upon those who undertook the care of
such cases, and who had not sufficient experience and knowledge to keep the
patients safe. It was known that if the patient could be kept safe, even for a
short time, there might be a perfectly fair chance of recovery. Anything happen-

Digitized by v^.ooQLe

NOTES AND NEWS.

568

[July,

ing to such a patient was a loss to society which ought not to be allowed to take
place.

Dr. Andribzen said he had read Dr. White's paper very carefully, and agreed
with most of its propositions. Several speakers had laid emphasis on the point
that no hard and fast lines should be followed. As practical men they agreed
that that was so. The general propositions laid down by Dr. White were, in the
main, excellent and wise, and one could exercise one's discretion in departing, in
minor respects, from any of them. One difficulty which he had found in his expe¬
rience was the disobedience of relatives. One saw a patient who was suffering
from slight maniacal or hallucinatory confusion, which one thought would last a
certain time and probably prove dangerous; accordingly the relatives were advised
that he should be certified. The relatives seldom followed the advice immediately,
but they hesitated and hoped on, preferring to keep the patient at home, by means
of which risks were run. Dr. Winslow had just drawn attention to the risk of
suicide. During the past twelve months two cases occurred in his own practice
which brought home to him seriously the importance of that. It would be wise
if there were some legal provision by which a medical man who was called in to
see a case of insanity, and who was satisfied that it was dangerous and required
segregation, should have some means of notifying it, as in the case of the notifi¬
cation of infectious diseases. If some such notification were compulsory it would
be better for the patient and for the medical man attending the case. He was
particularly struck by Dr. Savage’s remark about the medical ethics involved in
the habit of giving rash opinions on the recoverability of such incurable affec¬
tions ; that remark ought to be made known to the profession at large. It was
true that even in cases of general paralysis, the relatives were told that if the case
had come under earlier treatment it would have recovered. He remembered two
cases of the kind which passed through his hands and were sent to an institution,
and in which the same remark was made. One boy he saw last year had dementia
praecox, and subsequently developed mild maniacal excitement. It was a hopeless
case from the beginning. Any one who had had experience of that class of case
would know beforehand that permanent mental enfeeblement would follow, and
that the intellect would be permanently damaged; but the relatives had been
misled to believe that if the boy had been sent earlier to an asylum his break¬
down would have been obviated.

Dr. Hayes Newington thought the Secretary had set before the Association a
very large dish of debatable matter in putting forward the discussion on the Care
and Treatment of Persons of Unsound Mind, and Lunacy and the Law. The two
papers lately read, together with that of Sir W. Gowers read in November, raised
the whole subject of lunacy. There was no doubt that Sir William Gowers,
whether rightly or wrongly, was taken as wanting to tear down the provisions of
the Lunacy Law too much, so as to allow of the treatment of lunacy cases in
private houses, to an amount which exceeds that which the opinion of most mem¬
bers of the Association can endorse. There was no question that, if such was Sir
William’s aim, he wanted to do that which alienists knew from practical ex¬
perience was wrong. Dr. White had contributed a very useful warning against
going too far in that direction. He had proved to the public what most members
of the Association knew, that if a bad case was taken and put into a bad house in
the hands of a bad person, then very bad results would ensue. But at the same
time it was known that there were cases which did very much better in good
houses, in good hands, and beneficial results were more likely to follow than if
they were sent to an asylum. But Sir William Gowers seemed to go further, for
he desired some radical change in the law, and a very large change. There was
no question about some change in the law being required. At present the law
was being broken day by day, and one was told it would be broken because the
friends of some patients would not have them certified, and we have to reckon
with this determination. But that was not all—several patients were deprived of
proper treatment because the law could not be observed. It was well known that
the certificate required two considerations: (1) that a patient was of unsound
mind; (2) that he needed detention. Members knew several cases, probably less
among the acute than the chronic, where there was absolutely no necessity to
detain a patient,—in fact, many of them, if they were well advised, went into
houses voluntarily. For that reason the law must certainly be altered; he fore-

Digitized by v^.ooQLe

NOTES AND NEWS.

569

* 903 .]

saw that if there was some relaxation in that way, not only would more people
be tempted to put themselves under some care for their own benefit, but it
would be much more difficult for the wrong-doers, those who took patients in
the teeth of the law, to continue their practices. One hundred years ago people
were sentenced to be hanged for the merest offence, such tas the stealing of
is. ifrrf. from the person, or something of that kind. As a result, not one tenth
of them actually were hanged, because the penalty was obviously too great
for the offence. It was very much the same now with regard to certification.
There were a certain number of insane patients in respect to whom doctors and
friends objected to the certificates, because those certificates and the attendant
formalities were too great a penalty for the mild alienation seen in the patient.
Yet, according to the law, those patients could not be received into any house
but an institution ; it would be wrong for such a patient to be in that hotel where
they were meeting now, for instance, because it was an offence for any person
to receive for payment an alleged lunatic. But if one went further and endeavoured
to put a foot rule on the Lunacy Law one would see the necessity for alteration.
We discharge a patient not recovered but better, who had not got a home to go
to. Where was he to go ? He must not stop with anybody else unless as a free
guest, otherwise it would be a breach of the law. That might appear a small
view to take, and might seem to be straining a fact, but it was not so. It would
be remembered that two years ago a householder was brought before Sir Frederick
Lusbington, at Bow Street, for chastising a brother of weak mind with the cane,
and in other ways ill-treating the patient. That was ill-treatment in the view
of such an expert as Dr. Maudsley. However, the magistrate held that correction
with the cane, under the circumstances, was not wrong, and he discharged the
defendant. But the defendant was successfully prosecuted under the Lunacy Law
five minutes afterwards for receiving his brother, without proper authorisation
under the Lunacy Law, for payment, although, as a matter of fact, the keep of the
patient cost £120 a year, of which the brother only received £100 a year. It
made a great deal of difference to a medical man when considering a doubtful
case whether he was liable to be prosecuted or not. He did not think alienists
had any right, from their point of view, to limit in any way the treatment of patients.
It could not be said at the present time that all patients could appropriately be
treated under the present provisions of the law, and therefore the law should be
judiciously extended to meet those cases.

Dr. Ernest White replying said: The excellent discussion of to-day has amply
justified my paper. We all agree that some change of existing methods with
regard to trie care and treatment of persons of unsound mind in private houses
and nursing homes is necessary, although we may differ as to what this change
should be. Legal reform is urgently called for, and we must look to the Legis¬
lature to rectify matters. I will now refer to what we have heard to-day. Dr.
Rayner draws attention to the desirability of early care and treatment under
efficient safeguards, and especially dwells upon the fact that the custodians,
medical and others, must be experienced. To Dr. Weatherly we are much
indebted for the letter of that great humanitarian the good Lord Shaftesbury,
which sharply delineates the defects of the past, and renders clear to us the
possible abuses of the present and future. Dr. Weatherly has also alluded to
the extension of the voluntary boarder system, which has been dear to my heart
for some time past, and which was strongly advocated in my paper. I have had
opportunities of seeing the working of the voluntary boarder system in well-
managed private asylums, and sincerely trust it will soon be extended to county
and borough asylums receiving private patients.

We have at the present time 240 private patients at Stone, and many of these
might be treated as voluntary boarders preparatory to discharge. The main
advantage, however, would be for the treatment of incipient cases. Dr. Savage
has told us of his 2078 would-be custodians, all more or less qualified, probably a
few more and the majority less, except it be that the standard of qualification is a
very low one. I am much pleased with the suggestion of Dr. Henry Winslow,
that the chief custodian should be held legally and not merely morally responsible
for his patient. If culpable through inefficient care, whereby suicide or other
accident might happen, he should be liable to prosecution. It is gratifying to us
that Dr. Alliott has spoken from the other point of view, of single care uncer-

Digitized by v^.ooQLe

570

NOTES AND NEWS.

[July,

tified, for from personal knowledge of his patients I can state they have all spoken
well of the care and attention they received, and of their comfortable surround¬
ings when under his medical supervision.

And now to summarise. I believe we desire—

(1) An extension of single care, certified or notified.

(2) The registration of persons and houses receiving patients to ensure efficient
custodians and suitable environment.

(3) A licensing of these houses if necessary, with periodic inspection by deputy
or district commissioners.

(4) An extension of the voluntary boarder system to county and borough
asylums receiving private patients, and an extension of the existing voluntary
boarder system in private asylums, so that these patients shall be outside the
fixed number of the licence

(5) A voluntary boarder system for the cases received uncertified in single care
and in nursing homes.

In conclusion I desire to thank you for the kind attention and support you have
given me to-day.

Dr. T. Outterson Wood agreed with the suggestion of Dr. Weatherly, and
supported by Dr. Ernest White, that the voluntary boarder system should be
encouraged and made available for county asylums as well as licensed houses and
hospitals for the insane, and that in licensed houses voluntary boarders should be
notified to the Commissioners, but not included in the list of patients for which
the houses are licensed as at present. He also strongly supported Dr. Henry
Winslow in advocating the necessity for asylum-trained nurses for private
patients as the best means of checking the large number of suicides which
occur. The points he desired to especially mention were that for years the
Association had been actively engaged in procuring special legislation for cases
of incipient insanity. That certain forms of undeveloped insanity were suitable,
and others unsuitable for single care, and should be differentiated. That asylum-
trained nurses were necessary for mental cases, and hospital-trained nurses are
useless. That unskilled care is wrong, and that the perfunctory visits of a
physician cannot check abuses. That nursing homes should be registered and
inspected. That all doubtful cases of mental disorder cared for by persons other
than relations should be notified to the Commissioners, and that deputy Com¬
missioners and local experts should be appointed by the Lunacy Board.

The members dined together in the evening at the Langham Hotel.

SCOTTISH DIVISION.

A meeting of the Scottish Division of the Medico-Psychological Association
was held in the Central Station Hotel, Glasgow, on Friday, March 27th, 1903.

There were present Dr. C. C. Easterbrook, Dr. Graham, Dr. R. D. Hotchkis,
Dr. William W. Ireland, Dr. J. Carlyle Johnstone, Dr. John Keay, Dr. J. H.
Macdonald, Dr. Hamilton C. Marr, Dr. Parker, Dr. Alexander Robertson, Dr.
George Robertson, Dr. James M. Rutherford, Dr. Thomson, Dr. A. R. Turnbull,
Dr. Urquhart, Dr. W. R. Watson, Dr. Yellowlees, and Dr. Lewis C. Bruce, Divi¬
sional Secretary for Scotland.

On the motion of Dr. Carlyle Johnstone, Dr. Graham took the chair.

The Chairman thanked the members for again promoting him to the honour¬
able position of Chairman. He said that since the last meeting of their Division
one of their most respected members. Dr. Clouston, had passed through a very
serious illness, and it would be a pleasure for them to learn that he was now con¬
valescent and on a trip to more congenial climes for the recovery of his health.
He proposed to send a congratulatory letter to Dr. Clouston on his recovery,
expressly hoping that he would soon be back amongst them.

The Secretary then read the minutes of the last meeting, which were ap¬
proved of.

Alexander Spalding Mackie Peebles, M.B., Ch.B.(Edin)., Assistant Physician,
Perth District Asylum, Murthly (proposed by Drs. Urquhart, Bruce, and Mitchell),,
was elected an ordinary member.

Digitized by v^.ooQLe

1903 .] NOTES AND NEWS. 57 1

Expense of Reporting.

The Secretary stated that Messrs. William Hodge and Company had always
reported for them at previous meetings, and the charge they had maae was a very
moderate one, viz. two guineas, including the expenses of the reporter. The
reporting, however, of the last two or three meetings had been so heavy that
Messrs. Hodge and Company did not see their way to continue doing the work at
the same charge, and now offered that at future meetings their charge should be
at the rate of $*• per hour for attendance, and is. per sheet for the extension of
the notes, with travelling expenses when required.

After some discussion it was agreed to leave the matter in the hands of the
Secretary to make the best terms he could with Messrs. William Hodge and
Company.

Membership of Council—Examinbrships and Divisional Secretaryship.

The Secretary stated that the vacancies which had occurred were—a vacancy
in the Council; a vacancy for the Examinership in Psychological Medicine; a
vacancy for the Nursing Certificate Examinership and the Divisional Secretary¬
ship. The Nursing Certificate Examinership, he understood, was in future to oe
held for three years by each Examiner, but that the Examiner was to be re¬
appointed annually, and, as Dr. Carlyle Johnstone had been appointed last year
for the first time, he presumed that he would hold the Nursing Certificate
Examinership for the next two years. There was a vacancy in the membership of
the Council, and he had now to vacate the office of Examiner for the Psychological
Certificate, having held it for two years.

Dr. Turnbull proposed that Dr. Campbell, the Senior Assistant of the Crichton
Institution, be nominated to fill the vacancy in the Council.

This was seconded by Dr. Keay, and unanimously agreed to.

Dr. Hotchkis proposed that Dr. Parker be nominated for the vacant Exami¬
nership, and on being seconded, this was unanimously agreed to.

Dr. Turnbull moved that Dr. Lewis C. Bruce be again asked to fill the office
of Divisional Secretary.

The Chairman thought there could be no doubt as to the propriety of this, and
Dr. Bruce was unanimously re-elected as Divisional Secretary.

Communications.

Dr. Carlyle Johnstone opened a discussion on the subject of Superannuation
Allowances for Scottish Asylum Workers (see page 474).

Dr. Lewis C. Bruce contributed a paper entitled “ Further Clinical Observa¬
tions in Cases of Acute Mania, particularly Adolescent Mania ” (see page 441).

After a vote of thanks to the Chairman, proposed by Dr. Ireland, the meeting
terminated.

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division was held by the courtesy of
Dr. Harding at the Northamptonshire County Asylum, Berrywood, on April 23rd,
x 9°3-

Among those present were DrsH. Bayley, T. R. Beale-Browne, W. Harding,
A. Miller, A. Newington, R. J. Stilwell, F. J. Stuart, J. Turner, T. Outterson
Wood, and Boycott (Hon. Sec.). Visitors: Rev. J. Cunningham, Rev. B. Mathews,
and Dr. W. Miller.

The wards and grounds were inspected, and after luncheon a meeting of the
Divisional Committee was held.

The General Meeting of the Division was held in the afternoon, Dr. Harding
being voted to the chair.

Dr. J. Turner gave a lantern demonstration in illustration of his article in the
January number of the Journal. He showed photomicrographs of the peri¬
cellular network surrounding the pyramidal cells of the cortex cerebri, and of the
two varieties of nerve-cells (pale and dark) which are differentiated by his
method.

Digitized by v^.ooQLe

572

NOTES AND NEWS.

[July,

Dr. F. J. Stuart showed the brain of a mierocephalic idiot, the right half of
which (corresponding to left hemiplegia in the patient) was microgyrous, and
was surface-marked on a plan totally different from the comparatively normal
marking of the left half of the cerebrum, there being nothing to suggest a
Rolandic fissure in the microgyrous half.

The minutes of the last meeting were confirmed.

Dr. A. Norman Boycott was nominated as Hon. Divisional Secretary for

1903-4.

The following gentlemen were by ballot elected ordinary members of the Asso¬
ciation :—Frederick Hudson Evans, M.R.C.S., L.R.C.P.Lon<L, Assistant Medical
Officer, Herts County Asylum, St. Albans (proposed by Drs. Boycott, Kidd, and
Grimmond Smith); Arthur Beresford Kingsford, M.R.C.S., L.R.C.P.Lond.,
D.P.H.(Camb.), 9, Burwood Place, Hyde Park, W. (proposed by Drs. Merrier,
Boycott, and Grimmond Smith); Percy Haughton Stratton, M.R.C.S., L.R.C.P.
Lond., Assistant Medical Officer, The Priory, Roehampton (proposed by Drs.
Savage, Chambers, and Boycott); Herbert Campbell Thomson, M.D.Lond.,
F.R.C.P.Lond., Assistant Physician, Middlesex Hospital (proposed by Drs. Percy
Smith, Chambers, and Boycott).

Drs. W. Harding, R. J. Stilwell, and J. Bayley were elected members of the
Divisional Committee of Management to fill the vacancies caused by the retire¬
ment of Drs. Alexander, A. Newington, and Ernest White.

The name of Dr. F. R. P. Taylor was selected for submission to the Council
for nomination to fill a vacancy upon that body at the next Annual Meeting.

The invitation of Dr. Rawes to hold the Autumn Meeting at St. Luke’s
Hospital in October, 1903, was unanimously accepted with great pleasure.

A hearty vote of thanks was accorded to Dr. Harding for his hospitality to the
Division, and for presiding in the chair.

The members afterwards dined together at the Grand Hotel, Northampton.

SOUTH-WESTERN DIVISION.

The Spring Meeting of the South-Western Division was held at the City and
County Asylum, Bristol, on Tuesday, the 28th April, 1903. There were present
Dr. Benham in the chair, Drs. Eager, Baskin, Cotton, Blachford, Braine-Hartnell,
Morton, Broom, Aveline, MacBryan, Miller, Rutherford, Marnan, MacDonald,
Hon. Sec., Ligertwood, and Bullen. Visitors: Prof. Fawcett and Dr. Brown.

The minutes of the last meeting were read and signed.

Dr. John Marnan and Dr. Henry Broom were both duly elected ordinary mem¬
bers of the Association.

Dr. MacBryan's name was recommended for a seat on the Council, and it was
resolved that Dr. Morrison and Dr. Turner should be elected to fill the two
vacancies on the Committee of Management.

The Chairman stated that he had very much pleasure in proposing that their
friend Dr. MacDonald should be elected their Honorary Secretary once more,
and he referred to the excellent services which Dr. MacDonald had (rendered.
The motion was carried unanimously. Dr. MacDonald, in reply, thanked the
members for re-electing him as their Honorary Secretary, and consented to accept
the office for this year; but having now held it for ten years he wished to say that
he thought the time had come when he would have to ask them to look out for a
successor.

It was unanimously agreed that the invitation of Dr. Morrison to hold the next
meeting at Hereford, in October, be accepted.

Communications.

A discussion took place upon the paper read at the last meeting by Dr. Baskin
upon “ The Treatment of Phthisis in Asylums by Urea and its Salts.”

Dr. Baskin brought with him a sample of the urea for the members to see.

Digitized by v^.ooQLe

NOTES AND NEWS.

573

1903 .]

He remarked that since the meeting in October last he had received a lar^e
cumber of letters from medical men throughout England. He stated that he did
not know of any asylum—except the Devon County Asylum—where urea was
being administered.

With regard to its administration he said the process was very clear, and was
described very simply in his paper of October last. Pure urea was the best
form to administer on account of its more pleasing taste and rapid solubility in
ordinary media, water, etc., at ordinary temperatures.

With regard to results, he spoke of a few cases which had occurred at the
Devon County Asylum; in two instances he was sorry to say death had resulted,
but these patients were very far advanced in consumption. He thought that when
urea was going to be administered it would be better to sdlect the cases; in such
conditions he thought the results would be satisfactory.

In conclusion he affirmed that it was perfectly clear that if experiments were
not made no advance could be gained, and he suggested that his paper should
receive their consideration.

The Chairman moved, and it was seconded and carrried, that a vote of thanks
be accorded Dr. Baskin for his able paper.

Dr. Bbnham contributed a paper entitled “ Remarks on Suicides in Public Asy¬
lums ” (see page 447). *

Dr. J. V. Blachford contributed a paper on “ The Frequency of Occurrence
-of Granular Ependyma in General Paralysis (see page 483).

Professor Fawcett spoke of the great importance of the subject, and of the
desirability of following up the matter, and expressed a hope that Dr. Blachford
would carry his work very much farther, and he felt sure that by doing so it would
result in great credit to the institution.

Dr. Bullen congratulated Dr. Blachford on his excellent paper, and trusted
that he would prepare, at some future date, another paper on microscopic inves¬
tigations, which would be a most interesting subject.

The Chairman said that a valuable subject had been opened up, which he
hoped they would not allow to drop.

At the conclusion of the meeting the Chairman said they all regretted to hear
that Dr. MacDonald had been so ill and thoroughly run down. He could fully
appreciate his position, because last year he himself was in a similar state of
health. He understood that Dr. MacDonald was going to Switzerland, and he
^trusted that he would come back with all his old energy and vigour restored.

Dr. Eager returned thanks, on behalf of the meeting, to the Chairman for his
generous hospitality.

The members ana visitors dined together in the evening at Stuckey’s Restaurant,
Bristol.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held at
•Cheddleton Asylum, Leek, on the 30th April, 1903. Dr. Menzies occupied the
•Chair.

Members present: Drs. McLeod, Macphail, Miller, Menzies, Bedford Pierce,
Rice, Rambaut, Sheldon, Torney, Trevelyan, and Hitchcock.

Visitor: Dr. F. Edwards.

The minutes of the previous meeting were read and confirmed.

Dr. Miller proposed that Dr. Bedford Pierce should be recommended to the
Council to succeed Dr. Hitchcock as Hon. Sec. to the Division, and expressed his
regret that Dr. Hitchcock should have been obliged from ill-health to resign
office. Dr. Bedford Pierce was unanimously appointed, and expressed his thanks
to the Division for electing him. At the same time he asked for their cordial
support, in order that the Division should continue to be a success.

Dr. McDowall, of Morpeth, having kindly invited the Division to his asylum
for the October Meeting, the invitation was cordially accepted, and the Secretary
was requested to endeavour to arrange the meeting for the first or second Friday
an October.

Digitized by v^.ooQLe

574

NOTES AND NEWS.

[J»iy,

Communications.

Dr. Trevelyan, Leeds, then read a paper on "The Permanence and Value of
* Dry Brain * Preparations,” and he showed specimens. He expressed his pre¬
ference for those preserved by Laskowsky’s method.

In the ensuing general discussion Dr. Menzies expressed the great obligation of
the Association for the most interesting and instructive paper and exhibits. Dr.
Menzies asked whether these dry specimens were of equal value to plaster casts
of fresh brains, and whether there was likely to be unequal shrinking in the
process of drying.

Dr. Trevelyan replied that the shrinking was equal and general, and that he
found real specimens which could be handled and pulled about were preferable
to casts, especially for teaching purposes, as the student so obtained a much more
memorable impression.

Dr. Rice showed a pathological specimen of a remarkably large aneurism of
the cerebral artery, and gave a very interesting description of the clinical features
which the case had presented during life.

The meeting closed with a hearty vote of thanks to the Chairman for presiding,,
and for his hospitality to the members.

THE INTERNATIONAL MEDICAL CONGRESS AT MADRID.
Section of Neurology, Mental Diseases, and Criminal Anthropology.

The meetings of this section were held in the Royal Library and Museum under
the presidency of M. Jos£ Maria Esquerdo y Zaragoza. A small room, in which
were placed glass cases containing ancient manuscripts, was assigned to this
section, and it was necessary to pass through a room occupied by another section
in order to reach it. However, there were no paintings on the walls, as in some
of the rooms devoted to the sections, to distract the attention. The first meeting
took place on Friday morning, April 24th, when the president took the chair at
nine o’clock. According to the general programme, which was handed to each
member, ten reports and sixty-six communications were to be read, but it was
impossible to carry out this arrangement, as there was not sufficient time allowed
for it. No meetings were held on three afternoons; the reception by the King at
the Palace on Friday, the Municipal Garden Party in the Buen Retiro Park on
Tuesday, and the Royal Garden Party in the Palace Gardens on Wednesday took
place about three o’clock, and, as every member of the Congress wished to attend
these functions, it was of no use having a meeting of the section. In addition,
Dr. Julian Calleja, the President of the Congress, wished to show the institution
for epileptics of San Jos£, which will be described later on, to as many members
as possible, and the excursion there was fixed for Monday afternoon. Thus there
remained only five mornings at which papers could be read from nine to twelve
o’clock and one afternoon, and the consequence of this was that many papers had
to be taken as read. One great defect in this, as well as in other sections, was
that no notice was put up stating the subject of the paper that was being read
and the name of the author, so that, especially when the reader of the paper was a
Spaniard, it was impossible to find out what was going on. Every day a journal
was published giving the names of the papers that were to be read in the different
sections, but as they were not always taken in the order in which they were
printed, much confusion was created.

Of the ten "reports,” which were considered of more importance than the
"communications,” the most interesting were those (1) by M. Bianchi, of Naples,
on a " Centre of Projection and Association in the Brain according to the Deter¬
minations of Actual Pathological Anatomy;” (2) by MM. Martinez and Lombroso,
of Turin, on " The Intervention of Psychiatry in the Reformatory Treatment of
Delinquents; '* (3) by Dr. Galiana, of Madrid, on " Toxic and Infectious In¬
sanities ; ” and (4) by Dr. Pregowski, of Heidelberg, on " The Affection described
sometimes as Periodic Neurasthenia, sometimes as a Circulatory Psychosis.”
Eleven authors had sent abstracts of their papers in French, and these were
printed and arrived about eleven o’clock on the first morning on which the section
met. Dr. Galiana gave the conclusions at which he had arrived with regard to

Digitized by v^,ooQLe

NOTES AND NEWS.

575

1903 .]

mental degeneration and alcoholism, and respecting syphilitic insanity. Under
the latter heading he considered the relation of syphilis to general paralysis, and.
said he was of opinion that general paralysis was not caused by syphilis. The
only ground for his opinion seemed to be that he had seen cases of this disease
in which there was no history of syphilis. Dr. Pregowski believed that the-
affection which he described was due to pathological modifications of the circu¬
latory system, and more especially to spasm of the cutaneous vessels.

It is impossible to mention all the “ communications,” but some of them may
be briefly noticed.

Dr. Sutherland, Deputy Commissioner of Lunacy in Scotland, read a paper,,
which was illustrated by maps and diagrams, on the “ Geographical Distribution
of Lunacy in Scotland and Ireland.” He thought that so many imbeciles under
five years of age dying of neglect, injudicious feeding, and infectious disease in
urban and rural areas accounted for the different ratios of insanity which pre¬
vailed in those areas. In the urban districts the ratio was 30 per 10,000, and in
the rural districts 90 per 10,000. The mortality of children under five years of
age was the reverse of this, being three times as great in urban as in rural
areas.

Dr. Gutzmann, of Berlin, read a paper on “ Neurasthenia and Troubles of
Speech,” the latter being divided into (1) loss of memory and loss of the faculty
of association of ideas, and (2) spasm or ataxy of the motor part of speech. The
first class improved under the general treatment of neurasthenia, but the second
must be treated by special exercises.

Dr. Lemos, of Oporto, read a paper on “ The Evolution of Delirious Ideas in
some cases of the Anxious Form of Chronic Melancholia.” Sometimes this form
of melancholia turned into a special form of secondary paranoia, with ideas of
negation, immortality, enormity, and grandeur, but the psychological processes in
these delirious conceptions were not apparently always the same. Sometimes the
ideas of immortality, of enormity, and grandeur of anxious melancholia closely
approached the hypochondriacal delirium and negation which is ordinarily
observed in these patients.

Dr. Manuel Iglesias y Diaz, of Madrid, read a paper on “ Pseudo-Criminal
Lunatics in Spain,” that is, persons who are insane and are guilty of legally
punishable acts or omissions, and persons who become insane while before the
courts or after conviction. About one fourth of the 472 cases which had occurred
during the last five years were given up to their friends as guilty of minor offences,,
and the remainder were required by law to be kept in the ordinary lunatic asylums.
There were, in the author's opinion, objections to this practice, and he preferred
to have lunacy pavilions attached to prisons.

Dr. L. von Frankl-Hochwart, of Vienna, contributed a paper on “ Pseudo¬
sclerosis,” and gave the history of a case which he had watched for eleven years.
The patient, a man aged forty-two years, died of cancer of the stomach. At the
autopsy the only lesion of the brain and spinal cord was the existence of a con¬
siderable number of granulations of Pacchioni. The author did not believe in the
opinion held by the Charcot school that pseudo-sclerosis was a manifesta¬
tion of hysteria. Pseudo-sclerosis resembled multiple sclerosis in many ways,,
but several symptoms which frequently occurred in the latter disease were
very rare in the former affection. Mental affection, however, was often very
marked in pseudo-sclerosis.

Dr. Fletcher Beach read a paper on the “ Care and Treatment of Epileptics
in England.” The author said that although epilepsy had existed from the time
of Hippocrates, the first institution for the colony treatment of epileptics in
England was only built fourteen years ago. There were two classes of cases
to be cared for in asylums or colonies, the insane and the sane epileptics. He
passed in review the dispositions made by various authorities since 1874 to-
ameliorate the condition of the insane epileptics, and described the measures
which many authorities propose to take in order to care for and treat them.
With regard to the latter cases, he described the institutions at |Maghull and
Godaiming, Surrey, and the colony for epileptics at Chalfont, to which he was
one of the physicians, and mentioned that another colony for the care and treat¬
ment of sane epileptics was in course of erection by the Lewis trustees at Chelford,.
Lancashire. Dr. Bower, who was present, discussed this paper.

Digitized by v^.ooQLe

576

NOTES AND NEWS.

Duly,

On Monday afternoon a visit was made to the San Josd Institution for poor
epileptics who are not insane, imbecile, nor idiotic. It is situated some distance
from Madrid on a large table-land, a considerable height above the level of the
.sea. It was founded by the Marquis of Vallejo, who gave a large part of his
fortune in order to buila an institution for epileptics in memory of his son, who
'died of epilepsy. The institution consists of eleven pavilions, five of which are
used respectively as an administrative block, a chapel, a home for the monks who
attend to and, if necessary, nurse the epileptics, a kitchen, and an infirmary, to
which is attached an operating theatre, which was fitted up with the most modern
appliances. The dispensary contained drugs of all kinds, not only for the treat¬
ment of epilepsy, but apparently for all kinds of diseases. Of the other pavilions,
two are for boys, two for young men, one for those of faulty habits, and one
for dangerous cases. In two of the pavilions there were schools and workshops,
and in the basement of another there was a gymnasium. The institution is
intended to accommodate 120 male patients, but at present there are only 55 in
residence, some of whom are boys. The pavilions are separated from one another
by plantations, but an unnecessary feature of the institution was a very high wall
which surrounded the pavilions. In England this is not considered necessary,
and as no patients were to be admitted if insane, imbecile, or idiotic there appeared
to be no reason for it. The patients seemed to be well fed, and were happy and
contented.

On the same evening the President of the section, who is the proprietor of the
Maison de Fous, gave a banquet to the members of the section in the dining-hall
•of the institution. It is not, as may be imagined, an asylum for idiots, but a
private asylum for the treatment of the insane. Bread is made in the establish¬
ment, and the cattle are put to death in a slaughterhouse fitted up for the purpose.
Dr. Esquerdo possesses vineyards, and makes the wine which is used by himself
and the patients. The writer of this notice had no opportunity of seeing the
wards and dormitories, but he was informed by Dr. Macdonald, of New York, that
the arrangements made for the patients were much inferior to those in use in
English and American asylums.

The members of the Association may be pleased to hear that three of their
number were made Honorary Presidents of the section. Dr. Wiglesworth, our
President, whom the papers persisted in calling Ugihiwerth, or some such name,
was elected an Honorary President at the commencement of the work of the section,
Dr. Sutherland was elected and took the chair after reading his paper, and Dr.
Fletcher Beach was elected on the concluding day, and took the chair for two
hours until called on to read his paper. During the time he occupied the chair,
among other papers that were read two were by Americans, Dr. Hughes, of St.
Louis, and Dr. Hoppe, of Cincinnati; the former’s paper was entitled " New Views
of the Virile Reflex,” and the latter’s “ A Contribution to the Study of the Cortical
Origin of Disturbances of Sensation.”

SUPERANNUATION ALLOWANCES FOR SCOTTISH ASYLUM

WORKERS.

Memorandum submitted by the Scottish Division of the Medico-
Psychological Association of Great Britain and Ireland.

1. Provision has been made by the Legislature for the granting of Super¬
annuation Allowances to the Officers and Servants of the County and Borough
Asylums in England. (53 Viet., Ch. 5, Sect. 280, 281, and 282.)

2. Similar statutory provision has been made in the case of the District
Asylums in Ireland. (53 and 54 Viet., Ch. 31; also Loc. Gov. [Ireland] Act,
1898, Sect. 83 [13] and Sect. 84 [13I).

3. The Directors of the Chartered Asylums in Scotland are also empowered to
grant Superannuation Allowances. (29 and 30 Viet., Ch. 51, Sect. 25.)

4. In other departments of the public service generally the Superannuation of
Officials is provided for.

Digitized by v^.ooQLe

NOTES AND NEWS.

577

1903 .]

5. In the Scottish District and Parochial Asylums alone no Superannuation
Allowances are obtainable by the Officers and Servants, however Ion? and
meritorious their services may have been, or however much they may be in.
capacitated by injury, ill-health, or other conditions arising from the nature of
their employment.

6. The Officers and Servants of the Scottish District and Parochial Asylums
have exactly the same kind of duties to perform, and they run the same risks a*
the employees in other Asylums.

7. Of all public employments, Asylum service is the most anxious and re¬
sponsible, and the most dangerous to the health of both body and mind.

8. The omission from the Scottish Lunacy Acts of a satisfactory scheme of
Superannuation Allowances for the Officers and Servants of the District and
Parochial Asylums entails a peculiar injustice on a highly important body of
public servants, for which they receive no compensation in the shape of higher
salaries and wages r or otherwise, their remuneration being such as to render it
quite impossible for them to make adequate provision for old age or infirmity.

9. This exceptional and anomalous treatment of Scottish Public Asylum
workers is not only grievously prejudicial to these individuals, but it is also
opposed to public policy and detrimental to the best interests of the insane. It is-
in the highest degree necessary, for the efficient and successful administration of
our Asylums, for the protection of the insane and the promotion of their welfare
and cure, to secure and retain the services of the best possible officials, and to do
all that is reasonable to remove any cause of discontent and restlessness. It
cannot be expected that such persons will be induced to take up and continue in
a line of wort, in itself in many ways repugnant, unless terms are offered to them
at least as good as those obtainable in other Asylums and in other public depart-
ments, which draw their recruits from the same class of people. As a matter of
fact it is found extremely difficult to obtain the services of persons possessed of
the qualifications requisite for the proper care and treatment of the insane, whilo
the number of the changes which take place annually in the staffs of the Asylums
is deplorable. It is believed that this very unsatisfactory state of matters is-
largely due to the fact that in the Asylums in question the employees have no
prospect whatsoever of receiving annuities when they retire, worn out by the
exacting duties of their calling, or incapacitated by the various accidents to which
it renders them liable. The General Board of Commissioners in Lunacy for
Scotland have frequently referred to this matter in their Annual Reports, and
they have pointed out how prejudicial these frequent changes are to the interest*
of the patients in the Asylums. The General Board have long been, and still
are, in favour of the provision of a scheme of Pensions for all Scottish Public
Asylums.

10. Members of Parliament are respectfully invited to give this Statement due
consideration, and they are earnestly desired to support in Parliament any
measure calculated to satisfy the reasonable claim of Scottish Public Asylum
Officials to be treated on the same principle as the Officials in English and Irish
Asylums.

Thb following Memorial was, on the i6th March, 1903, at the request
of the Parliamentary Committee, addressed by their Honorary
Secretary, Dr. Fletcher Beach, to the Secretary for Scotland.

I am requested by the Parliamentary Committee of the Medico-Psychological
Association of Great Britain and Ireland to bring before your Lordship the subject
of retiring allowances for the officers and servants of district and parochial asylums
for the insane in Scotland, and to beg your Lordship’s favourable consideration
of the following statement.

It is a remarkable fact that these officers stand by themselves in the public
asylum service of the United Kingdom in not having any prospect whatever of
eceiving annuities when they retire, worn out by the exacting duties of their
ailing, or incapacitated by the various accidents to which it renders them liable.

Digitized by v^.ooQLe

578

NOTES AND NEWS.

Duly,

In the public asylums of England and Ireland some provision for the granting
of pensions has been made by the Legislature, and similar provision has been
made in the case of chartered or royal asylums of Scotland; but in the Scottish
district and parochial asylums alone retiring allowances are not obtainable,
although the workers in these asylums have exactly similar duties to perform and
run the same risks as other asylum employees.

How trying and arduous these duties are, how numerous and serious are the
risks which they entail, must be well known to your Lordship. The nature of
asylum work is such that few can hope to continue in it for a prolonged period
without incurring the hazard of mental or physical break-down, while the workers
are also exposed to those dangerous assaults which are from time to time com¬
mitted by homicidal and violent patients. I beg to draw your Lordship’s atten¬
tion to the following extract from the Report of the Select Committee of the
House of Commons on Lunatics, 27th July, i860*.

“ It would further seem desirable to reduce the time at which committees of
visitors may grant superannuation allowances to their medical officers. Their
•duties are so peculiar, and such painful consequences are known to result from
incessant intercourse with the various forms of this distressing disease, when pro¬
longed for many years, that your Committee believe it would tend to greater
efficiency if the period which stands at present at twenty years were reduced to
fifteen.” Although this recommendation is confined to medical officers, it is
applicable with equal force to all others employed in the care of the insane.

Your memorialists venture to think that no argument will be required to con¬
vince your Lordship that the anomalous condition under which the great majority
of Scottish asylum officials labour amounts to a grave injustice.

While this actual and relative injustice to a large body of individuals engaged
in the public service appears of itself to call for a change in the law, it is urged
that the interests of the community in general, and of the insane in particular, are
likewise involved on the following grounds. Public economy demands that our
asylums shall be so served as to secure the speedy and effectual recovery and
restoration to civil life of all persons suffering under mental disorder to whom
recovery is possible. Public sentiment insists on the care and treatment of all
insane persons being conducted on lines which call for exceptional tact, intelligence,
and temper on the part of the guardians of this afflicted and helpless class. It is
obviously necessary that everything possible, that is fair and reasonable, should
be done to obtain and retain the services of persons possessing these peculiar
qualifications. In private administrations, which require special services, the first
and principal step taken to attract suitable employees is to offer terms in advance
of, or at least equal to, the average. In all other departments of public employ¬
ment candidates are attracted and their services secured by the prospect of
receiving more or less adequate retiring allowances. It may be said, without fear
of contradiction, that no public employment is in its nature less attractive than
the service of our public asylums, and that in no other service are the duties so
frequently repelling or so dangerous to the health of both body and mind; while
it is certain that the scale of wages and salaries at present being paid, or likely to
be paid in the future, in the Scottish public asylums will not allow of their
recipients saving out of them an adequate provision for old age or infirmity. The
consequences of this prejudicial and imprudent treatment of Scottish asylum
servants are easily discernible. Apart from the injustice from which many old
and faithful servants have suffered and are suffering, it is found extremely and
increasingly difficult to secure the services of persons fit to be entrusted with the
responsible care and treatment of the insane, and the number of changes which
take place in the staffs of the asylums every year is deplorable. The General
Board of Commissioners in Lunacy for Scotland have repeatedly referred to this
matter in their reports, and they have pointed* out how prejudicial these frequent
changes are to the interests of the insane. It is evident that they must be so, and
•every one acquainted with asylum administration knows how disastrous the results
have been.

It is respectfully submitted that the omission from the Scottish Lunacy Acts of
a satisfactory scheme of retiring allowances for the officers and servants of district
and parochial asylums is detrimental to the efficient administration of these
institutions, is prejudicial to the best interests of the insane, is inconsistent with

Digitized by v^.ooQLe

NOTES AND NEWS.

* 903 -]

579

sound financial policy and public sentiment, and entails a grievous injustice upon
a highly responsible and important class of public servants.

Your memorialists are conscious of the difficulties which stand in the way of
•effecting any statutory change such as is here suggested, but they feel confident
that if their views have your Lordship's sympathy and support these difficulties
will not prove to be insuperable. The addition or alteration of a few words in the
•existing statute would secure all that is now craved.

Trusting that your Lordship may find it possible to give a kindly consideration
to this statement as made on behalf of a body which is peculiarly entitled to
speak from knowledge and experience, I am, etc.

ASYLUM WORKERS' ASSOCIATION.

The Annual Report for 1902 shows that for the twelve months ending the 31st
December, 1902, the membership comprised 119 Life Members, 119 Associates,
and 4664 Ordinary Members, making a total of 4902, as compared with 4116 on
the roll of 1901.

The Executive Committee point out that, on the strong recommendation of the
sub-Committee on “ Medals," they have been compelled to increase the minimum
length of service for competitors for gold medals to thirty-five years instead of
thirty as originally proposed, and for silver medals to thirty years instead of twenty-
five.

This change has proved necessary in consequence of the unexpectedly large
number of entries at the lower periods of service.

In accordance with a suggestion thrown out by Sir James Crichton Browne in
his address at the annual meeting, a Reading Union has been established for the
members, under the supervision of a sub-committee, who have drawn up a code of
rules which it is hoped may be the means of placing the “ Union " on a firm and
permanent basis.

The “ Homes of Rest" fund has aided seventeen applicants during the year,
and the whole report shows that the Association is vigorous and flourishing.

LUNACY ADMINISTRATION IN VICTORIA.

Reference has frequently been made in these columns to the maladministration
of the Lunacy Department in Victoria, chiefly owing to the division of authority
and political interference. Thirty years ago a commission of Inquiry recom¬
mended that the asylum staffs should be placed on a different footing from the
other civil servants. Twenty years ago a similar recommendation was made by
a Royal Commission, and every board of inquiry since has repeated the advice.
Nothing has been done, however, and recently matters have culminated in a most
complicated “ asylum scandal," as the newspapers term it, and monstrous instances
of political defiance of official experts. In April last one of the medical officers
at Kew Asylum, whose name has been most mysteriously withheld, suddenly
absented himself without leave and was found in a private hospital. His in¬
capacity for his responsible position had been for some time apparent to his
superior officers. He was granted three months' leave with the understanding
that he would resign at the end of that time. When that time came, however,
the Chief Secretary (the Minister at the political head of the Department) ordered
him back to duty. The Inspector-General (Mr. J. V. McCreery) protested, and
the Chief Secretary then suggested that the officer in question should be examined
by a board of medical men. The inspector agreed to this, but the officer objected
to the personnel of the suggested board, and the Chief Secretary finally asked
Dr. Jamieson and Dr. Joske to report as to whether the officer was fit for duty.
These two gentlemen are paid official visitors to asylums; it appears, however,
that they were not asked to report in their official capacity, but to send in a

Digitized by v^.ooQLe

NOTES AND NEWS

580

[July,

confidential report for which they were specially paid. There is a third official
visitor, Dr. J. W. Springthorpe, but it appears the officer to be examined objected
to him. Dr. Jamieson and Dr. Joske reported that the officer had suffered from a
nervous break-down brought about by indulgence in alcohol, chloral, and other
drugs, but that he had now recovered and might be returned to duty in a less
responsible position. The Chief Secretary then, in spite of the inspector's further
protests, gave a written direction that the officer was to be placed on duty as
senior medical officer at Yarra Bend—the other large metropolitan asylum—and
in just as responsible a position as at Kew. At this stage the inspector (Mr.
McQeery) became ill and went on leave, and Mr. W. Beattie Smith became
acting inspector. Dr. Springthorpe, hearing of the circumstances, determined to
exercise the powers invested in him as official visitor by the Lunacy Act, and to
institute an inquiry. The Act empowered him to compel the attendance of
witnesses and to examine them on oath. At the inquiry he summoned Dr.
Jamieson and Dr. Joske to give evidence. They protested, and insisted on taking
their seats as members of the board of visitors, and asking questions of the
witnesses. They both declined to give evidence. As the result of a prolonged
inquiry Dr. Springthorpe found that the officer was placed on duty by the direct
order of the Chief Secretary against the strong protests of the inspector, the acting
inspector, and the acting superintendent of Yarra Bend Asylum. No such officer
should under any circumstances be in medical charge of patients such as the
insane, and the one position that should be absolutely closea to such a man was
that of medical officer in an asylum. In the course of his inquiry Dr. Spring¬
thorpe applied to the Chief Secretary for a copy of the report by Dr. Jamieson
and Dr. Joske, and was informed by that gentleman, “ I have made full inquiries
into, and finally dealt with, the matter/ 1 and the request was refused. At this
stage the papers dealing with the case came before Mr. Smith officially in his
capacity of acting inspector. Just before going on sick leave Mr. McCreery had
intended to lay a charge against the officer, but had not done so. Mr. Smith felt
that it would be futile to lay a charge, as the evidence upon which the charge was
to be laid had already been placed before the Minister, and the latter had, to use
his own words, " finally dealt with the matter/ 1 and was not likely to stultify himself
by sending the case on to the Public Service Commissioner, and it was at his option
to do so or not. Mr. Smith accordingly wrote a memorandum asking the Minister
to reconsider the evidence or to consider his (Mr. Smith's) retirement, as he felt
that it was impossible to insure proper administration if the medical officer referred
to should remain on duty. It should be stated that Mr. Smith has been twenty years
in the service, is not entitled to pension or compensation, and in the ordinary course
of promotion by seniority would in a few years have reached the highest position
in his department. He is regarded by the whole profession as the ablest man in
the lunacy service, a most capable administrator, a strict disciplinarian, and a
thorough expert in insanity. He is also the clinical lecturer on tne subject at the
university. The Chief Secretary replied that, as Mr. Smith failed to grasp the
legal position in respect to laying a charge and wished the Minister to adopt an
improper course of procedure, he must accept his resignation. The press and the
profession are unanimous in protesting against the Minister’s action, but there the
matter rests at present, and Mr. Smith is dismissed and the officer retained.—
From the Lancet , October 18th, 1902.

The state of affairs at the metropolitan asylums at Melbourne remains sub
judice. The Minister informed Dr. W. Beattie Smith that the executive council
had accepted his (Dr. Smith’s) resignation, and Dr. Smith replied that the official
correspondence showed that while he sought to have determined the question of
whether the service should be properly conducted or whether the terms of his
retirement should be considered he had not actually tendered his resignation.
" At the same time,” he said, “great as is my interest in the special work to which
I have devoted nearly the whole of my professional life, I have no desire to press
my services on the State nor to hold office without the confidence and support
which are essential to the proper fulfilment of its duties.” The executive council
appointed Dr. J. A. O’Brien, the Government medical officer, as acting inspector-
general of insane in place of Dr. Smith. Dr. O’Brien immediately suspended Dr.

Digitized by

Google

NOTES AND NEWS.

581

1903.]

Stuart Macbirnie, " the medical officer,” for alleged misconduct, and drew up a
series of charges against him, according to the provisions of the Public Service
Act. The Public Service Commission then appointed a board with a police
magistrate as chairman to investigate the charges. The board has held several
meetings, at which Dr. Macbirnie has been represented by counsel. Very much
the same evidence has been given as at the inquiry held by Dr. J. W. Springthoipe.
Dr. Macbirnie’s counsel at the outset accused the chairman of the board of bias,
and stated that there was conspiracy on the part of Mr. McCreery, Dr. Smith, Dr.
Mullen, and others to put Dr. Macbirnie out of the service. The charges against
Dr. Macbirnie were to the effect that on April 21st last he was under the influence
of liquor and unfit for duty; that he had created a disturbance in the precincts of
the asylum; that the use of alcohol or drugs, or both, by him had necessitated
prolonged leave of absence; that he had absented himself from duty contrary to
the request of the superintendent on April 23rd last; and that his conduct was
subversive of discipline.—From the Lancet , December 6th, 1902.

Dr. Stuart Macbirnie has, we are informed, since resigned.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

Seven hundred and sixty-six candidates applied for admission to the May
examination for this certificate. Of this number 174 failed to satisfy the examiners,
fifteen withdrew, and the following were successful:

England.

Bucks County .—Lily Mary Thorp, Annie Goss, Lily May Welford. Charles
Watson, Albert Edward Collins.

Cumberland and Westmorland.— Maggie Mackie, Mary Ellen Currie. Walter
Part, George Howe, Leonard Aynsley, James Reid.

Derby County .—Hannah King. Thomas Devaney, Arthur Litchfield.

Devon County. —Annie Mary Harford, Edith May Bright, Edith C. Crouch,
Fanny Fry. Joseph Foxall, James Charles Teague.

Durham County. —Kate Adelaide Smyth, Elizabeth Alma Carter.

Essex County. —Annie Carr, Emily Elizabeth Miller, Florence Simonds, Wini¬
fred T. Williams.

Kent County , Barming Heath. —Mercy Scutt, Clara McAlister, Kathleen Naomi
Hussey, Margaret Miller. Ralph Joseph Humphrey.

Kent County , Chartham Downs. —Florence Brown. John Glanville Kellow.

Lancaster County , Rainhill. —Alice Hollerton, Florence Peach, Agnes Annie
Peace, Carrie Busby, Emily Margaret Alderson, Ellen Pascol, Florence Hastings,
Margaret Jane Williams, Florence Mary Baldrey, Edith Lilly Johns. Herbert
Deakin, Ellis Suttin, William Thomas Saunders, William Henry Thomas, Walter
Davis, George Richardson, John Richard Howden, Arthur Edwin Herbert, George
Wilkes, James Humphreys, John Joseph Lewington, Harry Helliwell, Walter
Lewindon, Arthur Page, Samuel Marriott.

London County , Banstead. —Frances Alice Crabb, Edith Maud Nutheen, Eva
Harris, Laura Higton, Alice Mary Hoskins, Edith Maria Osborne, Agnes Law¬
rence Waterman, Katie Bracey, Ada Jeffrey. Allan Pring, George Lawrence,
Evan Jarvis, Arthur Ernest Smith, Joseph John Massara, James Jordan, Tom
Christian, Richard James Hyder, WiUiam Roby George.

London County, Bexley .—Ethel Grace Allen, Margaret Coleman, Elizabeth
Crompton, Ethel May Mumby, Rachel Gage, Mary Agnes Carrigan, Caroline
Elizabeth Ford, Edith Widdop, Caroline Nixon, Ethel Beatrice Fuller, Elizabeth
McQuade, Florence Louisa Joscelyne. Thomas Sharp Treweeke, William James
Millard, Thomas William Stainsby, Edmund Baker, Charles William Lodge,
Harry Dyson, Herbert Stanley Berry, Sydney Allen, William Charles Jose,
Edmund Stanley Burch, Ernest Henry Valentine, Edwin John Hill, William

XLIX. 40

Digitized by v^.ooQLe

NOTES AND NEWS.

582

Duly,

Hunt, George Poffiey, Albert Victor Self, Albert Edward Brian, Frederick
Charles Cannon.

London County , Cane Hill .—Emily Hart. Reginald Best, James Townsend,
James Irons Andrews.

London County , Claybury. —Georgina Tuft, Margaret Ellen Moore, Tattie
Owen, Margaret Garriy, Constance Haste, Harriett Hailes, Beatrice Mary Cathe¬
rine Bracken, Rosa King, Edith Blanche Read, Janie Lander. William Charles
Cook, John Henry Shuman, Howard Talbot, Walter Charles Lamb, Robert
Almond Bryning, Albert Hayward, Joseph Doran, Charles Curtis Haylock.

London County, Hanwell. —Helena Wickles, Mary England, Ada Castle,
Florence Alice Evans, Edith Jane Ingram, Amy Grove, Emilie Mary Mannock,
Edith Castle, Edith F. Holdaway, May Higgins, Edith Annie Johnson, Harriet
Robins, Nellie Agusta Spencer, Rose Ed line Rose, Eliza Creed.

London County , Epsom.— Annie Rayment, Lizzie Tillett, Alice Yuill, Gertrude
Louisa Abbott.

Middlesex County .—William David Roskilly, Maurice Donoghue, Frederick
William Mawson.

Northumberland County .—Christopher Fairs, Richard Richards, Patrick Malloy,
William Thomas English, Matthew James Meynell. Florence Heslop, Mary
Baker, Rits Marion Bunton, Hannah O’Hanlan.

Oxford County. —Charlotte Emma Brain, Mary Buckingham, Mary Nelson,
Edith Alice Draper, Eleanor Ade, Agnes Jennings, Alice Beatrice Kirby, Mary
Ellinor Washington, Kate Nelson, Lydia Jane Buckingham.

Salop and Montgomery.—Emm*. Whootton. Edward William Craggs.

Stafford County, Bumtwood. —Frances Helen Glover. William James Perry.
Adeline Perry, Annie Wall.

Stafford County, ChedcUeton. —Alice Campbell Denman.

Suffolk County. —Elizabeth Annie Fuller, Alice Gertrude Bloomfield, Agnes
Louisa Spooner, Annie White, Emma Clara White, Doris Annie Sharpe, Jennie
Hines, Ethel Maud Greenard. Joseph William Verity, William Thomas Barrows,
William Hewitt, Thomas Houghton, William Munson. Helen Florence Watkin-
son. Harry Robert Rogers.

Surrey County, Brookwood. —Sarah Jane Day, Hannah Earnshaw, Catherine
Matthews, Lucy Palmer, Florence Mary Smith, Sarah Edith Myatt. William
Ayling, William Cummins, Harry Gardiner, Thomas Huntingdon, Frederick
George Knott, George Ledger, Frank Nash, George Edwin Page, Ernest Robert
Witthames.

Sussex County, Haywards Heath .—Alfred Bristow, Edward Cottingham, Harold
S. Heaney, Richard Tanner.

Sussex County, Chichester. —Isabella Rogers, Ellenora Letitia Best, Mary Ann
Ward, Ruth Rollins, Ellen Bertha Kent. Thomas Kerslake, Robert James
Bucknell, Harry George Munt, Frank Pearson, Walter Melmoth, James Newell.

Warwick County. —Martha Jane Thomas, Jessie Dicken, Emma Elizabeth
Crooke, Rosetta Reader, Florence Agnes Hughes, Fannie Bottrell. Robert
Cowley, Francis James Bradnock, Alfred Buckingham.

Wilts County. —Ernest Groves, John Wheeler, Richard Alexander, Charles
Sims, Thomas Russ, Edward Weston.

York, North Riding. —George Charles Childs.

York, West Riding, Menston. —Mary Ellen Dobson, Lizzie Moody, Nellie
Charlton, Elizabeth Jane Keena, Jane Tyreman, Laura Hart, Mabel Charlton,
Annie Elizabeth Robinson. Ellis Broadley, William Henry Beaumont, Joseph
Gathorne Stansfield, William John Robinson, Evan Broadley, George Blackburn.

York, West Riding, Wadsley. —Hilda Worrall, Mary Ellen Stewart, Ada Col-
graves, Constance Ethel Bass. Patrick Long, Frederick Swallow, Harry Barter,
Frederick Catterall, John Hutchinson, James Moxon.

York , West Riding, Wakefield. —Lilian May Hartley, Sarah Ann Hoyle, Marion
Hobbs. Benjamin Warcup, George Portas, Harry Kirkup, William Appleby.

Derby Borough. —Martha Anderson. Frank Hodkinson, Edward Newham
Holland, Benjamin Hardy.

Plymouth Borough. —Sidney Penney, Ernest George Burton, John Hooper
Bertie Wilberforce Casely.

Digitized by v^.ooQLe

1903-] NOTES AND NEWS. 583

Sunderland Borough. —Frances Knott, Jane Forster. William Allen Grant
McHardy, George Brown, Abraham Manning.

West Ham Borough. —Susan Richardson, Alice Hannan, Gladys Madeline Read,
Mary Phelemena Walts. Albert Charles Bird, Nelson Ellis, Walter William
Winchester, George Jacklin.

Birmingham City % Winson Green. —Rose Ellen Elton, Clara Jackson, Lydia
Ellen Fitzhugh. Leonard Corfield, Thomas Perry.

Bristol City. —Harry Davis, Alfred Summers. Eleanor Rutherford, Florence
Henrietta Flook, Minnie Coles, Harriet Gardner, Lily Florence Warfield, Delia
Agnes Kelly.

Exeter City .—Emily Annie Warren, Alice Marion Warren.

Hull City. —Elizabeth Ann Pearson, Anne Grainger, Ada Mary Rogers, Kate
Epton. James Warren.

Newcastle City. —Sarah Wray, Catherine Melvin. Robert Clavering, William
Parker, George Alfred Smith.

Notts City. —Amy Wood, Lucy Ball, Minnie Kate Trewavas, Gertrude Till,
Mary Elizabeth Moulds. Charles F. Taylor.

Caterham. —Benjamin Bucknell, John William Woodall, George Carey, Henry
Lewis, Frederick Bungay. Sophie Coe, Minnie Homewood, Rosanna Flood,
Artis Alice Lloyd, Dorcas May Wood.

Leavesden .—Annie Goodwin, Helena Hannah N. Blumberg, Gertrude Maud
Johnstone, Mary Sarah Winfield. Charles Ridgway, Sydney Frank Allan, Albert
William Pauli, Ernest Simons, Joseph Dennis, Alfred Pearce, Alfred Monk, Henry
Richardson, Joseph Garrison.

Wameford , Oxford. —Martha Bird, Amelia Beesley. Richard John Brooks.

Bethlem t Royal. —Ina Nellie Scott, Sophie Knowles, Amy Louisa Symonds,
Mary Matilda Tarr, Margaret Annie Evans, Kathleen Langley, Maud Hetty
Whitehead. Edward William Perry, Isaac B. Linton, Albert James Coston,
Frederick Herbert Andrews, George Edward Keane.

Camberwell House. —Maud Riches, Mimmie Moore.

Northumberland House. —Annie Needs, Laura Finch, Charles Thomas Brown,
Albert Blake.

Peckham House. —Ernest Arundell Harris.

Retreat , York. —Louisa Pilling Fletcher, Annie Tindle, Annie Emma Zantler,
Ethelwyn Rowntree. William Hayes.

Wood End House .—Emily Stowers, Martha Young.

Wye House } Buxton. —Duncan McRae. Mary Poulton.

Bridgend t Glamorgan. —Sarah Jane Brewer, Charlotte Burnell, Amy Sloman
Cook, Morfydd David, Helen O’Flarthy Edwards, Adelaide Francis, Adie Havard,
Mary Hearn, Ada Lean Jenkin, Margaret Alicia Jones, Annie Margaret Knorr,
Rhoda Roberts. John Cox, Edward Howard Davis, Jenan Griffiths, John
Griffiths, Michael Joyce, Rees Lewis, Rees Morgan, William Gilbert Price,
Charles Woolls.

Abergavenny. —Emily Ann Evans, Charlotte Gratton. Alfred Davies, Frederick
Thomas Hill, Thomas Nauncey, James Lawrence, George Meredith, William
Thomas.

Ballinasloe .—Anne Mulvey, Mary Fitzpatrick, Catherine Kelly, Mary Anne
Malane, Anne Morgan, Mary Hannon. James Callaghan, Malachy Tully,
Michael McHugh, Patrick Kelly, John Hynes, Bernard Kelly.

Cork District. —Nora Barrett, Julia Kehely, Cathleen Geraghty, Mary Anne
Callaghan, Henrietta Evans, Susanna Perratt, Mary Donovan, Hanna F. Barry.
Timothy Barry, John Kelly, William Moyinham.

Donegal District. —William Allison.

Richmond District. —Teresa Evans, Clara Stacey Willis, Mary Ann Lotterdell,
Lizzie Behan, Jane Moran, Bridget McGormack, Mary E. Ryan, Mary Ann
Wogan. Patrick Marron, Michael Matthews, John Mulligan, Patrick O'Bryan,
Gilbert Dando, Martin Kenna, Willian J. Grogan, Patrick Murray, John P.
Fogarty, Thomas Fagan, Thomas Boylan, Francis Mohan, Tim O’Leary, Andrew
Walsh.

Farnham House. —Sarah McMullan.

Highfield House. —Ellen Kavanagh.

St. Luke's Hospital. —Emily Marie Thatcher, Matilda Gertrude Rooke.

Digitized by v^.ooQLe

584 NOTES AND NEWS. Duly,

St. Patrick's Hospital, —Bessie King, Etta Foster, Lily Wisely. Michael J.
Tighe.

Scotland.

Fife and Kinross.—Mary Bryien, Robina Johnstone, Robina Cunningham,
Agness Inglis,Jessie Kinnear Morran, Rachel Hutcheson, Maggie Neilson, Margaret
Anderson. William Mitchell, George Hall, James Kidd, John Anderson, James
Wilson.

Gartloch.— Archibald McDougall, John Clarke Donald. Kate McPhillips,
Jenny Agatha Browne.

Govan District. —Mary Anderson, Charlotte Barnaby, Georgina Thomson,
Isobel Ross, Maiy Tait. John Cormack, William Mathieson, Peter Mathieson
Alexander Blaekie, James Shand, William Macrae.

Inverness. —Mildred Roberts, Jessie McErlich. Peter Stewart.

Lanark District. —Elizabeth Kelso Scott, Robina Swanson Kempen, Mary
Scott Finlay, Usa Fraser Marr, Catherine C. Morrison, Mary Stewart, Mary L.
Allen, Gracie Shepherd Kerr, Malcolm Haggart, James Martin, Owen Donnelly,
John MacEwan.

Mavis hank. —Annie Elizabeth Sutor, Elizabeth Ryrie Langland.

Midlothian and Peebles. —Elizabeth Darwood, Mary Grant, Isobella Grant
Gordon, Hugh Corsie, James McDonald, George Anderson, John Sellars.

Perth District. —Annie Heron, Gertrude Hutcheson, Winifred Cameron.

Riccartsbmr .—George Lindsay, George Leys Gibb, Robert Gordon.

Roxburgh District. —Margaret Jane Weir. William Coull.

Smithston. —Rebecca Harkness, Eliza Ann Lawrie, Dolina Morrison. David
Dinnie.

Stirling District. —Catherine Collison, Jennie Weir, Walterina Peterkin,
Caroline Geddes, Emily Potter, Margaret Milne Clark. James Hughes.

Woodilee District. —Edith M. Dickson. David McDonald, Charles McRae,
Donald MacIntyre, John Baskin, Edwin Knight. Jane Brown, Joan McPhee,
Mary Mclnnes, Christina Gibb, Maud Hannah, Isabella Paterson, Annie Maclean,
Rachel Doig, Margaret Campbell.

Aberdeen , Royal. —Elsie McDonald, Maria Scott, Annabella Thomson, Maggie
Watt Batchen, Mary Wilson, Janet Melvin, Jane Dawson Munro.

Crichton , Royal.—- -Catherine Murray, Margaret McDonald, Margaret McLeod
Sharpe, Janet Harrison, Dina Milne, Nellie Grieve Alexander, Catherine Corbett,
Annie Lawson Harper, Agnes Thorn Emslie, Jeanie Russell, Isabella Littlejohn.

Edinburgh , Royal. —Christina Robertson, Annie Gordon, Isabella Hy. Martin,
Wilhelmina Rodger Cameron, Alice Maria Milne. John Ross, Thady Gilbride,
John Duncan, John McDonald.

Glasgow , Royal. —Helen Urquhart, Agnes M. Airlie, Elizabeth Cameron, Annie
Sinclair, Catherine McVicar.

James Murray's t Royal. —Janie E. S. Morrison. Alexander Cameron, William
Keith Tasker.

The following is a list of the questions which appeared on the paper:—1. What
is the spinal column and what are its uses P Of how many bones is it constructed
and how are they united P 2. Where is the liver situated, what is its use, and what
part does its secretion play in the process of digestion P 3. Describe the structure
of the skin. What are its functions P 4. What symptoms should you expect to
find in a case of disease of the respiratory organs P 5. Mention the more common
forms of insanity, and state briefly the distinctive features of each. 6. What is a
fracture ? What is the difference between a simple and compound fracture P Which
is the more serious injury ? Why P 7. What are the chief kinds of sick diet and
why are they given P Describe the mode of preparing beef-tea. 8. What special
points woula you observe in bathing insane patients P 9. State the normal tem¬
perature of the human body ; the average rate of the pulse (a) for a man, (6) for
a woman; and mention how many times in a minute an adult, as a rule, breathes.
10. Describe carefully how you would wet-pack a patient, and state what precaution
should be taken during the time the patient is in the pack.

Examination for Nursing Certificate.

The next examination will be held on Monday, November End, 1903.

Digitized by v^.ooQLe

* 903 -]

MOTES AND NEWS.

585

Examination for Professional Certificate.

The next examination will be held on Tuesday, July 21st, 1903.

Gaskell Prize.

The next examination will be held on Wednesday, July 22nd, 1903.

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.

NOTICES OF MEETINGS.

Medico-Psychological Association.

The sixty-second Annual Meeting of the Association will be held in London on
Thursday and Friday, July 16th and 17th, 1903, at the Rooms of the Association,
11, Chandos Street, Cavendish Square, London, W., under the Presidency of Dr.
Ernest W. White. There will be a meeting of committees as follows, on
Wednesday, July 15th, under the retiring President, J. Wiglesworth, M.D.,
F.R.C.P.Lond.:

Educational Committee at noon, Parliamentary Committee at 2 p.m., Rules
Committee at 2.30 p.m., Statistical Committee at 4 p.m. The Council will meet
at 9 a.m. on Thursday, July 16th, at 11, Chandos Street, Cavendish Square, W.

The Annual Meeting will commence at 11 a.m. on Thursday, when the usual
business of the Association will be transacted.

2 p.m.—the President’s Address, after which a discussion will be opened by
A. R. Turnbull, M.D., upon "Female Nursing of the Male Insane.”

Friday, at 10 a.m., F. W. Mott, M.D., F.R.S., " Tumours of the Brain in
Asylum and Hospital Practice,” with lantern demonstration and photographs.

2 p.m.—" Clinical and Experimental Observations on Hebephrenia and Kata-
tonia,” by Lewis C. Bruce, M.D., Physician Superintendent, Perth District
Asylum, and A. S. M. Peebles, Assistant Physician, Perth District Asylum.

" A Case of Double Consciousness,” by Albert Wilson, M.D.

" Mongolian Imbecility,” by Charles H. Fennell, M.A., M.D., M.R.C.P.Lond.

[Friday afternoon papers may be taken, if time permits, on Friday morning.]

Dr. and Mrs. Corner will be " At Home ” on Friday afternoon Irom 3.30 to 7
o'clock at Brook House, Southgate, Middlesex, and invite members of the
Association and ladies. The band of the Royal Artillery will play a selection of
music.

The Annual Dinner will take place on July 16th (Thursday) at the H6tel
M6tropole (Whitehall Rooms), at 7.30 o’clock. Tickets one guinea (wines in¬
cluded).

Members are requested to notify their intention of dining to the Secretary.

On Saturday, July 18th, the President, Dr. Ernest W. White, invites members
of the. Association to luncheon at 145 o’clock, at the City of London Asylum,
Stone, near Dartford, Kent, and members are requested to reply direct to Dr.
White. The institution can be visited before or after luncheon.

South-Eastern Division. —The Autumn Meeting will be held, by the courtesy
of Dr. Rawes, at St. Luke’s Hospital, in October, 1903.

South-Western Division .—The Autumn Meeting will be held, by the courtesy
of Dr. Morrison, at the Hereford County and City Asylum, in October, 1903.

Northern and Midland Division. —The Autumn Meeting will be held, by the
courtesy of Dr. T. W. McDowall, at the Northumberland County Asylum,
Morpeth, in October, 1903.

Digitized by v^.ooQLe

586

NOTES AND NEWS.

[July, 1903.

APPOINTMENTS.

Brown, Josephine, M.B.Lond., appointed Assistant Medical Officer to the
Lincoln County Asylum, Bracebridge.

Cross, Harold R., L.S.A., Assistant Medical Officer to the West Riding Asylum,
Wakefield.

Hearder, F. P., M.D.Edin., appointed Senior Assistant Medical Officer to the
North Riding Asylum, York.

Keay, John, M.D.Glas., F.R.C.P.Edin., Medical Superintendent to the Bangour
Asylum.

rhilpott, A. J. W., M.B., Ch.B.Melb., appointed Senior Medical Officer of the
Yarra Bend Asylum, vice Stuart Macbirnie, M.B., Ch.B.Glas., resigned.

Walker, Ernest T. Leay, M.B., C.M.Glas., appointed Assistant Medical Officer
to the Warneford Asylum, Oxford.

Digitized by v^.ooQLe

THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psycho logical Association
of Great Britain and Ireland .]

No. 207 ["n'o"*! 1 . 1 *] OCTOBER, 1903. Vol. XLIX.

Part I.—Original Articles.

The Presidential Address , delivered at the Sixty-second
Annual Meeting of the Medico-Psychological Associa¬
tion, held in London on July 16th , 1903. By Ernest
W. White, M.B.Lond., M.R.C.P., Professor of Psychological
Medicine, King’s Coll., Lond.

Gentlemen, —In commencing the work of the office to
which you have elected me, I desire to convey to you my sense
of the honour conferred and of the responsibility which this
honour entails.* In heartily thanking you, I assure you it will
be my constant care to maintain impartially the rights of
members and the freedom of debate. While checking exu¬
berant verbosity, I shall endeavour to encourage useful
discussion and to expedite business at all our meetings, and
shall look to you for the support which is necessary to preserve
intact the dignity and privileges of the Chair.

For fifteen years I have been closely connected, either as
South-Eastern Divisional Secretary, Examiner, Auditor, or
member of Council and of the Standing Committees, with the
work of this Association, and am therefore fully conversant with
its requirements and aspirations. I do not, however, attribute
to this fact my election as your President, but am inclined to
deem it a mark of regard for the work done in recent years in
the public asylums of the metropolis to advance the care and
xlix. 41

Digitized by v^.ooQLe

588

PRESIDENTIAL ADDRESS,

[Oct,

treatment of the insane. Our much esteemed editor of the
JOURNAL, Dr. Henry Rayner, in 1884 was the last medical
superintendent of a county or borough asylum in the metro¬
politan area who presided over us. We are fortunate in still
retaining his valuable services.

Inasmuch as ours is an association with large vested interests,
high aims, and great responsibilities, it has occurred to me that
I can best serve those interests by addressing you to-day not
upon any special subject, as has been done on several recent
occasions—notably last year by Dr. Wiglesworth, with marked
ability,—but upon the legal and general desiderata for the
insane and those to whose care they are committed, and upon
whose efficiency their chances of recovery so much depend.

I am the more induced to take this course for these reasons.
We are near to legislative changes. There is much diversity
of opinion upon the changes necessary. We recognise that
certain sections of the law have not worked in the best interests
of our patients—nay, further, have tended in many instances
to delay their treatment and retard their recovery,—that early
treatment must be encouraged by new enactment, that effi¬
ciency in both care and treatment must be ensured, and that
abuses which have existed in the recent past must be checked
and rendered impossible in the near future.

Before, however, we discuss our requirements, we must
remember that the occasion demands a retrospect as well as a
prospect. What were the incidents of the year just concluded?
What was its scientific progress ? What were our losses by
death? The most striking incident was probably the disas¬
trous fire at Colney Hatch Asylum, whereby fifty-one lives were
lost. The facts of this calamity are indelibly imprinted on the
memories of all of us ; and a fire which occasioned the greatest
loss of life of any in the metropolis since the great fire of
1666, and coming as it did so near home, cannot fail to
engage our attention as to its cause and lessons. The pro¬
bable cause was a spark or sparks from the smoke shaft distant
about twenty-six feet from the window of the clothes room,
which might have been open at the top an inch or more at
night to prevent stuffiness, for it is the usual custom so to leave
the windows of these rooms. The stoker would fire up at
5 a.m. to get his day rooms warm for the patients and staff
at six, and the high wind blowing would carry the sparks in

Digitized by v^.ooQLe

1903.] BY ERNEST W. WHITE, M.B.LOND. 589

the direction of the clothes room, in the upper part of which
the fire was first discovered about 5.20 a.m. Now what are
the lessons this fire conveys ? They appear to be—

1. That all temporary buildings are unsuited to the insane.

2. That provisions for dealing with fires must be complete
in all our institutions, and that our fire brigades must be as
efficient and self-reliant as they can be made.

3. That all stoke-holes, furnaces, and smoke shafts at various
points in the buildings must be abolished, and live steam from
one general station used as the heating agency in place thereof.

4. That all alternative exits and escape staircases must be
systematically used by patients for their egress ; otherwise in
the event of fire the insane refuse to leave except by the door
they are accustomed to go out by.

It is a moot point whether outer doors should be master-
locked at night. I think it unnecessary, since electric bells can
be fitted which will ring when the door is opened at forbidden
hours. Before leaving this subject I must allude with pride
and satisfaction to the one bright feature in the catastrophe,
the heroic conduct and self-sacrifice of Dr. Seward and his
staff. They worked to exhaustion in their efforts to save life
and relieve suffering. We are proud of such fellow-workers
who so nobly did their duty!

The large percentage of deaths from pulmonary tuberculosis
in public asylums and hospitals for the insane has engaged our
attention during the past year. Thirty years ago, when I first
took duty in this branch of medicine, the insane were deemed
peculiarly liable to this disease ; in fact, insanity was thought
to predispose to death by pulmonary tuberculosis. To-day,
however, we recognise that this predisposition arose in the
main from defective hygienic conditions, too little cubic space
by day and night, insufficient ventilation and ill-regulated
heating, too little fresh air and exercise, uncleanly habits, and
a total absence of isolation whereby alone infection can be
guarded against. The general hygiene of our institutions has
been vastly improved in recent years, and during the past
twelve months the question of constructing or allotting suitable
hospitals and sanatoria for the isolation and proper treatment
of patients suffering from pulmonary tuberculosis has attracted
the attention of the committees of many public asylums. In
some cases temporary isolation hospitals or special wards and

Digitized by v^.ooQLe

590

PRESIDENTIAL ADDRESS,

[Oct,

grounds have been set apart for this purpose. Amongst others
the authorities of Lancaster, Warwick, Claybury, and Leavesden
Asylums in England; Woodilee, Gartloch, and the Crichton
Royal Institution in Scotland, have taken steps in this direction.
The subject is a difficult one, as the varied mental states have
to be considered (in addition to the physical condition of our
patients) in planning or allocating buildings for this purpose ;
but the action of these committees is undoubtedly in the right
direction. While discussing this matter I would draw atten¬
tion to the value of light and its health-giving properties in the
general treatment of the insane. Our day rooms should have
light on all sides. At Stone the wards are only separated by
glass screens, and we have glass panels in the upper half of
every door (single rooms included) except where contra¬
indicated. When we first introduced these in 1887 the
Committee said, " What a dreadful glazier’s bill we shall
have! ” My reply was, “ The more glass you have the less
you will have broken, because the less will be the feeling of
restraint to the patients,” and such has proved to be the case.

In the matter of artificial ventilation our inlet air-ducts in
asylums are commonly fouled by patients pushing the dibris of
food, bits of clothing, cigarette ends, etc., through the gratings.
To overcome this Messrs. Kite and Co. have made, from my sug¬
gestion, a grating for wards and dormitories removable by the
ordinary gas or shutter key, whereby access is gained to a flap
regulating the intake, and to a wire tray which catches the
dtbris mentioned, which cUbris can then be systematically
removed. The warm air can also be diverted by the nurses
from the ward below to the dormitory above, and vice versd.

The introduction of electric plant into asylums has brought
with it many advantages, and not the least of these has been
the exhaust fan ventilator. Our dormitories, formerly never
properly ventilated without draughts, are now kept delightfully
sweet at all times and cool in summer by electric fans which
extract the vitiated air from several points in each ceiling; and,
moreover, the exhaust draught can be carefully regulated by the
night staff.

The great increase in the mortality from dysentery in
asylums in recent years continued to engage attention during
1902. It is a regrettable fact that this disease has become
endemic in some of the most recently constructed institutions,

Digitized by v^.ooQLe

I 9°3-]

BY ERNEST W. WHITE, M.B.LOND.

59 1

in which it has undoubtedly been introduced by cases trans¬
ferred from other asylums where the disease existed. Thanks
to the investigations of Dr. Mott and others, we have recognised
that this endemic disease may at any time become epidemic
and communicable under conditions of overcrowding and
defective sanitation. Fortunately the attention drawn by the
register for diarrhoea and dysentery instituted by the Com¬
missioners in Lunacy will tend to check any such sanitary
defects in our buildings. Active workers in the Association
have also recently been occupied in investigating autointoxi¬
cation, the toxaemic origin of certain forms of mental disease,
and the value of antitoxic treatment—a subject which offers an
excellent field for scientific research. Many of us in years
past have been struck by the marked mental improvement in
apparently chronic cases during an attack of enteric or other
febrile disorder—an improvement, alas ! of but a temporary
nature, and attributable solely, I believe, to the antitoxic action
of the fever germs.

The splendidly equipped pathological laboratories of London
and Edinburgh, fed by the asylums of the metropolis and
Scotland respectively, continue to pursue their excellent work,
as evidenced by the Archives published last year. The
appointment of pathologists to our large institutions for the
insane, and the prominence thus given to pathological research,
is being productive of excellent results. Combination in patho¬
logical investigation under capable directors, however, promises
even better results than can be achieved by individual efforts,
and such combination should therefore be encouraged in other
parts of the kingdom and empire.

In contemplating the active field of our workers in psychiatry,
we are irresistibly reminded of those whom the hand of death
has removed from our ranks, some in the plenitude of years,
others in the full maturity of manhood, and others, alas! in the
age of early promise. In 1902 Mr. Holland, the Nestor of the
Lancashire superintendents and father of Whittingham Asylum,
went to his rest after a period of well-earned retirement
extending over nearly a quarter of a century. About the same
time Dr. Hills, the doyen of East Anglian alienists, who for
twenty-six years controlled with ability and success the destinies
of the Norfolk Asylum, paid the debt of nature after fourteen
years* freedom from responsibility. It is a curious fact that his

Digitized by v^.ooQLe

592

PRESIDENTIAL ADDRESS,

[Oct,

former chief at the Kent Asylum at Banning Heath, Dr. James
Huxley, an early member of this Association (elected June,
1847), a pensioner of forty years’ standing, and a brother
of the late Professor Huxley, survives him. Other losses in
this category were Dr. Gasquet, formerly of the Burgess Hill
Retreat, a quiet worker of a retiring disposition; and Dr. George
Mickley, formerly of St. Luke’s Hospital, who enjoyed for but
a short period the pension allotted him. Under the second
heading we lament such men as Drs. Arthur Strange, Bonville
Fox, and Law Wade. The first-named lived a generation for
his people at Bicton, universally beloved by all connected with
the Salop and Montgomery Asylum. In Bonville Fox we lose
a delightful personality and a cultured physician, who had the
best interests of this Association at heart ; and by the death of
Law Wade the public asylums of the West of England were
deprived of one of their best superintendents. In April of last
year many of us listened to an interesting paper on asylum
dysentery read at the South-Eastern Divisional Meeting at
Brookwood by Dr. Macmillan, one of the assistant medical
officers at Claybury, a young physician of promise. Little did
we surmise that within a few months he would fall a victim to
the disease he was investigating, to the great sorrow of all who
knew him and appreciated his qualities of mind and energy in
scientific research.

The concluding of this brief retrospect brings us to the pros¬
pect, and to the desiderata of our Association and of its various
divisions. The Lunacy Commissioners’ Blue Book issued in
June, 1902, tells us the indisputable fact that insanity is on the
increase, that the average annual increase of patients for
the quinquennial period ending December 31st, 1901, for
England and Wales was 2270 (2140 rate-paid and 130
private), an increase exceeding the average annual increase of
the preceding ten years by 483, and that of the preceding five
by 500. The average annual increase of the rate-paid insane
in the county of London is about 500, but curiously enough
this increase has been greater in those years in which large new
asylums have been opened by the County Council. This Blue
Book also tells us there is one insane person to every 298 sane,
whereas in 1859 the proportion was one to 536 ; and that the
advance in the ratio has been almost entirely in the rate-paid
class; that there has been no sustained advance in the average

Digitized by v^.ooQLe

1 9°3-]

BY ERNEST W. WHITE, M.B.LOND.

593

recovery rate in the past thirty years ; and that there has been
an important diminution in the death-rate. The last-named
facts point to the accumulation of the chronic insane. To learn
that there has been no material advance in the recovery rate with
the development of rational principles of treatment and the
vastly improved environment of the insane is not pleasant
reading, and it is our duty to discover, if possible, why this is so.

In the first place we must discuss the population we are
dealing with. Are there any racial or environmental changes
when compared with the population of 1859? Under racial
changes we note—

1. That with the increase of our population there has been
less encouragement for eligible aliens to settle in our country
and intermarry with our people; consequently less infusion
of new blood into the race than formerly. The aliens we do
receive are mostly needy town-dwellers of poor physique, with
neurotic inheritance and frequently with constitutions under¬
mined by disease. Moreover they are often undesirables of
the criminal type. Such immigrants are likely to be detri¬
mental rather than of benefit to the future nerve stability of
our race.

2. The influence of heredity. This was fully discussed by
Dr. Wiglesworth in last year’s address. The intermarriage of
neurotics and those with inherited taint of insanity, now all too
common, should be discouraged by every one, and prevented if
possible by State interference. Only last year a young fellow,
a private patient at Stone, on recovering from an attack of
acute mania, married almost immediately the daughter of a
lady patient who was a bad case of chronic mania. The
fiancee used to visit her sweetheart and mother the same day.
I did my utmost to discourage the alliance, but in vain.
Disaster awaits the progeny.

3. The altered type of occurring insanity. When I look
back to the admissions in county and borough asylums thirty
years ago, I am forcibly impressed by the fact that there is a
vastly increased number of cases of melancholia relatively to
mania in new admissions nowadays. Then in the Norfolk
Asylum we had plenty of cases of true acute mania, most of
which had a definite cause and made good recoveries in from
two to six months. Now we seldom see that typical acute
mania, but are inundated with cases of melancholia without

Digitized by v^.ooQLe

594 PRESIDENTIAL ADDRESS, [Oct.,

definite cause, of insidious onset, in which treatment is beset
with many difficulties, convalescence protracted, relapses are
common, and from which chronic insanity often results.

During the last few years one has also been struck by the
large number of cases of evolutional mental breakdown occur¬
ring in patients from eighteen to twenty-eight years of age of
the upper and middle classes, the result of the strain of educa¬
tion and the worries of life upon brains unequal to the stress
under which we live. Is it, then, that the race is less robust
mentally as well as physically than formerly, and that mental
breakdown tends to the asthenic type ? There are, I fear, facts
which might lead us to this conclusion.

4. Too early marriages among the poor and too late marriages
in the upper and middle classes are more frequent than fifty
years ago ; these do not conduce to a healthier stock mentally
or physically.

5. I am afraid we must conclude that there are more con¬
genital imbeciles born relatively to the births generally than in
1859. We are undoubtedly perturbed by the ever-growing
feeble-minded element in the community, for whom early legis¬
lation is demanded. It was stated publicly the other day that
one person in every 150 of the population belongs to this
section ; and when we consider how unfitted imbeciles are to
battle with every-day life, and how incapable they are of
adaptation to their environment, we must not be surprised that
the feeble-minded at large are constantly a source of trouble,
and often bring disgrace upon themselves and their families.

6. Inherited syphilis and hereditary tendency to pulmonary
tuberculosis must operate as factors in causation more than
formerly. That interesting disease, infantile general paralysis
of the insane, of which I have seen quite a large number of
cases recently at the neighbouring asylum at Darenth, has
probably for its sole cause inherited syphilis. I must add
I am not one of those who believe in syphilis as the only
etiological factor in general paralysis of the insane; but
knowing'what we now do concerning syphilis as a cause of
insanity, surely we should take part in agitating for the replace¬
ment upon the statutes without delay of the Contagious
Diseases Act (Man).

7. The abuse of alcohol is, as we all recognise, both a cause
and symptom of insanity, often indistinguishable. We are now

Digitized by

Google

1903-]

BY ERNEST W. WHITE, M.B.LOND.

595

a spirit-drinking race, which we were not in 1859. There is
no standard of purity of these spirits. May not both the
immaturity and the adulteration by noxious constituents be
important factors in the causation of insanity, and should not
the Legislature enforce both the maturity and purity of all
alcoholic drinks ?

8. Many weaklings who would formerly have died in
infancy are now reared to marry and reproduce a faulty stock.

Under environmental changes we note—

1. The population is urban rather than rural to-day. We
are rapidly becoming town-dwellers. Overcrowding is common.
The people breathe less pure air and have less outdoor exer¬
cise under the beneficent action of the sun’s rays. Their food
is badly selected, less easily digested, and less nutritious than
formerly. It is, moreover, frequently badly cooked.

2. The stress of life is far greater than formerly. Over¬
education during development, late hours and unnatural excite¬
ment, must leave their marks upon the race as well as upon the
individual. Having discussed briefly certain conditions affecting
the vitality and predisposition to mental disease in the present
population, we are led to consider the existing arrangements
and desiderata for the care and treatment of the insane. This
I propose to do under the two headings, (a) rate-paid, ( b ) private.

Much has been done in recent years to improve the means
of care and treatment of the rate-paid insane in the counties
and boroughs. Unfortunately on the score of economy the
patients have been congregated in too large communities under
one roof, and especially has this been the case in the county of
London, with its huge asylums, each containing from 2000 or
2500 patients. Has not this been false economy? It may
be urged that with the larger number you can show a somewhat
lower weekly maintenance rate, but true economy would be in
better results in recoveries even at a considerably higher main¬
tenance charge for a short time. Think of the cost to the rate¬
payers of the patient who becomes insane at twenty and lives
to the age of seventy or eighty years in a county or
borough asylum ! Huge institutions containing both acute and
chronic cases stand condemned by the public and the expert
alike! The medical superintendent knows relatively nothing of
the patients individually. There is a certain amount of classi¬
fication, it is true, and the cases are allotted for treatment to

Digitized by v^.ooQLe

596 PRESIDENTIAL ADDRESS, [Oct.,

the care of the various assistant medical officers. These gentle¬
men are not all enthusiasts in medical treatment, or equally
skilled. Some may do their utmost for the recent cases com¬
mitted to their charge; others go the rounds and perform their
ward duties in a perfunctory manner, devoting their best
energies to the amusements which form a feature in asylum
life, and which may be more to their taste. The recent
admissions under officers of the latter class, unaided by medical
science, tend to drift, and this is where the daily supervision of
the medical superintendent is needed, but only obtainable in
asylums with less than 600 patients.

The many chronic cases apparently drifting to dementia one
has seen in recent years subjected to school discipline and re¬
educated back to natural life and mental health, is a source of
great encouragement in our work in this direction, and forcibly
impresses upon us the necessity of safeguarding, if possible
by legal as well as medical effort, all patients against being
classified as incurable and neglected as regards treatment
while chances of improvement and even of recovery still exist.

For a long time past the possible value of physical drill for
the female insane, who cannot be employed outside at manual
labour, has occurred to me. We must have systematic methods
of rousing the listless and apathetic drifting to dementia from
their lethargy, and I believe good will result from the estab¬
lishment of these physical drill classes. When alluding to this
the other day at Claybury, I was delighted to learn the idea
had also occurred to Dr. Ewart, who had started such a class
and was hopeful of beneficial results. Since writing the above
I find Dr. Goodall has also initiated physical drill at the Car¬
marthen Asylum.

At last the separation of the acute insane in the hospital
from the chronic in the asylum, on the one estate, advocated by
many of us twenty years ago, is being generally recognised as
imperatively necessary to prevent the curable cases being lost
sight of in a crowd of chronic sufferers. These acute hospitals,
to my way of thinking, should be of the linear gallery type,
the buildings extending east and west, the galleries with
southern frontage being used for day space and transit, and
intersecting the ward day rooms at right angles. The wards
then are only separated by glazed screens in the galleries, and
the sick wards are of the true hospital type and terminal,

Digitized by v^.ooQLe

I903-]

BY ERNEST W. WHITE, M.B.LOND.

597

removed from the noise and excitement of the centre, and having
large secluded gardens. Telephones nowadays bring medical
aid sufficiently near these terminal hospitals. There must be
a subway under the galleries and wards for air-ducts, pipes,
etc., with a trolley-way for food and stores, and a lift for each
ward. The buildings should be two-storied, with all the
upper floor for dormitories and single rooms. The other single
rooms would be on the north side of the galleries on the
ground-floor. The advantages are cheapness of construction
atid up-keep, compactness, facilities for medical and general
supervision and treatment, and ease of administration. We
have it all at Stone except the subways, and I know of no
asylum in which acute cases can be so readily treated and
supervised medically and generally. You have small wards,
so much to be desired, and yet in an emergency with a
temporary reduction of staff the dividing glass doors can be
thrown open and the wards become one for the time being.
The through traffic of wards, so much decried in the past in
the asylums of the linear gallery type, was probably their
strongest recommendation. The insane are very inquisitive,
they like to see people through their wards, and appreciate
anything which relieves monotony ; hence detached villas will
never be popular with many convalescing patients who take
interest in their environment, and to whom the daily life of the
wards and main buildings offers an attraction. I shall not
readily forget that when we opened our new female hospital,
which is terminal, one lady in the ward through which there is
most traffic begged not to be sent there, adding, “ How would
you like to live in a village through which no one ever passed ? ”
Again, the large associated dining hall is most popular,
although some medical superintendents in the South do not
believe in it. With ease of access from the neighbouring wards
of either division, the patients look forward to all their meals
in the hall. It varies the monotony, associates them with
members of the other sex, gives them an opportunity of
enjoying music during dinner, they get their meals quickly
and properly served from the kitchen, and it allows of the
wards being thoroughly ventilated while they are away. With
the pavilion type of asylum, and the blocks at some distance
from the central hall, I grant there are difficulties, but surely the
advantages outweigh the difficulties. A time limit must be

Digitized by v^.ooQLe

598

PRESIDENTIAL ADDRESS,

[Oct.,

fixed for the residence of patients in the acute hospital, which
should be highly equipped in staff and material and should
possess all the armamentaria for scientific treatment Chronic
patients from the main building should assist by day in its menial
work. Detached villa blocks for the chronic insane, classified
according to employment, with a separate villa for imbeciles,
should be productive of the best results in work done, and
should add to the comfort of the patients. The acute hospital
and detached villa blocks will soon be in full swing at the
East Sussex Asylum at Hellingly ; and the Ewell Epileptic
Colony, opened on the first of the present month by the
London County Council, is a further example of the housing
of a gregarious class of the chronic insane and weak-minded
with a view to their useful and beneficial employment. In
London we have the advantage of possessing the chronic
imbecile asylums of the Metropolitan Asylums Board, to
which we can draft many of our quiet and harmless chronic
dements under Section 25, Lunacy Act, 1890. Similar in¬
stitutions in the provinces would, I believe, be of great benefit,
and would open out accommodation in the county and
borough asylums, now occupied by this class of patients.

A Bill, known as the Lunacy Acts Amendment (London)
Bill, has been introduced this session in the House of Lords
by Lord Carrington. It was read a second time on July 7th.
It is entitled “An Act to authorise the London County Council
to provide receiving houses for the reception of persons men¬
tally affected or alleged to be of unsound mind, and to
authorise the detention of such persons in such houses, and for
other purposes connected therewith.” It passed through com¬
mittee without amendment last Thursday. Gentlemen, there
is more in this Bill than meets the eye. The houses are to
be not only receiving houses, but detaining houses for treat¬
ment. I think I shall be able to show you that the receiving
houses (and there are to be at the outset two of these at a cost
of j£i2 5 ,ooo each, but the ultimate number is not limited)
are in reality our old friend the hospital for the insane in
London (London County Council, Special Report, 1890) in
another garb and in duplicate. The memorandum states the
object of the Bill is to enable the London County Council to
establish houses at which persons alleged to be lunatics may be
received for preliminary examination and treatment. It con-

Digitized by v^.ooQLe

I 9°3-]

BY ERNEST W. WHITE, M.B.LOND.

599

tinues as follows :—“ In the existing practice in London under
the Lunacy Acts, persons supposed to be lunatics are for the
most part taken to a workhouse in order to be examined
before being sent to a lunatic asylum. Experience shows that
this system is unsatisfactory, and leads occasionally, in the
individual cases, to harm which might be avoided.

“ It is believed that the proper treatment of mental disease
in its earlier stages, or of symptoms of incipient mental
disease, will often obviate the necessity for sending to a county
lunatic asylum persons who, under the present arrangements,
cannot be otherwise dealt with.

“It is claimed for the system proposed that it will thus be
not only beneficent, but economical in its operation by tending
to lessen the number of persons detained as lunatics in the
county asylums at the public expense; while it will be useful
in assisting the classification of patients and the diagnosis and
cure of mental disease in its earliest stages.

“It is proposed that the receiving houses shall be available
for the treatment of out-patients.

“ The receiving houses will be under the supervision of the
Commissioners in Lunacy, and conducted in accordance with
the law regulating county asylums.”

Now Clause 2 provides for the treatment of out-patients at
the receiving houses with proper accommodation, medicines
appliances, and requisites for the care and treatment of such
out-patients ; in fact, the complete equipment of an out¬
patient department.

Clause 4 provides for the appointment of a superintendent
of each receiving house, who shall be resident medical
officer. It also authorises a staff of such other officers as the
visiting committee think fit, and it specifies they may appoint
a visiting physician or surgeon to any such receiving house.
By Clause 11 the duration of the detention order in the
receiving house made by the Justice is fixed at six weeks,
but the period of detention may from time to time be extended
by a Justice on the recommendation of any two members of
the visiting committee, for any further period not exceeding
three weeks at any one time. Clause 13 ensures provisions as
to care, treatment, and visitation practically identical with those
of the Lunacy Acts 1890-91. By Clause 14 patients can
be removed from one receiving house to another.

Digitized by

Google

6oo

PRESIDENTIAL ADDRESS,

[Oct.,

The above are the chief clauses. Now is there any guarantee
that the superintendent, who will also be resident medical
officer of the receiving house, shall have been properly trained
in the treatment of mental diseases in a public institution for the
insane? Will the visiting medical staff appointed have had
proper experience in the treatment of mental diseases in public
asylums ? As by Clause 11 acute mental cases can be detained
in these receiving houses for treatment practically as long as
the visiting committee, acting upon the advice of the medical
staff, think fit, would the heart of the metropolis be suitable for
these institutions ? The scheme in reality means that these
receiving houses in London are to be the acute hospitals for
the insane and teaching centres for the medical schools, the
present large asylums being utilised only for chronic cases.
Few of us will admit that the acute insane can have their
proper environment in the heart of the most populous city in
the world. How are cases of acute mania and melancholia to
be treated there ? We know the value of rest in bed in certain
acute cases of insanity, but where are the majority of the
patients to have the benign influence of the sun, fresh air, and
exercise? Where beneficent employment, recreation, outdoor
and indoor amusements, so essential to successful treatment?
Six years since, when visiting Glasgow with my committee, we
found the authorities there had receiving houses for classification
of the insane prior to distribution within the week to their
various asylums. It is true a certain number of cases dependent
upon drink recovered within seven days, but those receiving
houses were not what these will be—hospitals for the insane
where the patients can be detained for treatment six weeks, or
even three months or more. The principle of the receiving
house in London for classification is certainly right, but there
should be no power of detention beyond from seven to fourteen
days, which period would amply suffice for certain transient
cases. I believe, however, that psychopathic hospitals on the
outskirts of London for acute cases would be a boon for treat¬
ment and of benefit to students. We want facilities for treatment
of incipient and unconfirmed insanity in the poorer classes,
both as indoor and outdoor patients in our general hospitals,
and as voluntary boarders and outdoor patients at the county
and borough asylums. The out-patient department is an
accomplished fact in several hospitals and asylums; the in-

Digitized by v^.ooQLe

1903.] by ERNEST W. WHITE, M.B.LOND. 601

patient wards for certain border-line mental cases is a desideratum.
For many rate-paid imbeciles and chronic dements we ought
to develop, under proper supervision, the boarding-out system
so much in vogue in Scotland. True economy lies in this
direction, and the reduced population in our rural districts
should facilitate this undertaking.

From patients we turn to staff, and under this heading there
are one or two points which demand our attention. In the
first place the pension question is ever with us. Some of you
will remember the great meeting of this Association held upon
this question at Bethlem Hospital on May 16th, 1888. On
that occasion I had the honour to lead a small—a very small—
minority, who were opposed to the compulsory modified Civil
Service scale of pensions. Well, we offered such persistent
obstruction that we really won the day, and I venture to think
you have reason to thank us for the uphill fight we successfully
carried through. I said then, and I say it now, no absolutely
fixed scale of pension is fair! Fix a minimum if you like,
make that compulsory, and have a sliding scale for merit to the
present permissive maximum. By that means, bad, indifferent,
and good officers and servants will not all be treated alike.
Power must be left in the hands of the visiting committees to
regulate pensions according to merit. They will seldom do
wrong. Those asylum officers who were most afraid in 1888
that the coming county councils would treat them badly in
the matter of pensions, have realised in many instances their
mistake, and the precedents already established must guide the
near if not the distant future. It is to the interests of visiting
committees and county councils alike to keep a service
popular, and this can only be attained by the granting of
liberal superannuation allowances on retirement to all those
who have served them faithfully and well. Whatever is done
for England and Wales in regard to pensions must be granted
also to Scotland, Ireland, and the Colonies. In South Africa,
where the Civil Service scale applies at present, I am told an
agitation is proceeding to have ten years added to the indi¬
vidual^ life as well as the ten years for special service. This
would allow of retirement at fifty years of age. It is undoubtedly
a move in the right direction, for few of those who have devoted
their best energies to the care of the insane are equal to the
constant strain of the work in the sixth decade of life. We

Digitized by v^.ooQLe

602 presidential address, [Oct.,

desire also a gratuity clause for deserving officers or servants,
or for the widow or children of any deserving officer or servant
who loses his life in the service.

The next point upon which I must speak is the dearth of
applicants for the vacant posts of assistant medical officers at
county and borough asylums. Twenty years ago there would be
thirty or forty applicants for each vacancy ; now we get some
seven or eight, or even fewer. Why is this ? It must be the office
is less attractive than formerly, or is it that the additional year
to the medical curriculum, the better pay obtainable of late for
locum tenens work,and the many colonial attractions, have reduced
the supply of candidates? How is this dearth to be overcome?
Since the higher posts are limited in number, and but a small
proportion of assistant medical officers can ultimately become
superintendents, it seems to me only right that an assistant
medical officer should be able to retire, say at the end of five
years if he so desires, with a gratuity of £500, or at the end of
ten years with one of ;6iooo. This suggestion is very similar
to what obtains in the army medical service. It would attract
more young men of promise to our ranks, it would ensure them
the wherewithal to buy a practice at a comparatively early
age, it would disseminate throughout the country a more general
medical knowledge of mental diseases, and it would protect
assistant medical officers against remaining as such until at an
age when only a small superannuation would await them.
Similar and proportionate gratuities should be given to members
of the nursing staff, male and female. This, I believe, is the
custom in the post-office service on the marriage of their
female clerks. Before leaving the rate-paid insane and their
custodians, I would congratulate the Association upon the con¬
tinued success of its scheme of training for nurses, male and
female, and upon the enhanced value of the Medico-Psycho¬
logical Nursing Certificate obtained after due examination. I
am not a little proud that the City of London Asylum was in
the van in this movement, for we commenced a systematic
course of lectures and examinations for the nursing staff in
1887, and issued our own certificates in 1890, but abandoned
these on the institution of the nursing certificate of the Asso¬
ciation.

We now come to (£) the private insane. The only de¬
siderata for the registered hospitals are—(1) the size of these

Digitized by

Google

I 9°3-]

BY ERNEST W. WHITE, M.B.LOND.

603

hospitals should be limited, and (2) their charity should be
extended. The registered hospitals are doing a great work,
but the control of large funds requires careful supervision. I
would add that those of the registered hospitals with out-of-
date buildings situated in populous districts should, in the
interest of the patients, be moved into the country at the
earliest possible date.

Next as regards licensed houses or private asylums. The
Act of 1890 provided, as we all know, for the gradual extinc¬
tion of these by competition. Under it no new licence can be
granted, and there can be no addition to any existing licence.
Those conversant with the demand for high-class accommoda¬
tion know full well that the upper classes will not, as a rule,
send their relations to public institutions, and therefore the best
licensed houses will always be in request. The question then
arises whether the time has not arrived for some alteration of
the law in regard to these—an alteration which will admit,
under proper safeguards, of the reception of an increased
number of patients. Moreover the voluntary boarder system of
treatment is so important, and has proved so valuable both for
incipient and convalescing cases, that this system should be
further encouraged by the voluntary boarders in licensed houses
not being counted in the number for which each house is
licensed, provided, of course, they do not encroach on the
recognised accommodation. The voluntary boarder system
should also be extended to county and borough asylums, both
for private and rate-paid patients. At the present time several
licensed houses receive rate-paid patients in large numbers.
This is contrary to the spirit of the Lunacy Acts ; it opens up
the road to abuses, and is a condition demanding rectification
by the Legislature at the earliest possible date. By the Act of
1890 the authorities in the counties and boroughs were en¬
couraged to provide accommodation either in their asylums, or
in annexes close thereto, for paying patients. There are
nearly 250 such patients at the present time in the City of
London Asylum. The reception of these patients has proved
a great boon to the middle-class public, whose relatives in the
past were frequently classed as paupers in order to be made
admissible for treatment in county and borough asylums. It
has, moreover, been of benefit to the institutions receiving
them. We charge a guinea a week, and, in a few cases
xlix. 42

Digitized by v^.ooQLe

604

PRESIDENTIAL ADDRESS,

[Oct.,

requiring special care, two guineas. A first-class diet is given,
and the balance on the maintenance goes to structural improve¬
ments and additional ornamentation of wards and gardens,
whereby both private and rate-paid patients benefit. The
paying patients are kept separate from the rate-paid as far as
possible, but the infusion of the higher civilisation has levelled up
the general tone and improved the moral and intellectual spirit
of the institution. Many superintendents have said to me,
“ Don’t you find the private patients an awful nuisance ? ” My
reply has been, “ They do give extra trouble, and their friends
also; but the work is much more interesting with the cultured
classes, and fully compensates officers, nurses, and attendants
for the extra labour entailed.” All paying patients are
employed as far as possible—the gentlemen in the gardens, on
the farm, in the workshops and wards ; the ladies in house
duties, needlework, etc.,—and I have been surprised to find how
much work you can by force of example encourage these
patients to do.

We are told there has been no increase in recent years in
the number of certified patients in single care. This is a
regrettable fact, and I think results from the large number of
single cases treated, often by unskilled persons, privately and
uncertified. Quite recently I dealt with this subject in a paper
“ Upon the Care and Treatment of Persons of Unsound Mind
in Private Houses and Nursing Homes,” a paper which elicited
a very gratifying discussion, demonstrating clearly that serious
legislative defects existed. The private insane ought to have
the earliest possible skilled care and treatment under efficient
official supervision. To ensure proper custodians and suitable
environment all persons and houses receiving uncertified single
patients should be subject to registration, and all such patients
should be notified to the Commissioners in Lunacy, by whom
or their deputies they should be systematically visited. The
voluntary boarder system should be extended to these registered
houses both for incipient cases and for convalescing patients on
their discharge from certificates. The chief custodian of every
patient should be held legally responsible for proper care and
treatment, and if culpably negligent or inefficient should be
liable to prosecution. Lastly, a large addition to the Lunacy
Commission by the appointment of deputy or district commis¬
sioners to carry out the necessary work of supervision is
urgently needed.

Digitized by v^.ooQLe

I 9°3-]

BY ERNEST W. WHITE, M.B.LOND.

605

Let us all agitate for the removal from the statutes and
discontinuance from, general use of the terms lunatic, lunacy,
asylum (when applied to a mental hospital for curable cases),
attendant, and airing courts ; person of unsound mind, insanity,
mental hospital, male mental nurse, and gardens taking their
places.

Finally, let us ever remember that we are the officials and
custodians of a great trust, that our life-work is a noble one
with vast possibilities for good or evil, that the State very
rightly safeguards the insane community on account of its
utter helplessness, and that the advance in treatment for which
we are all striving will more certainly be gained by the appli¬
cation of sure and steady methods founded upon experience
and directed upon scientific lines, rather than by the reckless
experimentation of the inexperienced upon defenceless patients.
As the navigators of bygone centuries in seeking their
Eldorado were encouraged from day to day by the discovery
of some new island, which led them ever onward on the bound¬
less seas to fresh lands and fields of adventure, until at last
the continent of their dreams lay before them, so may we,
urged onward by a strict sense of duty, and with a full
appreciation of our noble sphere of labour, by patiently pur¬
suing proper methods of scientific research and clinical investi¬
gation, hope to solve the hidden mysteries of the origin, pre¬
vention, and cure of the greatest of all human ills—insanity.

Dr. Blandford. —I have great pleasure in proposing, and I am sure you will
have equal pleasure in awarding, the best thanks of the Association to our
President for his very able and suggestive address. It is not our custom to
discuss the address of the President, and I have no intention of doing so on this
occasion. I would, however, with your permission, make one remark. I was
extremely glad to hear him draw your attention to that Bill which is now before
the House of Lords; I do not think it has yet got before the Commons. I am
pretty confident that what he said with regard to that Bill is strictly correct; that
it is a resuscitation of the old proposition that came up from the London County
Council in the year 1890, but which fortunately failed altogether and never became
law. You may remember that the chief provision was that the physicians who
were to have supervision of the home or homes were to have had no experience
whatever of the care and treatment of the insane.

Dr. Outterson Wood. —It affords me personally the very greatest pleasure to
have been asked to second this vote of thanks to our President for his address. I
think that his masterly and extremely practical paper, to which we have all
listened with so much pleasure, is the best proof we could have that we have
elected a man as o\ir President who will fulfil the duties of his office with credit
to himself and with satisfaction to the Association.

The motion was received and passed with applause.

The President. — I thank you very heartily for this expression of your approval.
It will be my earnest endeavour during my year of office to faithfully discharge
the duties of the position in which you have placed me.

Digitized by v^.ooQLe

6o6 REVISION OF THE STATISTICS PRESENTED BY [Oct.,

A Revision of the Statistics presented by the Committee
on Tuberculosis .

The attention of the Council having been called to a state¬
ment that errors existed in the Statistical Tables prepared by
the late Tuberculosis Committee, the Council inquired into
the subject, and finding, as a matter of fact, that such errors
did exist, decided to place the Tables in question in the
hands of a statistical expert for detailed examination and
Report. Dr. Chapman, late Medical Superintendent of Here¬
ford City and County Asylum, whose reputation as a statis¬
tician is well known, most kindly, at the request of the
Council, undertook the work, and the Council feels that the
Association is greatly indebted to Dr. Chapman for so freely
placing his talents and time at its disposal.

Report by Dr. Chapman.

The Council of the Medico-Psychological Association,
having found that certain of the statistical tables and calcu¬
lations in the Report of the Committee on Tuberculosis pre¬
sented in 1902 contained clerical and other errors, requested
me to revise the figures, and I have undertaken the duty.

The schedules used by the Committee on Tuberculosis were
placed in my hands, and I have gone through them with some
care. I have not re-calculated every figure in the Tables, but
have done so when any doubt arose. The revision submitted
does not in any way traverse any conclusions and recommen¬
dations contained in the Report of the Committee on Tuber¬
culosis, but, on the contrary, in several directions supports
them more strongly.

The tables now submitted are—

Table A, substantially as in the Report of the Committee on
Tuberculosis.

Table A v giving in somewhat fuller detail the summary
represented by Table A* of the Committee on Tuberculosis.

Table A 2 , giving the totals on which Table A L is calculated.

Table B, differing from that of the Committee on Tuber¬
culosis in the asylums being classified by their tubercular
death-rates for five years and not on the tubercular death-rate

Digitized by e.ooQle

1903 ]

THE TUBERCULOSIS COMMITTEE.

607

for 1899. They are classified into a “ better ” (re tuberculosis)
and “ worse ” division, according to whether the rate does not
or does exceed 2 per cent.

Table B x summarises Table B.

Table C, giving a tabulation for English county and borough
asylums of the relation of admitted to indigenous cases of
tubercle.

It may be noted that in Tables A, A lf A 2 , and C, the
subject-matter being patients, the unit of calculation is the
individual patient; whilst in B the subject-matter is asylums,
and the individual asylum is the unit of calculation. Each
asylum is a separate experiment, and it is practically im¬
material whether the experiment is made on 250 or 2500
patients. Chance fluctuations in the small asylums and a want
of homogeneity in the larger ones may reduce the accuracy of
the figures, but do not affect their relative value, which must be
assumed to be equal.

The table on p. 23 (p. 415 of Journal) of the Committee’s

Report should read as follows :

In England:

f Dement and")

L Imbecile J

2. Mania

Average.

. . .8|

. 4

3 -

Melancholia

• • • 34

4 -

General paralysis

. ij

5 -

Epileptic

. . . 24

In Scotland

'• t

"Dement and"
^Imbecile

■

• 34

Mania

. . . 24

3 -

Melancholia

. 24

4 -

Epileptic

. . • }

5 -

General paralysis

. 0

In Ireland .
1.

Mania

• 7

2 - \

"Dement and"
^Imbecile

• • • 4 t

3 -

Melancholia

• • • 44

This portion of the statistics is of little interest, as there are
no correlative figures to give them any meaning.

Digitized by v^.ooQLe

608 REVISION OF THE STATISTICS PRESENTED BY [Oct.,

The effect of size has also been re-calculated in Table D, using
the five years’ tubercular death-rate instead of that for 1899.
The results are substantially the same as those already given
in Chart II.

One or two points as to which these figures emphasise or
vary the conclusions gathered from them by the Committee
on Tuberculosis may be referred to.

Table B x shows as to sites that the “better” asylums have
a “good” soil in fully two cases out of three, whilst the
“worse ” have a “ bad ” soil in three cases out of four. This
result varies in each subdivision, but is only contradicted in
the case of the “ better ” Scotch asylums, where only three
out of seven have a “ good ” soil.

The broad result here is so pronounced that the value of a
“ good ” soil can hardly be doubted.

The hours spent in the open air are greater in the “ better ”
asylums throughout each of the five groups, the total figures
for seventy asylums giving 6 # 6 hours for the “better” and 5*8
for the “ worse ”—a difference of 14 per cent, in favour of the
better asylums.

As to day space, the “ good ” asylums have fractionally
greater space, viz., by thirteen feet. It is not so in every
group, and the total difference of thirteen feet is too small to
found any strong conclusions upon.

As to night space, the “ good ” asylums are better by forty-
seven feet, nearly 8 per cent.—quite an appreciable and signifi¬
cant quantity; only in the borough asylums (seven in number)
are there contrary figures.

Abundant space would appear to be more important at
night than by day, probably because more continuously
occupied.

Ventilation: in the “ good ” asylums artificial and natural
ventilation are about equal, in the “ worse ” as three to seven—
ratios distinctly in favour of artificial ventilation.

Scotland votes to the contrary by six to one. Were Scotland
omitted, then the “ better ” asylums vote fifteen to twelve in
favour of artificial ventilation; the “ worse ” are in favour of
natural by more than two to one (twenty-one to nine). This
is very strong evidence that natural ventilation is insufficient.
It may be noted that the Scotch asylums all have large night
space, averaging 814 feet against an average of 680.

Digitized by v^.ooQLe

I9°3-] the tuberculosis committee. 609

Tables C and C x tabulate figures given in the collected
schedules, which, though collected with an obvious prevision of
their value, were not reported by the Committee on Tuber¬
culosis. They refer to the extent to which tubercle was
detected on admission amongst the patients who died from
tubercular disease in 1899.

These figures may be studied from various points of view.
Though in some few schedules the facts are not given, and in a
few others appear to have been given without much investiga¬
tion, they are on the whole apparently trustworthy.

They refer entirely to the deaths in 1899, and say nothing of
patients suffering on admission from tubercle who recovered,
nor of those who acquired tubercular disease in the asylums
but did not die.

The figures show that for every 100 cases admitted (and
finally terminating fatally), 375 originated in the asylums.

It appears also that in the asylums with a higher tubercular
death-rate a larger number were admitted with tubercle than
in the “ better ” asylums. There is nothing to show how far
this is due to the number of tubercular admissions being larger,
or how far simply to fewer recoveries amongst them: we
know that in some asylums tubercular cases do recover in
considerable numbers.

The further remarkable fact comes out that in the “ worse ”
asylums, though the admitted cases are more numerous, the
indigenous are still more so.

In English county and borough asylums, in 30 “ better ”
asylums (omitting fractions and using round numbers), where
5 cases are admitted 17 cases occur in the asylum; whilst in
24 “ worse ” asylums 9 cases instead of 5 are admitted; but
the indigenous cases are not 17 as in the “ better ” asylums,
nor 31, which would be proportionate to the 9 admissions, but
38. If the 9 “worst ” be taken, then the admissions are 10;
but the indigenous cases are not 17, nor 38, nor 42, as they
would be if proportionate to the ratio in the “ worse ” asylums,
but no less than 56.

In the remaining asylums—English, Scotch, and Irish (only
twenty-four in number)—the admissions are much the same in
each group, the excess in the “ worse ” asylums being entirely
due to indigenous cases.

Whatever detailed interpretation we may make of these

Digitized by v^.ooQLe

6 lO REVISION OF THE STATISTICS PRESENTED BY [Oct,

figures, their broad meaning is clear, and that is that the more
tubercle there is the more there will be.

Their practical teaching, therefore, is most unmistakably
that the segregation of infected individuals is an imperative
necessity.

As to other practical points, the well-known value of an
open well-drained soil is so fully illustrated that it must be
more attended to in the future selection of sites for asylums;
and though asylums now existing cannot be moved, it deserves
the fullest inquiry in every case whether more might not be
done by deep subsoil draining to improve the condition of
asylums on heavy soils.

The association of natural ventilation with open fires is more
frequent in the “ worse ” asylums. This may mean to some
extent that these are older asylums, and may on that account
be more liable to tubercular infection. But we must associate
the fact that natural ventilation is much more usual in the
worse asylums, with the significant exception of the Scotch
asylums, which have natural ventilation but a very large night
cubic space.

The practical deduction is that natural ventilation appears
to be inefficient unless assisted by large cubic space, with
especial reference to night conditions, when it probably often
happens that warmth is maintained and draughts avoided by
checking ventilation to a dangerous extent.

Although it may be unnecessary to give a detailed tabulation,
it seems desirable to present some comparison of the ordinary
rate of mortality with the tubercular death-rate. For this
purpose the first fourteen (omitting two of under five years’
existence) county asylums in Table B, having a tubercular rate
not exceeding 1*5 per cent., are compared with the last fifteen
in the same table, with a tubercular rate of 2*5 or over.

The figures are—

Average number Average Average tuber- Total deaths Tubercular deaths

resident. deaths. cular deaths. per cent. per cent.

First 14 . 13,924 ... 1216*4 ... 1856 ... 87 ... 1*3

Last 15 . I5,3 8 5 ••• 1773*8 ... 530*8 ... 117 ••• 3*5

If the tubercular deaths be subtracted, then the two groups
contrast with an ordinary death-rate not of 87 and 117, but
of 7*4 and 8*2—a difference of only o*8 per cent. This o*8 per
cent., however, must be still further reduced, since an exa-

Digitized by C.oooLe

1903.] THE TUBERCULOSIS COMMITTEE. 6ll

mination of the schedules shows that in a good many cases the
tubercular deaths (not so certified) are but imperfectly returned,
especially in the earlier years. The correction for this would
probably be greater in the last than in the first group by some¬
thing like the proportion of 3*5 to 1*3. It is also tolerably certain
that when tubercle is in excess, either actual tubercle or the
causes favouring it would increase the death-rate without
actually existing active tubercle at the date of death.

With a very moderate allowance for these two circumstances
the o*8 would be much diminished, and it would appear that
the difference of 3 per cent, in the death-rates of the two
groups (one third more than that of the “better” group) is
entirely, or almost entirely, due to the presence of tubercle and
its causes.

The figures of the two Staffordshire asylums are sufficiently
exceptional to suggest they should be eliminated. The result,
however, is the same; without them the mortality of the
second group becomes 10*9, with a correction for tubercle of
2*8, making the two groups 7*4 and 8*i respectively, or a
difference of 07 instead of o*8 as before. The Staffordshire
asylums alone give a similar result, the general mortality with¬
out tubercle being high, but not remarkable, viz., something
like 10*5.

The inference from these facts seems to be that apart from
tubercle the general health of the patients in both groups is
not far from identical, and that the tubercle can hardly be due
to any essential difference in the patients in the two groups
of asylums, and cannot have any special connection with
insanity, (*) but is causally associated with the individual
asylums.

Though the statistics give some very definite indications, they
fail to completely solve most of the questions they raise. For
example, under present conditions it would appear that six
and a half hours in the open air is more efficient in avoiding
tubercle than merely six hours. There can, however, be little
doubt that if infective cases were isolated, and ventilation and
cubic space satisfactory, as much as even six hours would be
by no means essential to a low tubercular rate. Probably if
night space were 2500 feet, grave defects of ventilation, etc.,
would be comparatively innocuous, and so on. The practical
question is, What is a necessary minimum in each of these

Digitized by v^.ooQLe

612 revision of the statistics presented by [Oct.,

items, so that the combined effect shall be elimination of
tubercular disease at a minimum cost?

There is nothing to show that if isolation were efficiently
enforced the mass of the “ better ” asylums, at least, are not
adequately equipped in most of the other respects already.

A fuller statistical inquiry than the present would probably
confirm and define more clearly any conclusions that the
present one points to, but would probably not alter them to
any material extent. Further light might be got—and this
course seems decidedly suggested by the relations shown
between imported and indigenous cases—by a careful examina¬
tion and comparative study of the conditions prevailing in a
selected few of the “ better ” and “ worse ” asylums.

No analysis has been made of the dietaries. A careful
comparison of the dietetic conditions in, say, five (or ten) of the
“ better " and as many of the “ worse ” asylums, both from a
table d'hdtc and from a laboratory standpoint, would have some
value.

The following appear to be the most important deductions
from the statistics:

x. That infection is one of the strongest causative ele¬
ments in the prevalence of tuberculosis in asylums.

2. That a healthy (dry and well-drained) site is of extreme

importance. The value of a good site is well known,
but asylum authorities do not appear to be aware that
it is so great as these statistics show.

3. The causes of tuberculosis in asylums inhere in the

asylums themselves, and not in the character of the
patients sent to them. This must be very generally
true, since the exceptions, and possibly very marked
exceptions, that individual asylums no doubt present,
make so little mark on the statistics.

4. That time spent out of doors, cubic space indoors,

ventilation, etc., all appear on the side of the account
one would expect, but by margins usually too small
to be very significant. It would seem that probably
all these are inadequate, even in the “ better ” asylums,
for the proper treatment of tuberculosis, but that, on
the other hand, they are possibly sufficient even in
the “ worse ” asylums if tubercular taint be absent.
The only detail hinted with any definiteness is that,

Digitized by v^.ooQLe

1903.]

THE TUBERCULOSIS COMMITTEE.

613

with our present habits and prejudices, due ventila¬
tion can hardly be obtained without artificial means
and artificial heating in dormitories giving less than
800 feet per head.

T. A. CHAPMAN.

Addenda and Errata.

I ought to have mentioned that the “ average hours outside ” are the
sum of the hours spent “ in airing courts” and “ beyond airing courts,”
and that the eccentricities of the figures appear to be due to the
schedules having been so filled up that the figure is in most cases really
an “ average hours outside,” in others is the sum of the maximum spent
in airing courts by some patients and of that spent outside them by
others. It is, however, impossible to say which is which in more than a
few cases, and it is necessary to assume that the aberrant figures balance
one another. It is quite possible, of course, that they do not.

I may also mention an opinion I have formed that the uncertain
result of the day space figures, which equally appears, however they
may be manipulated, is due to day space being adequate in practically
all cases. This one would perhaps anticipate from its being so varied
by visits to dining hall, chapel, amusement room, etc., by time spent
out of doors, and by its conditions being well supervised by the visits of
officers, etc.

In the 8th line of Report I ought to have said that in Table A I have
re-calculated the totals in almost all cases, but not the M. and F. sepa¬
rately, nor other figures that I did not further use. There had been
nothing to raise any doubts as to these being correct; there are, how¬
ever, 1 find, a few requiring correction, as well as some errors of my
own. Of the latter none affect results. The transposition of 22 and
23, col. 3, Table A, might have done so, but the figures happen to be
nearly alike, and, as it happens, are correct in Table B where they
signify.

Errata.

Table A— M. F. Total.

Group 1, col. 2 . . 6. Bodmin should be 80 7*4 77

21. Leicester „ 12*5 8*3 10*2

23. Banstead „ 13*9 5*4 8*6

col. 3, 22 & 23. Totals want transposing:

22 = 2*0

23 = i*8

col. 4 . . 39. Brookwood should be 117 7*0 9*0

46. Wakefield „ 11*2 6*o 8 6

col. 5 . . 30. Morpeth „ 4*0 4*0 4*0

39. Brookwood „ 3*1 1*9 2*4

46. Wakefield „ 3*0 07 i*8

Group 2, col. 2 . .12. Warneford „ 6*8 2*4 4^4

col. 3 . . „ „ 1*5 0 0 07

16. Broadmoor „ o*6 ot 0*4

col. 5 . .17. Earlswood „ 19 2*8 2*2

Digitized by v^.ooQLe

6 14 OBSERVATIONS ON KATATONIA, [Oct.,

Table A ( continued). M. F. Total.

Group 3, col. i . . 8. Midlothian F. resident 114.

col. 2 . . 4. Perth should be 6*5 4*4 5*5

col. 3 • • „ 0*6 0*4 0-5

Group 4, Notet, 1898, not 1888.

Table A x , col. 2 . . 4. Ireland „ 6*8 7*4 7*1

Table B lt Div. 1, hours outside, English Counties 61.

Total . 6*3.

2, „ „ 5 * 9 *

( l ) Phthisical insanity is, of course, but a small component in these figures.

Clinical and Experimental Observations on Katatonia.
By Lewis C. Bruce, M.D., Physician Superintendent,
Perth District Asylum, Murthly; and A. M. S. Peebles,
M.B., Assistant Physician, Perth District Asylum, Murthly.

The following observations were made by my assistant (Dr.
Peebles) and myself with the object of observing the physical
symptoms of katatonia and hebephrenia. As the result of
these observations we were led to make some experiments in
the way of treatment, and we combined with this work some
experimental observations on rabbits.

We have had under observation twelve cases of katatonia—
ten women and two men,—but we have been able to observe
only three cases of hebephrenia. We are therefore only in a
position to place before you to-day our work on katatonia.

Physical Symptoms of Katatonia.

The history of the disease in our cases was quite in line
with the classical descriptions of Kahlbaum and Kraepelin.
Hereditary predisposition was present in six out of the twelve
cases. In some the habits were vicious and drunken, in others
the habits of life were good, and as the course of the disease
ran typically in both classes, it is hard to believe that the
defective habits did more than lower the resistive power of the
individual, and were therefore only a predisposing cause. Three
of the patients had suffered from previous mental attacks; in
one of these cases at least * the previous attack was one of
katatonia, which was apparently completely recovered from.
In every case the origin of the illness was gradual and insidious.

Digitized by v^.ooQLe

piled from Schedules.

Digitized by

Digitized by v^.ooQLe

TABLE C.

Showing the relation of admitted to total cases dying of
Tubercular disease in 1899, English County and Borough
Asylums.

1 .

Total average number
Resident, 1899.

11 .

Admitted Tubercular
cases died in 1899.

III.

Total Tubercular cases
died in 1899.

Total.

30 Asylums,
with rate not
exceeding 2*

12,646

17,304

29,950

106

214

256

470

24 Asylums
with rate

over 2*

11,001

12,098

23,099

*45

399

361

760

9 (of above
24) with rate
over 3*

4,059

4,309

8,368

203

178

38x

54 Asylums .

23,647

29,402

53,<>49

129

122

251

613

617

1230

Column III per cent, of
Column 11.

Per mi lie Resident.

Per mille Resident.

Total.

30 Asylums .
24 Asylums .

382

S 45

5X2

501

443

524

4*4

2’9

3*5

6*3

16*9
363

14*8

29*8

157

329

9 Asylums

677

711

693

7*3

5-8

6-6

500

4 i *3

45*5

54 Asylums

475

506

481

5*4

4*x

25*9

21*0

232

78 Asylums (in¬
cluding those
in C,) .

459

499

475

5*4

4*2

24*8 |

20*8

227

TABLE Ci.

Showing 1 the relation of admitted to total cases of Fatal
Tuberculosis in 24 English, Scotch, and Irish Asylums
not included in Table C.

Total average number
Resident, 1899.

II.

Admitted tubercular
cases died in 1899.

III.

Total cases of Tuber¬
culosis fatal in 1899.

Total.

IBS

Total.

17 Asylums
with tuber¬
cular death-
rate not ex¬
ceeding 2

per cent. (5
years* aver-

4.893

8,927

1 6

age) .

7 Asylums with
rate over 2

4.034

121 ’

per cent.
None of these
exceed 3 per
cent.

3.375

3,266

6,641

103

IO3

206

24 Asylums .

7.300

15.568

.78

I49

327 :

Column III per cent, of
Column 11 .

Per milie Resident.

Total.

17 Asylums .

258

287

269

5*9

4 # o

> 5*3

u *4

13*6

7 Asylums .

644

3°‘5

3**5

31*0

24 Asylums .

395

465

425

5'4

4*4

4*9

21*5

20*4

210

TABLE D.

Effect of size of Asylum on Death-rate from Tubercle.
(5 years’ average.)

English County and Borough
Size of Asylums. Asylums (59).

All Asylums In Tubercu¬
losis Committee Report.

No. of

T. rate

No. of

T. death-rate

Asylums.

per 1000.

Asylums.

per 1000.

Under 300

... 13

... II

300 to 500

... 18

500 to 700

... 16

... 21*5

700 to 900

... 14

... 22

900 to 1100

... IO

... 23

Upwards •

... 16

... 23

Totals and mean

Digitized by t^.ooQLe

Digitized by v^.ooQLe

1903 -]

BY LEWIS C. BRUCE, M.D.

6 is

Loss of energy, listlessness, and nutritive failure were invariably
present. Then hallucinations of hearing of a distressing
nature appeared, leading to impulsive actions, or delusions, or
to paroxysms of fear with complete loss of self-control, which
necessitated hospital treatment.

Out of the twelve cases, nine women and one man were
adolescents. Of the other two cases, one, a woman, was over
thirty years of age, and the other, a man, was over forty years
of age ; and yet the disease was absolutely typical in both.

On admission all the adolescents were poorly developed and
poorly nourished. The two older cases were both well
developed, but their body-weight was below par.

For convenience of description we have divided the disease
into two stages : (i) the stage of acute onset ; (2) the stage
of stupor terminating in recovery or complete or partial dementia.

The physical symptoms of the stage of acute onset were as
follows:—The alimentary system was disordered in every case.
There was no desire for food, often no thirst. Vomiting after
food was common. The heart’s action was frequently rapid,
irritable, irregular, and intermittent. The arterial pressure
gradually rose until the acute s£age terminated. The skin
during mental paroxysms poured with perspiration ; blotchy
and pustular rashes were present in 50 per cent, of the cases.
No deficiency of urine or urea was noted in any case. Each
of the women patients menstruated once during the period of
acute onset, and then ceased to menstruate until recovery or
dementia terminated the disease. Dulling of sensibility to
touch, heat, and pain was very common. The pupils were
always dilated and sluggish in their reaction to light. The
special senses of sight and hearing were not affected so far as
outward impressions were concerned, but taste and smell were
often completely disorganised : two patients mistook strych¬
nine for sugar, and at least five of the cases were unaffected by
strong ammonia. In every case the organic reflexes of mic¬
turition and defecation were not under the control of the
patient; these cases always tend to be wet and dirty. The
skin and tendon reflexes were exaggerated. At uncertain
intervals the voluntary muscles passed into a state of katatonic
spasm, which lasted variably for a few minutes or hours.

The mental state was essentially one of confusion. Vivid
auditory hallucinations, always of a distressing nature, were

Digitized by

Google

6 i6

OBSERVATIONS ON KATATONIA. [Oct., 1903.

present in every case. There was an appearance of preoccupa¬
tion and fixed attention in these cases as they sat up in bed
listening intently. Or they would suddenly run to windows or
doors in response to imaginary voices. Very frequently these
hallucinations led to paroxysms of terror, when the patient
shouted and struggled and perhaps tried to jump through a
window, run out of the door, or hide under the bed. In the
intervals between paroxysms the patients might lie for hours
with eyes closed, apparently oblivious to all around. In other
cases, again, there were brief periods of sanity, but the patient
had always a confused appearance, and was soon exhausted if
spoken to. The power of continuous attention was gone.
There was no memory of what occurred during the acute stage.
Sleep during this period was deficient. The temperature was
irregular, sometimes slightly febrile in the evening, sometimes
paradoxical. In 50 per cent . of the cases the acute period
terminated in a distinct febrile attack. Leucocyte counts during
this stage showed a moderate persistent leucocytosis, the
increase being chiefly in the polymorphonuclear and large
mononuclear elements. Coincidently with the febrile attack,
or if the febrile attack was wanting, the stuporose or second
stage was ushered in by a high leucocytosis, the increase being
in the polymorphonuclear cells. Chart No. 1, illustrating the
first stage of the disease, shows the temperature, pulse, and
leucocytosis per c.mm. of blood. It will be noticed that the
acute stage terminated in a sharp fever, that coincidently the
leucocytosis rose to 68,000 per c.mm. of blood. At the
termination of the acute stage the patient may pass into a
typhoid state; only one out of our twelve cases presented this
symptom. Bacterial examination of the blood was made in
eight cases. The method adopted was to run 3 to 4 c.c. of
blood into 200 c.c. sterile broth by means of an exploring
needle passed into any prominent vein in the forearm. Five
of the flasks were sterile. Three contained organisms. Two
of these were apparently accidental contaminations, but
the third, obtained from the case which had passed into a
typhoid state, presented a pure culture of a short streptococcus.
The patient recovered from the typhoid state and passed into
stupor. On testing the agglutinative power of her blood upon
this streptococcus, we found that in a dilution of 1 in 30 with a
broth culture of the organism, agglutination was complete in

Digitized by v^.ooQLe

Chart

2 -

IB!

■

□

m i

■

■i

111

■

■1

■

EJ5

■

§£

■

□

■

■1

iff

■

!»

■

□

■

□

■

!■

■

□

xjo S? £? 55 o

43 3 S 2 3 3

«“*■" |isS2Sll.

Ill <9

,31

§§§§§?

Digitized by Google

6 i 8

OBSERVATIONS ON KATATONIA,

[Oct.,

two hours. Control normal bloods gave no reaction at the end
of twenty-four hours. The blood of the same patient failed
to agglutinate Bacillus coli communis , nor did her blood
agglutinate a very small coccus isolated from the blood of a
case of acute mania. We have tested the agglutinative power
of the blood of all our acute and three demented cases to this
streptococcus in dilutions of i in 20 and 1 in 30. Eight gave
definite complete clumping, three gave partial reaction, four
gave no reaction. No control ever gave a reaction. The
agglutinative reaction was slow, but was generally complete in
six hours. No control ever reacted in twenty-four hours. We
have tested the agglutinative power of the blood of fifty other
patients, not cases of katatonia, to this streptococcus, and only
five gave the agglutinative reaction. It is probable, therefore,
that the agglutinin frequently present in the blood of patients
suffering from katatonia is a specific agglutinin.

In no case under observation did the acute stage last longer
than four weeks. This of course only includes the period of
acute symptoms, not the prodromal period. The second or
stuporose stage of this disease came on immediately after the
febrile attack where such a symptom was present, or in
default of the febrile attack a high leucocytosis heralded the
onset of this stage. The physical symptoms of this stage are
so well known that I need not do more than mention them.
The alimentary tract was still disordered. The heart’s action
was weak and slow, the extremities were blue and cold, and
the feet and hands became cedematous. The arterial tension
fell. The lungs were liable to tubercular infection. The
temperature was uniformly subnormal. The skin sometimes
desquamated in small branny scales, sometimes was very
greasy, and a condition of “ varnished ” skin was noted.
Amenorrhoea was a constant symptom in women. It was im¬
possible to test the sensory functions, but the special senses
were quite active, as these patients knew what was passing
around them. There was a tendency to retention of urine and
faeces, the patient resisting these organic reflexes. The skin
reflexes continued increased, but the tendon reflexes often
could not be elicited on account of muscular resistance. The
voluntary muscles were thrown into resistance by any attempt
at passive movements. The mental state was one of stupor,
often complicated by delusions. Impulsive actions, curious

Digitized by v^.ooQLe

I9O3.] BY LEWIS C. BRUCE, M.D. 619

attitudes, mutism, rhythmical movements, sudden outbursts of
apparently maniacal excitement as sudden in termination as
onset, all the innumerable physical and mental oddities to
be seen in this disease, were well illustrated by the cases
under observation. Sleep returned and was, as a rule,
excessive. The condition of the leucocytes during this second
stage was interesting. Immediately upon the onset of the
stupor the leucocytes might fall to below 8000 per c.mm. of
blood, but soon they rose again, running on an average
between 12,000 and 16,000 per c.mm. The percentage of
polymorphonuclear cells fell to about 60, the lymphocytes

Chart 2.

fOm

N /o *

j 5 /<*

/ 8,000 IOZ

16,000 101

IkfiOO 100

I2j000 99

10,000 98

Sfioo 97
Sleep.

Puls£.

■

□

■

m ^ mm

■MM

^ mmm

■

w—
8

□

increased, and a transient eosinophilia occurred in every case.
Three out of the twelve cases have recovered, and in them it
was noted that the polymorphonuclear cells never fell below
60 per cent . As recovery progressed the leucocytosis did not
necessarily rise, but the percentage of polymorphonuclear cells
increased. When recovery was complete the percentage of
polymorphonuclear cells fell again to about 60. The leucocy¬
tosis never fell, however, lower than 12,000 per c.mm. Three
cases which have become demented, and a fourth which has
every appearance of becoming so, presented the following
peculiarities:—Early in the stuporose state their leucocytosis
fell frequently to 8000 and 10,000 per c.mm., and the per-
xlix. 43

Digitized by v^.ooQLe

620

OBSERVATIONS ON KATATONIA. [Oct., 1903.

centage of polymorphonuclear cells was below 50. In one of
the cases the polymorphonuclear percentage fell sometimes
below 30. Some indication as to prognosis can therefore be
obtained by examining the blood of these cases.

Experimental Observations on Rabbits .

The object of the experiment was to ascertain if the strepto¬
coccus isolated from the blood of the case of acute katatonia
produced any form of disease in rabbits. Rabbit No. 1 was
injected intra-venously with 1 c.c. doses of broth culture of the
organism. Rabbit No. 2 was injected intra-venously with 1 c.c.
doses of a filtered broth culture of the organism.

Rabbit No. 1 during a month received in all 7 c.c. After
each injection the temperature rose one or two degrees, and
latterly the temperature was irregularly febrile independently
of injections. At the end of the month the animal became
listless, dull, and lethargic, and the cutaneous reflexes were
exaggerated. The animal always took food. In the middle
of the sixth week we injected intra-venously 2 c.c. of an intra¬
cellular extract of the streptococcus. The temperature imme¬
diately fell to subnormal, and continued subnormal for two days.
The rabbit at the same time wakened up out of its lethargy.
Since then the animal appears to have become immune to the
organism.

Rabbit No. 2 showed no reaction to the intra-venous in¬
jections of the filtered culture, which points to the fact that in
broth cultures the toxin of this streptococcus is purely intra¬
cellular.

Rabbit No. 3 was inoculated subcutaneously with living
broth cultures of the streptococcus. Rabbit No. 4 was inocu¬
lated subcutaneously with an intra-cellular extract of the
organism. Both animals gave a slight febrile reaction to the
injections, but no other symptoms were noted.

Rabbits Nos. 5 and 6 were sprayed with living broth cultures
of the streptococcus, and by licking themselves were there¬
fore infected by the alimentary tract. Both animals gave
definite results. One or two days after infection their tem¬
peratures rose and continued irregularly febrile, independently
of subsequent infections. In Rabbit No. 5 a definite febrile
attack was noted ten days after the first infection with the

Digitized by v^.ooQLe

Chart 3.

Digitized by

Google

622

OBSERVATIONS ON KATATONIA,

[Oct.,

organism. This febrile attack lasted irregularly for three
weeks, when the temperature fell to normal, i.e . 9 101*4 in a
rabbit. Both animals took food, but they looked unhealthy,
and nutrition was imperfectly performed. They both suffered
from transient attacks of lethargy, and in both the superficial
reflexes were increased. Both animals became immune to the
organism about six weeks from the date of the first infection,
and any further infection not only failed to raise the tem¬
perature, but actually lowered it to subnormal for one or
two days.

Rabbits Nos. 7 and 8, sprayed with broth cultures of the
streptococcus killed by heat (6o° C. for 30 minutes), presented no
symptoms. Every rabbit, with the exception of Nos. 2, 7, and
8—No. 2 was intra-venously injected with filtered broth cultures,
and Nos. 7 and 8 were sprayed with dead cultures,—developed
a specific agglutinin to this streptococcus, complete agglu¬
tination taking place within the hour with dilutions of 1 in 50
and 1 in 100. We found, however, in testing the normal agglu¬
tinative power of rabbits* blood, that certain rabbits possess
serum capable of agglutinating this streptococcus in dilutions of
I in 20 and 1 in 30. The agglutination is often incomplete. We
have never been able to pass the organism through an animal
and obtain it again from the blood.

The treatment of katatonia is eminently unsatisfactory. All
but one of our cases, treated by rest in bed, fluid diet, saline
purgatives, ran through the various stages of the disease
unchecked. Our first effort at experimental treatment was to
immunise a goat to the streptococcus obtained from the acute
case of katatonia. We used the serum of this goat to treat
two cases in a condition of stupor in subcutaneous injections of
12 c.c. daily. Treatment in both cases had to be discontinued
on account of erythema and general urticaria. In one acute
case it produced the same complication and no beneficial
effect. We next exhibited the serum in 10 c.c. doses by the
mouth in two stuporose cases. In both cases the temperatures
fell very low, and continued very low during the period of
administration of the serum. The patients showed no signs of
improvement. The serum was again tried by oral administra¬
tion in huge doses, 80 to 140 c.c. in a day in the twelfth case
of our series during the acute onset of the disease. Here
it again lowered the temperature, but its curative effect was

Digitized by ^.ooQle

1903 ]

BY LEWIS C. BRUCE, M.D.

623

practically nil. We then treated five stuporose cases with
subcutaneous injections of broth cultures of the organism killed
by heat (6o° C. for 30 minutes). Three of these cases were
patients whose serum had failed to agglutinate this strepto¬
coccus. Our object in this experiment was to rapidly raise
the active immunity of the patients.

Case No. 1 received injections of 33 c.c. in fourteen days.
The highest temperature recorded was 99*8° F., and at the end
of three weeks the patient had gained 6 lbs. in weight. There
was no mental improvement.

Case No. 2 received 146 c.c. in forty-two days. The highest
temperature recorded was ioi*8 ° F. We believe this tem¬
perature to have been due to some accidental cause, as this case
was quite immune to large doses of the dead culture. The
patient gained 3 lbs. in weight during treatment, but there was
no mental improvement.

Case No. 3 received 82 c.c. during a period of twenty-four
days. The temperature was never febrile. There was no
gain in weight and no mental improvement.

Case No. 4 received 66 c.c. during a period of thirty-two
days. This patient gained 8 lbs. in weight. The temperature
rose once to 99*2° F. There appeared to be slight temporary
improvement mentally.

Case No. 5 received 56 c.c. during a period of thirty-three
days. There was no febrile temperature. The body-weight
increased by 3 lbs., but there was no mental improvement.

Eleven days after the last injection in each case the
agglutinative power of the serum was tested. In every case
the serum possessed a high power of agglutination. After
the failure of the goat’s serum to arrest the acute onset of
the disease in the twelfth case of our series, we commenced to
actively immunise the patient by means of subcutaneous in¬
jections of broth cultures killed by heat. This case was a very
acute one; each mental exacerbation was heralded by an attack
of vomiting and a feeling of sinking in the epigastrium.
Within twenty-four hours of these prodromal symptoms the
patient passed into an attack characterised by vivid hallu¬
cinations, wild terror, impulsive actions (especially trying to
jump through windows), noise, and sleeplessness. We anticipated
each attack by injecting first 4 c.c. and later gradually increasing
doses. On each occasion the attack was aborted. In a week

Digitized by

Google

624 OBSERVATIONS ON KATATONIA, [Oct.,

the pulse-rate had fallen, and each injection lowered the
temperature, which was inclined to rise prior to an attack. In
this case the treatment undoubtedly arrested the disease, but
how the injections acted we cannot explain. It is not possible
that an immune body was formed in the short period which
elapsed between the injection of the dead culture and the im¬
provement in the patients condition, a matter of two or three
hours at the very outside. Towards the later part of treatment
this patient also received by the mouth 2-minim doses of Acidi
Carbolici, highly diluted, thrice daily, but improvement was
most marked before this treatment was added to the injections
of dead cultures.

Our conclusions from these observations are that katatonia
is an acute toxic disease with a definite onset and course, in
which the symptoms vary according to the resistive power of the
patient, but in which the following diagnostic symptoms are
never absent:—A prodromal period of gradual onset, which
leads into the period of acute onset, with aural hallucinations,
mental confusion, paroxysms of excitement, impulsive actions,
katatonic spasm of the muscles, a hyperleucocytosis which at
the termination of the acute stage indicates a virulent toxaemia.
In the second stage a condition of stupor with muscular
resistiveness to passive movement.

2. That even at the onset of the disease there is in about 70
per cent '. of the cases an agglutinin in the blood-serum which
appears to be a specific agglutinin to a short streptococcus
which was isolated from the blood of an acute case of kata¬
tonia.

3. That by infecting rabbits through the alimentary tract or
blood-stream with this streptococcus a condition of malaise with
irregular temperature, increased skin reflexes, and mental
hebetude is induced. This disease tends to terminate naturally
in healthy rabbits in about six weeks, and a condition of
immunity is established to this organism.

4. That treatment by an antiserum obtained from a goat
has given no beneficial results.

5. That active immunisation of patients in the stuporose
state produced no curative effect.

6. That active immunisation in the acute onset of the disease,
tried so far in one case only, produced undoubted benefit, but
how this beneficial effect is brought about cannot be explained

Digitized by

Google

625

1903.] by LEWIS C. BRUCE, M.D.

by any theory at present held with regard to the production of
immunity.

Discussion

At the Annual Meeting in London, July 17th, 1903.

The President. —We are much indebted to Dr. Bruce for this most excellent
paper, and for the experimental work which he has done in regard to this interest¬
ing disease. I shall be glad if those present will give an account of similar cases
which have occurred in their practice.

Dr. Robert Jones. —I am very unwilling to begin the discussion, because I know
there are several members present who have not only had cases of the same kind
under their care, but have written extensively on the subject. I congratulate Dr. Bruce
upon the experimental work which he has been doing. I am incapable of discussing
the paper from this standpoint, because I have not worked in that direction ; but if
his paper leads to anything which will modify what I consider to be the greatest
scourge among our educated youths, it will do a great amount of good. I am
astonished to see the number of stuporose cases which have come under my care
recently, comparatively speaking; that is, within the last half of mv experience—
say ten or more years. My experience goes back nearly a quarter of a century, and
it was quite uncommon to have cases of katatonia and dementia praecox many years
ago, but now they have become comparatively common. At Claybury Hall, where
we have only fifty private cases, we have as many instances of this stuporose form
as in the main asylum with its 2400 cases! I was very much struck by our
President’s remarks—with whom, indeed, I have lately had an opportunity of dis¬
cussing this form of insanity—respecting the prevalence of these cases, and I shall
make use of my own experience in an address on a coming occasion. Dr. Bruce
says the rise of temperature is more or less typical of a patient who is under treat¬
ment for some time. I should like to know how much of that is due to the
patient’s condition under treatment,—that is to say, how much is due to the
difficulties that nurses and medical officers have in feeding these cases P I referred
yesterday to a case of cesophagotomy at the London Hospital. Precisely the
same chart is seen in this case, if food goes into the bronchial tubes or gets
into the lungs, after a certain time it gives rise to the same temperature reaction,
more especially if the food taken has been milk, and I have at the present time a
case of this kind which takes nearly ten pints of milk in the twenty-four hours l
I should like to know what Dr. Bruce’s experience with regard to the difficulty
of feeding these katatonic cases may be, and whether he connects the late rise of
temperature with a sort of subcatarrhal pneumonia—a form of broncho-pneumonia
which may eventually end in death, but which presents no symptoms in the way of
cough or expectoration ; and, indeed, very few symptoms on careful auscultation.
The early temperature one can to a certain extent understand, for there is a very
marked “ apprehensiveness ” in these cases. A case comes to my mind which used
to be dressed surgically at St. Bartholomew’s Hospital in my student days, and
which was reported in the Hospital Reports . When the dresser went to dress a
fractured tibia in the case of a child, the temperature sometimes rose to ioo°, and
after the dressing was over it went down again to normal. There is no doubt that
fear or apprehensiveness may cause such constitutional disturbance as may involve
a rise of temperature. I do not wish to take up the time of the Society any
further, but we have had an extremely interesting paper from an accurate
observer, and I congratulate Dr. Bruce on producing what I consider to be a
distinct addition to our knowledge.

Dr. Andriezen. —I have for some time paid attention to this particular subject
of dementia praecox, and recently I have published in the Hospital an article on
the subject, dealing especially with the varieties of this disease. I am extremely
pleased to have the opportunity of hearing Dr. Bruce’s paper, because it is an
example of the newer and better type of clinical work which is so necessary for the
advancement of our knowledge of many of these obscure mental disorders. A
large amount of evidence has been collected to show—and that is borne out by
cases one has seen and studied—that toxaemic conditions occur in many varieties

Digitized by v^.ooQLe

626

OBSERVATIONS ON KATATONIA,

[Oct.,

of dementia praecox. But I think we should not ignore the fact that has been
insisted on by the French school of alienists, that the whole group of insanities
which come under the heading of dementia pnecox shows, almost from child*
hood, symptoms indicating some degree of what the French call degeneration
of the brain. Sometimes it is allied to imbecility. Many subjects of dementia
pnecox who after adolescence become katatonic or demented, show in child¬
hood extraordinary characteristics, and tendencies to obsessions and impulses of
various kinds, duch conditions last practically throughout life—at least until
dementia supervenes,—showing that throughout the whole period of growth, in later
childhood at any rate, the brain is, as it were, evolving in a very abnormal,
anomalous fashion. And this must be borne in mind as the chief factor, because it
is in such subjects that toxjemic conditions will give rise to such extraordinary
reactions as profound stupor, resistiveness, and silly vagaries of conduct which the
mentally healthy individual afflicted with toxsemic conditions would not exhibit
apart from mental confusion. It struck me very strongly in the course of Dr.
Bruce's paper that his observations went far to show that we must drop to some
extent the old psychological metaphysical views which we have held about mental
diseases for so long. It is not so very long ago that, in Dr. Tuke’s Dictionary of
Psychological Medicine, the author of the article on katatonia, looking at it from the
old standpoint only, said there was practically no such illness—that katatonia was
really a melancholia which passed through a period of mania and went through
stupor, and finally ended in a state of dementia. It would be extraordinary if a
disease worthy of the name were a compound of four diseases. We know that
that is not so, but that it is one disease which passes through four or five stages,
which in their entirety constitute the disease. Katatonia and varieties of
dementia pnecox appear to us, from the most refined type of clinical research,
to be undoubtedly diseases in the strict sense of the term, for they run their
course through various stages, but these stages are not diseases by themselves,
—in other words, that katatonia is not mania, or melancholia, or stupor, nor
is it dementia ; but that it is a disease which has characteristic stages through
which it passes, and which have a natural sequence, although some of
these stages may be slightly abbreviated or aborted. But the whole series
of stages, taken together, comprise the disease. I am glad to hear Dr. Jones
say he meets with more cases of katatonia than formerly. I meet with more
cases of it than I used to. It is interesting to hear Dr. Bruce’s observation that
the toxaemia need not necessarily be febrile. It used to be widely believed in
asylums that it was. In the very early stage of general paralysis, the temperature
having been regularly taken, we looked for a rise of temperature but seldom found
it, and then we doubted whether there was toxaemia at all. But at that time, which
was ten or eleven years ago, we made no observations on the leucocytes, and we
were not certain whether there was toxaemia or not. But the observations made
during the last eight or nine years tend to show that a certain amount of leuco-
cytosis above the normal occurs in the early stage of general paralysis, and where
there is a slight febrile reaction leucocytosis is very much more marked, showing
that we have here a new means for determining whether some serious degree of
toxaemia is present or not. As regards katatonia my studies have been chiefly in
the clinical direction, but the conclusions I have come to in this respect seem to
show that it must be deemed worthy of inclusion in our system of classification; it
has not yet been included in our psychological tables or statistics. Many of the
cases of katatonia have been called “ stupor,” and other cases have been included
as katatonia which were merely secondary stupor. If more papers of this character
were read which contained clinical evidence of the sort which is necessary, it would
do much to clear our ideas and make us drop a good deal of our old psychology,
helping us to a better classification of the types of mental disease.

Dr. Hayes Newington. — I used to pay attention to this condition of stupor, and
katatonia is certainly a new product since the time when 1 did pay attention to
the matter. I have read one or two papers on katatonia, and I have noted what
has been said about it here, and especially what fell from Dr. Andriezen.
Katatonia is talked of as a disease. But if it is to be regarded as a separate
disease we want a definition of it, and when we have got that we want it accepted
generally. But in many of these questions of nomenclature—especially that
dreadful word “confusion,” which is becoming so prominent—one comes to see that

Digitized by v^.ooQLe

1903 ]

BY LEWIS C. BRUCE, M.D.

627

so many people have so many different opinions. We find that one man is talking
of a group of symptoms under a name which perhaps does not quite cover the par¬
ticular group of symptoms which another man might associate with the same term.

Dr. Mott. —I should like to congratulate Dr. Bruce on this attempt to throw
some light on an obscure disease. It is an effort in the right direction, it seems to
me, to find out what the exciting cause in these cases is. And the toxic idea is
the one which I think should be studied carefully. I would like to ask Dr. Bruce
one or two questions. First of all, does he claim that there is a specific strepto¬
coccus in this disease ? His experiments on rabbits rather led me to suppose that
he did claim a specific organism which would produce in the rabbit, when the
toxin was injected, a condition somewhat similar to that observed in the patients.
Now, to prove that, it would be necessary, it seems to me, to take streptococci
from other sources, or else perhaps you have only sick rabbit. I do not wish for
a moment to throw any cold water on the very laudable attempt which Dr. Bruce
has made, because I really think that this is a move in the right direction, and I
think Dr. Bruce will fully admit any criticism that I offer is in the most friendly
spirit. It is no good sitting down and looking at these patients any longer; the
proper thing is to find out what is the cause of the toxic condition of the blood.
To make his experiment more complete with regard to rabbits it would be better—
and I speak from some experience in experimental medicine—if he would try some
other animal. Rabbits are very fallacious animals; many mistakes have been
made by using them. If he could use the streptococcus or the toxins from the
blood of these cases on the dog, he would find that animal much more intelligent
and satisfactory, because streptococci are very potent organisms, and produce pro¬
found effects. Another question I would ask Dr. Bruce is, are these streptococci
generalised in the blood in such cases, or where do they exist ? Where has he
obtained his cultures from ? I understand he has only got it in one case (Dr.
Bruce : Yes). Of course it would be much more demonstratively proved if he got
it in every case. And I think that the temperature chart which he shows is rather
suggestive of a possible complication. If this disease were due to streptococcus
one would have expected the temperature to be high early in the disease, when the
leucocytosis is still active. I offer it as a suggestion, that this would have to be
answered before we could accept the view that this was the cause of the condition.
Dr. Jones pointed out that it is very easy to get a little broncho-pneumonia in
these cases, and one which you cannot discover by physical signs. I have seen
that so often in making post-mortem examinations, and no doubt Dr. Bruce has
also seen it; and it would give rise to that temperature and to leucocytosis. But
I do say that Dr. Bruce is to be heartily congratulated on a move in the right
direction, and I wish him every success in this attempt, by clinical observation and
experimental research, which is the only way, to solve some of these difficulties
which we have to deal with.

Dr. B ruce. — I am much obliged to the various gentlemen who have spoken for their
criticisms. Taking the first temperature chart, I quite admit that the temperature,
on the face of it, looks exactly like that of a case where there has been a little
accident in feeding. But that is not the only temperature chart I have. The
majority of mjr cases I never touched, beyond observing them carefully at the bed¬
side and working in the laboratory at the blood. I interfered in no way with the
course of the disease. The cases were in charge of special nurses, and there was a
temperature similar to this in other cases, without symptoms in the lung; and they
were overhauled by both of us and by a clinical clerk, and we could detect nothing
in the lung which would account for this. The blood was sent up to Burroughs
and Wellcome’s laboratory to be tested for typhoid fever, because the condition
of the patient suggested that illness. Again, there are other cases where
you get a rise of temperature to only 99 0 or ioo n for one night, but a huge
leucocytosis; and then two or three days afterwards the patient passes into a state
of stupor. I am willing to admit that these temperature charts, of which I have at
least ten good ones, might be construed as being due to pneumonia, and I have so
frequently seen broncho-pneumonia in acute mania producing such charts that I
was very suspicious. But it was not till I got a series of cases that I began to
think, here is the termination of an acute attack; the temperature falls, the
leucocytosis goes down, and the patient goes straight off into stupor. These
cases were fatal, with one exception. I had to feed one case with the nasal

Digitized by v^.ooQLe

628

OBSERVATIONS ON KATATONIA.

[Oct.,

tube, but all the others were carefully fed with milk. They got three to
four pints of milk during the day, and a pint at night, in addition to other
fluid diet. The idea of filling these patients up with custards and hard food
which requires much digestion is irrational and bad treatment, besides being cruel.
1 agree with Dr. Andriezen that in all these cases hereditary predisposition is the
chief cause. There must be some very serious change in the resistive power of the
patient from youth upwards. But I do not agree with Dr. Andriezen when he calls
these cases dementia praecox. I do not know that there is such a thing. Why
should we classify a disease in accordance with its termination ? If we carried
that out we should say all disease is death, because it ends so. And if you classify
a case according to whether it ends in dementia or not, to be consistent you would
have to classify all diseases under one heading. There is a great difference
between katatonia and hebephrenia; you do not get the same agglutinin in the
blood in hebephrenia that you do in katatonia. Dr. Hayes Newington says when
you get a collection of symptoms you cannot always call it a new disease; and
apparently he is not very much in favour of the new name katatonia. You have a
distinct collection of symptoms, which are apparently a distinct disease. What shall
you classify it as ? Are you going to classify it as melancholia, or as mania ?
You get a collection of symptoms which are neither the one disease nor the other.
What will you do ? Shall we stick where we have been for the last twenty years
because we are afraid of putting a new name to our collection of symptoms ?
Katatonia is not melancholia ; compare them one with the other. Take the blood
of a case of mania, and you will not get the blood agglutinated by streptococcus.
There must be some specific condition ; there must be some difference between
katatonia and mania, and between that and melancholia; and we must have some
name, otherwise we cannot classify such cases.

Dr. Hayes Newington. —The reason I raised the question at all was that we
heard dementia praecox mentioned, which was also a new name, and they both
seemed to be recognisable diseases in certain quarters.

Dr. Bruce. — I think every case except general paralysis would come under the
term dementia praecox according to some works in America; and under some of
the names they have brought out, such as 11 depressive insanity,” even general
paralysis could be included. Dr. Mott’s criticism I value very highly, and I agree
with him about the rabbits. A rabbit, I find, is a most unsatisfactory animal to
work with ; its temperature seems to go up very readily, and it is easily frightened.
I do not know that I could go the length of saying that this streptococcus is the
specific one which causes the disease, but apparently it must have something to do
with the disease; it is either a primary or a secondary infection, because you get
this agglutinin so constantly in the blood of these cases, and I am not certain
whether the streptococcus is present in every case. In the only case in which I got
it, it was in the blood ; and in the few instances in which I have got organisms in
the blood of the insane the patients have been in a desperate state—in a state of
typhoid collapse,—and you may say the organisms were the terminal infection.
They existed in the blood, and on examining the films which we took on the same
day I got two typical examples of this organism, showing it must have been fairly
numerous in the blood on that day. The girl was treated with frequent saline
infusions, and she made a very good recovery indeed. I have examined the
alimentary tract in all cases where there was vomiting, and we have made cultures
and tried to isolate the organism from it, but have failed. We have not obtained
that organism again from any source whatever in these cases of katatonia. I got
it from a girl, but I never examined the vagina, as there was no likelihood of
infection. If this sort of work will stimulate anyone to make similar observations,
then I shall be very pleased, because I am absolutely certain that any future advance
which we are to make in psychology, so as to bring our speciality abreast of other
specialities and equal to the advances in general medicine, must be made by work
at the bedside in association with work in the laboratory.

Digitized by ^.ooQle

1903.] FEMALE NURSING OF MALE PATIENTS.

629

Female Nursing of Male Patients in Asylums . By
A. R. Turnbull, M.B.Edin., Medical Superintendent,
Fife District Asylum.

The question of utilising female nursing to a greater extent
than formerly in the care of male patients in asylums has
roused much interest of late years, and has been brought under
the consideration of the Association on several occasions. In
advocating the adoption of this form of nursing one is apt to
give the impression that the method is something entirely new
as applied to asylum patients. But that is not intended, for
in reality the system has existed to some degree for a long
time; and it is only the question of the advantages of extending
it, and making it much more systematic and complete, that is
now raised. In some places on the Continent it has been in
use for a number of years, and is developed to a greater extent
than is usual in this country. In April last I had an oppor¬
tunity, in company with Sir John Sibbald, formerly Commis¬
sioner in Lunacy for Scotland, Dr. Fraser, Commissioner in
Lunacy for Scotland, and Dr. Robertson, medical superinten¬
dent of the Stirling District Asylunvof visiting two institutions
in Holland and seeing the method in practice; and I now venture
to submit some notes, not by any means exhaustive, of what
was observed there, and to make these, and my own further
experience of the system at the Fife Asylum since 1896, when
I had the privilege of reading a paper descriptive of it at the
annual meeting of the Association, the basis of my remarks at
this time.

The institution first visited was Meerenberg, near Haarlem.
This asylum gives accommodation for over 1300 patients,
of whom more than 600 are males. Some of these are private
cases, paying high or moderate rates of board, but the great
majority correspond to the class of our rate-supported or
pauper patients. The medical superintendent, Dr. van Deventer,
was formerly in charge of the largest of the general hospitals
in Amsterdam. He was appointed to Meerenberg in 1892,
and since that time has re-organised the staff there most care¬
fully and with great enthusiasm, and in doing so has made it
his aim to bring the nursing and care of the patients into line
as much as possible with what is looked for in a well-managed

Digitized by

Google

630 FEMALE NURSING OF MALE PATIENTS, [Oct.,

hospital for general diseases. In a tabular statement attached
to an interesting paper by Dr. van Deventer it is shown that
at Meerenberg the staff on the male side consists of fifty-seven
females and forty-six males. In each section of the asylum
there is a head female nurse, who takes her orders from the
medical officer in charge and is responsible for seeing his
directions carried out by the staff under her. The ward for
idiots is entirely under female charge. Two wards for restless
cases (containing 108 patients out of a total male population
of 609) are staffed with male attendants only, though still
under the supervision of the head nurses of their respective
sections of the asylum. In all the other wards there is a mixed
staff of males and females, the latter being the more numerous
in almost every instance, and always having the main charge
and responsibility. The head male attendant has his principal
duty in supervising the patients when they are in the work¬
shops or outside in the grounds. In going through the wards
at Meerenberg one finds abundant evidence that this system of
female care is carried out in practice in a very thorough way,
and that the nurses have by far the most important part in the
oversight and charge of the male patients. In the indoor work
of many of the wards th$ male attendants are relegated very
much to ordinary domestic duties, and have little to do with
the direct management of the patients. Dr. van Deventer in¬
dicates that the male attendants do not find the same satisfac¬
tion in their ward duties as the female nurses do ; and doubt¬
less this is due, in part at least, to the subordinate position they
have to take in the wards, without prospect of promotion.
Consequently it is difficult to secure and keep a good class of
attendants, and Dr. van Deventer considers that to obviate
this difficulty it is desirable to employ only those who under¬
stand a trade, by which they may be enabled to rise afterwards
to better posts. Another point which impressed itself strongly
on me is that in the management of a few very excited and
troublesome cases there is a tendency to resort to the use of
seclusion somewhat more readily than would be considered
advisable by many of us,—this being, indeed, inevitable, as it is
recognised that on the ground of physical strength alone the
nurses could not be expected to control these patients for any
prolonged period. But in making reference to that point I do
not in the least imply that seclusion is used more freely at

Digitized by v^.ooQLe

1903.] BY A. R. TURNBULL, M.B.EDIN. 63 I

Meerenberg than elsewhere in Holland, for I have not the
material for making a comparison in regard to it, and it is
quite possible that at Meerenberg the amount of seclusion is
not greater, and may even be less, than what it is in other
Dutch asylums. Under Dr. van Deventer’s superintendence
there has been built at Meerenberg a sisters’ home, giving
accommodation for over 130 nurses, while in addition about
sixty nurses have rooms in the asylum buildings proper. The
home, in addition to the bedrooms, has a very large hall, in
which the nurses dine in association; a smaller sitting or recrea¬
tion room; and—a feature which impressed us most favourably
—a study room, which is well supplied with diagrams, models,
instruments, and books bearing on the subject of the training
of attendants on the insane. It may be of interest to mention
the system of training of nurses which is adopted by Dr. van
Deventer, as it differs much from what is usual in our country.
During the first year the probationers remain in the nurses’
home and learn domestic work there. During the second
year they go to the laundry section, learn the work of the dry
laundry (without being expected to work in the wet laundry),
are employed in making and repairing the clothing of the
patients, and have the supervision of the patients working in
that part of the asylum. It is only after this preparatory in¬
struction that they take duty in the wards proper, and after a
year’s work there (making a total of three years’ training)
become eligible for examination for the certificate of efficiency.
There can, I think, be no doubt that the system of female care
of male patients at Meerenberg, as administered by Dr. van
Deventer, with the valuable assistance and special knowledge
of Mrs. van Deventer (who is a trained nurse, and, though hold¬
ing no official position in the asylum, takes a keen interest in
the work, and gives it her most hearty support), secures intel¬
ligent, efficient, and tactful management of the patients, and
that the relations between the nurses and the patients are of a
very satisfactory kind.

The other institution visited was the Wilhelmina Hospital in
Amsterdam. It takes the place of the old Buitengasthuis or
Infirmary, which is now abandoned. Dr. van Deventer was
formerly superintendent of the Buitengasthuis, and the newly
erected Wilhelmina Hospital was being opened under his
direction when he was called to Meerenberg. It is now under

Digitized by v^.ooQLe

632

FEMALE NURSING OF MALE PATIENTS, [Oct,

the superintendence of Dr. Kuiper. It consists of a block for
medical cases, another for surgical cases, and another for mental
cases (male and female). But while the building for mental
cases is thus part of a general hospital, it is also an asylum in
the usual acceptation of the term, for the patients here are
under certificate and legally subject to compulsory detention.
The procedure, in fact, is that the patient is certified as being
of unsound mind, and authority got for placing him in one of
the regular asylums of Holland. Then under a special arrange¬
ment the Burgomaster of Amsterdam issues a further order by
which power is given to send the patient to the Wilhelmina
Hospital instead of to the asylum ; and from the hospital he
can afterwards be either discharged to his own home or trans¬
ferred to the asylum, as may be found desirable. The building
was planned for sixty patients on each side, but the pressure of
requirements has made it necessary to receive a much larger
number. On the male side, which is the more crowded, there
are over a hundred beds. It is intended that the limit of
residence should as a rule be six weeks, but a few cases are
kept for much longer periods. As, however, the admission
rate on the male side is about thirty per month in a total popu¬
lation of a little over a hundred, it is evident that the movement
of the patients must be very rapid, and that many of the cases
must be instances of the short-lived forms of insanity, such as
that following on acute alcoholism. Except that the doors are
locked, the arrangements of the building are very similar to
those of the wards of an ordinary hospital. The patients are
mainly in dormitories; many of them are treated in bed, and
the medical care and the attendance by the nurses are carried on
in the same way as in a ward for ordinary medical or surgical
ailments. There are a few separate small rooms for the treat¬
ment of very troublesome or noisy cases. Under the medical
staff a matron and a head nurse are in charge of the building;
and we were much interested to find that the present matron
Miss Kruisse, served for four years on the nursing staff of the
Edinburgh Royal Infirmary, and still keeps up a very friendly
intimacy with the lady superintendent of nurses there. On the
male side more than half of the staff under the matron and the
head nurse consists of female nurses. It is, however, considered
that the most restless cases are more suitably managed by men,
and the rooms for them are staffed with male attendants under

Digitized by ^.ooQle

1903 ]

BY A. R. TURNBULL, M.B.EDIN.

633

the supervision of the matron and the head nurse. For night
supervision there are three dormitories, in which respectively
are placed (1) restless cases, (2) less restless cases, and (3) calm
or convalescent cases. The first and second of these are under
male attendants ; the third only is under female charge, and for
it male assistance can be got readily if required. For the
hospital’s diploma in general nursing it is necessary to have
three years’ training. Time spent in the mental wards is
allowed to count in making up the three years ; but if the
certificate for mental nursing is also desired it is necessary to
serve again in the mental wards for several months after getting
the general diploma.

Our party felt themselves greatly indebted to Dr. and Mrs.
van Deventer, Dr. Kuiper, Miss Kruisse, and the members of
their staffs for the very kind reception given to us, and for the
courtesy and readiness with which they supplied us with all
the information we desired.

I turn now to my own experience in the Fife Asylum. In
the paper read before the Association in 1896 I described the
plan which had been introduced there some time previously of
having the male sick-room under the charge of the female staff*.
The object aimed at was that all cases on the male side which
had to be in bed on account of bodily illness should, whenever
possible, be in the sick-room, and should be nursed and managed
in exactly the same way as if they were in the ward of an
ordinary general hospital. I was able then to speak most
favourably of the result of the experiment as having had a
very beneficial effect both on the patients and on the staff*.
The system has been continued up to the present time, and
the added experience of seven years has confirmed and empha¬
sised all that was said in its favour in 1896. The difficulties
which one looks for in dealing in this way with male insane
patients have vanished when put to the test of practice ; the
care of the patients has been greatly improved ; the patients as
a rule appreciate what is done for them, and submit readily to
be guided by the nurses ; and the nurses take readily to the
work and find pleasure in it—and, indeed, they often say that
the male sick-room is more easily managed than any of the
wards on the female side. It accentuates the feeling that there
is real nursing to be done in asylum duty. Under our present
arrangement newly admitted cases, if requiring treatment in

Digitized by v^.ooQLe

634

FEMALE NURSING OF MALE PATIENTS, [Oct.,

bed on account of their mental state, are also sent to the sick¬
room. I must guard against giving the impression that every
patient for whom bed-treatment is desirable goes without excep¬
tion to the sick-room. In my experience this is not the case,
but the number of those who have to be kept away on account
of the sick-room being under female charge is found in practice
to be remarkably small. It is, in fact, limited almost entirely
to those patients who on account of acute restlessness, noise, or
similar disturbing condition are not suitable for association with
other patients, sick or otherwise. In the Fife Asylum these
are treated in separate rooms in a small ward in the main
building, quite away from the sick-room, and are under the
charge of male attendants. It is, I think, an error to expect
that all the cases sent to an asylum will be suitably managed
under one system alone, and it is better that our arrangements
should possess some elasticity and allow of the details of
management being varied as circumstances may require. For
example, a tall powerful man in the acutely maniacal stage of
early general paralysis was admitted to the asylum some months
ago. He was exceedingly restless, incessantly leaving his bed
and trying to get out of the room, very resistive, often struggling
in an obstinate way with those near him, and quite unable to
take any proper care of himself. He was evidently unfit for care
in the sick-room, both because he would overtax the strength of
the nurses and because he would disturb the other patients
there. This condition lasted for many weeks, and during that
period he was kept in bed in a room in the small ward already
referred to, and was under the charge of male attendants, who
were able to manage him without resort to seclusion and
without any cessation of direct supervision. In time the acute
excitement passed off; and now, when the increasing paralysis
and consequent bodily weakness from the advancing brain
disease are the more prominent and urgent conditions in his
case, he has been transferred to the sick-room and is easily
managed by the nurses. But, as already indicated, such cases
constitute only a very small proportion of exceptions, and the
great majority of patients requiring bed-treatment can go to
the sick-room. The system has proved so successful, and is so
evidently beneficial, that it is regarded as an essential part of
the organisation of the asylum ; and when some additions which
are at present being made to the hospital building are com-

Digitized by v^.ooQLe

1903.] by a. R. TURNBULL, M.B.EDIN. 635

pleted I hope to extend it still further, and to place several
more rooms under the direct charge of the nurses.

If now we consider the question, To what extent can
female care be advantageously utilised in the management of
male cases ? I would in the first place say that there are two
classes of patients for whom it has been proved to be service¬
able. At one end, as it were, of the line of male patients are
those who, on account of bodily ailment, require special sick
nursing, which can without doubt be best given by trained
female nurses. A number of asylums have adopted the plan
to that extent, with results which show that it has passed
the stage of being tested and can now be regarded as having
proved its value. At the other end of the line are patients
whose insanity is of a chronic form, who are in good bodily
health, and who are quiet in conduct and present no special
difficulty of management. In some asylums it has long been
customary to have this class partly under female charge; and
of course we all know that in the case of chronic patients
discharged from asylums as still unrecovered, and placed under
private guardianship, the supervision is very largely in the hands
of females. For example, in the Fife Asylum there has been
for more than thirty years a detached villa for thirty-two
patients of this class, under the charge of an attendant and his
wife. The plan has worked for all these years without any
difficulty, and the presence of the attendants wife is bene¬
ficial in securing greater tidiness and orderliness in the house¬
work, and in the serving of meals, etc., and in promoting a
better tone of conduct among the patients. From the position
already occupied at each end of the line, it is, I think, possible
and advantageous to extend the system to a considerable
degree among the patients who lie between the two groups
which have been referred to. There is now a growing recog¬
nition of the fact that some forms of insanity of recent occur¬
rence derive benefit from rest in bed, even when there is no
special bodily ailment present; and that brings them into the
group for sick-room care. Similarly many senile patients,
bordering as they do on the class with active bodily ailments,
are easily and beneficially kept under female charge. And
again, those cases which progress steadily to recovery may
with advantage remain in the hospital under the nurses, and
be saved from the possibly unfavourable experience of being

XLIX. 44

Digitized by v^.ooQLe

6 3 6

FEMALE NURSING OF MALE PATIENTS, [Oct.

placed among confirmed cases in the chronic wards. With
suitable arrangements of the buildings there need be little
difficulty in increasing the number of quiet chronic patients
who are partially under female supervision. What has been
done at Meerenberg shows that it is possible to extend the
system through nearly all the wards on the male side. But
while I greatly admire Dr. van Deventer’s work, I am not
persuaded that it is advisable, as well as possible, for us to
develop the system on exactly the same lines as have been
followed at Meerenberg. I have found that the nurses, in
taking charge of male patients, prefer for obvious reasons to do
so by themselves, and do not care to undertake it in association
with male attendants. Except, therefore, in those instances in
which a married couple are in charge of a ward or separate
house, with or without a staff of junior attendants to assist
them—and, as already indicated, I believe that this method
can be extended with advantage,—my feeling is against having
a mixed staff in any ward. The ward staff should, I think, be
either entirely male or entirely female. I have already mentioned
that a proportion of the recent and acute cases require, according
to my experience, to be under male charge. Then we know
that, in addition to its curative function, an asylum has also a
very large duty in taking care of the chronic insane, most of
whom will spend practically all their days in the institution.
For them it is requisite to provide a routine of life which will
include regular outdoor employment and exercise during the
largest part of every day, with suitable supervision of their
conduct and habits at all times. For that purpose attendants
are evidently necessary ; and if we debar mixed staffs except
in the circumstances already referred to, it means that a con¬
siderable number of the wards for chronic cases must still
remain under male charge so far as actual attendance is con¬
cerned. I would apply the same principle in regard to night
supervision. If the number of cases requiring active nursing
at night is sufficiently large to fill a ward, I would place it
under the charge of the nurses. But much of the night-work
in an asylum is of a kind that is more suitably done by male
attendants, and I would put the larger part of it under them,
or even the whole of it rather than have a mixed staff in any
ward. In conclusion, I would say that in asylum work among
male patients there is scope for the aid both of attendants and

Digitized by v^.ooQLe

1903-]

BY A. R. TURNBULL, M.B.EDIN.

637

of nurses, and our aim should be to i&cure the best features of
both classes of assistance. In doing so it is, I believe, possible
and advantageous to extend further the use of female nursing
on the male side, while still retaining much important work for
the attendants.

[Note.— As Dr. Robertson was expected to take part in the
discussion, I intentionally did not make any reference to the
great development of the system of female nursing which he
has instituted at the Stirling District Asylum, hoping that he
himself would describe it. Unfortunately Dr. Robertson was
prevented from attending the meeting.—A. R. T.]

Discussion

At the Annual Meeting in London, July 16th, 1903.

The President. —I am sure we are much indebted to Dr. Turnbull for his paper,
which we value very highly, upon the nursing of the male insane by female nurses.
It is a subject which has engaged the attention of most of us superintendents
throughout the kingdom. I began in a very small way in my male hospital
with a married charge attendant, the wife being a trained hospital and
trained asylum nurse. I now have both charge attendant and wife with the
certificate of the Association, and the wife is a trained nurse too. I find they work
admirably. The sick are far better looked after than they were before in those
little attentions in regard to which women are so needful. The comforts of the bed
are so much increased, and the various little attentions in sick nursing, which can
never be done by a man, are properly carried out by female nurses. I have not
extended this method so far as Dr. Turnbull and Dr. Robertson have, but I am
watching what they are doing, in the hope that we may be able to extend it more
fully.

Dr. Robert Jones. —I should like to say one or two words in praise of male
attendants. I cannot but think that in the large number of cases with which we
deal, especially at Claybury, we have a different type from those in the urban
districts outside London, or those in rural districts. Of course one knows very
well that the presence of females exercises a very considerable inhibition upon
men; and if insanity is to be regarded as a loss of inhibition, there, to my mind,
comes the personal magnetism, or personal effect, of the female nurse. We know
very well that when the ladies have risen from the dinner table the stories will not
bear analysis; just so it appears to me to be with the insane. You bring them to
associate together at entertainments, and you will find occasionally that even the
most excitable will be tolerated as an agreeable neighbour in the entertainment
room. I should like to know whether Dr. Turnbull looks upon this question from
the maintenance point of view. It is, of course, cheaper to run asylums as far as
you can with woman labour, and I should like to know whether that entered into
his consideration in regard to female nursing. It does seem to me that a good
deal might be said in favour of the male attendant. As an example of that I have
at the present time a male patient who swallowed a mutton vertebra, and in
consequence of which he had to go to the London Hospital, where he is at the
present time, having undergone the operation of cesophagotomy. His surgical
needs are looked after by the female nurses of the hospital, but he has one of our
own male attendants by day and another by night; and I learn that the attendance
given by the male staff is very much appreciated indeed by the hospital authorities.
We know how difficult it is to keep patients from having bedsores in the late

Digitized by v^.ooQLe

638

FEMALE NURSING OF MALE PATIENTS,

[Oct,

sages of general paralysis; and {^hink at one of the asylums mentioned by the
Lunacy Commissioners, via., that at Yarmouth, for sixteen years they have not had
a bedsore; and there, I believe, the nursing has been carried on by male attendants.
It is not that male nurses are inefficient, but it is, I presume, that the female nurse
has a very distinct mental effect upon the male patient. I was very much surprised
to hear of the mixing of the staff at the asylum under Dr. van Deventer in Holland.
I had some reports sent to me in regard to Dr. Deventer’s asylum, and I am glad
to find Dr. Turnbull’s personal reminiscence corroborates these, and that his own
experience has been so happy in this respect.

Dr. Oswald. —I desire to take part in this discussion, but first of all I wish to
congratulate Dr. Turnbull on the very temperate and able way in which he has
opened the discussion which is now before us. We recognise Dr. Turnbull as a
pioneer in this department, and all of us who have adopted female nursing in male
wards look upon him as our master, in that we are all practically imitators of his
method. In Scotland during recent years much attention has been directed to
this subject; and very few of the Commissioners* Reports on any Scottish
asylum have refrained from mentioning this method of nursing, commending it if
it existed, and if not already adopted, strongly advising that it should be
introduced. I desire to specially agree with Dr. Turnbull as to the disadvantage
there is in having a permanent mixed staff in any ward ; and, if the evidence of the
male attendants is to be taken, there are certainly male patients for whom female
nursing is not only to their harm, but very much to their harm. Quite recently I
had an application from an attendant who had been a long time in a Scottish
asylum which is adopting female nursing in the male wards. This attendant
said his only reason for leaving was because he found the presence of females in
the ward was producing in the patients the very symptoms that he was put thereto
try to avoid (hear, hear) ; and he said for that reason he felt he could no longer
conscientiously do his duty, and therefore he asked to be relieved from the position
which he held. Quite apart from the evidence of attendants—and I believe there
is still a large ana useful scope of work for male attendants in asylums,—I think
if one takes the evidence of patients there are undoubtedly those who would
rather not be nursed by female nurses. I had five years’ experience of this method,
and I think at Gartlocn we were among the first after Dr. Turnbull to introduce it.
We had there about seventy men under female nurses, and I was in the habit, when
patients recovered and went away, of asking them to give me their opinion and
to state whether they preferred to be nursed by men or by women. In a few
cases I had letters from patients who said they had thought of asking to be
removed from the wards where nurses were in charge, to the asylum wards where
male attendants were on duty. They gave their reasons for it, and they were
perfectly good and obvious. I think for that reason we ought to consult the
wishes of the patients, and I do not think the verdict would be unanimously
in favour of the nursing being undertaken entirely by women. On the other
hand, I believe there is a very large class of patients who can, with advantage
to themselves, be nursed by female nurses. And it is a fact that epileptic and other
irritable patients are more easily soothed—there are fewer outbursts of excitement,
and fewer trivial accidents happening—when you have these patients nursed by
women. But I am specially ot the opinion—and I would wish to emphasise my
agreement with Dr. Turnbull on the matter—that it is inadvisable to have a mixed
staff in wards. I have tried it, and found it to be not what it should be: the
nurses did not like it, and the attendants did not like it; and the nurses would
do things for patients if they were alone which they would not do if male attend¬
ants were with them.

Dr. Thomson. —I take some interest in this subject. I wrote a communication
to the Journal of Mental Science a year ago because I was much struck by a
paper which was read by Dr. Robertson at the annual meeting, I think in
Edinburgh. It was reproduced in the Journal, and I was very much astonished
and struck by it. I am also astonished by what Dr. Turnbull said to-day in
advocacy of this, to my mind, preposterous nursing of male insane patients by
females. I think the whole subject is summed up in the meaning we attach to the
term “ nursing,” the term “ sick,” and so on. I quite understand and readily
admit that women nurses do as well as men—I deny they always do better—in
nursing the sick ; and by the sick I mean those who are in bed. I mean not only

Digitized by

Google

1903.]

BY A. R. TURNBULL, M.B.EDIN.

639

those who are being treated in bed for their acute mental trouble, as seems to be
generally done, but those who are bodily sick. I admit that they might be nursed
by women nurses; but one must consider how very few actually sick one has in
any asylum. I cannot help repeating a great deal of what I said in that com¬
munication to which I have referred. I go round my asylum to-day, with
450 male patients perhaps, and I do not find half a dozen sick people in bed.
These cases can be analysed. What are they P One may have an ulcer in his
leg, another may be in the last stage of general paralysis, another has an ailment
which might occur to anyone. That these people can be nursed by women
1 admit; they may as well be nursed by women. We have heard this general talk
about nursing by females, using nursing in its widest meaning; but what does
this mean ? I maintain that there is no nursing to speak of required. What the
majority of our patients require is attendance; they require all the assistance that
is necessary for people who cannot take the initiative themselves. They require
dressing, and so on, in the same way that a very old gentleman wants a valet
to dress him and help him when he has a call of nature. In general hospitals we
find that while patients are in bed the female nurse will do anything for them; but
as soon as the man is convalescent and leaves the bed he attends to himself—his
bathing and his calls of nature. Are we to apply that arrangement to insane or
asylum patients ? Or what is the detail of the arrangements adopted ? Do the
women nurses accompany these bodily healthy patients to the lavatory ? I was
hoping that Dr. Turnbull, or some of these advocates of women nursing male
patients, would tell us the details. It is all very well to talk about the womanly
and sweet qualities, and about women having a benign influence upon men. I
grant you that women have an influence on men, and men on women. The
reason, I am told, that female assistant medical officers are not more popular in
asylums is because they have not that moral control over female patients that males
have. From Dr. Robertson’s paper I may be permitted to quote. He said, “At
the times for the calls of nature and bathing, and so on, they are handed over to
men.” Can anything be more preposterous than that in dealing with insane
patients? It is impossible that any discipline, or management, or fixation of
responsibility can be carried out if when a patient wanted to go to the lavatory
he was handed over to a male attendant, and when not he was looked after by
a charming female nurse. No, sir; it is part of this great fad which has come
over us to run everything on hospital lines. An asylum is not a hospital, and a
hospital is not an asylum. We ignore the important and capable qualities of the
male attendant. My experience is contrary to that of some others who have
spoken. I have greater confidence in the nursing capacity of my male attendants
than in that of my female nurses (hear, hear). That is all I have to say, except
to protest generally against this absurd idea of employing trained hospital female
nurses to act as attendants on the male patients, because that is what it amounts
to. No one denies that the few sick in an asylum could be nursed equally well by
women as by men, and in certain asylums where the proximity of the male and
female divisions will admit of it the women might be employed a little more
in nursing and feeding the melancholiacs who would not take food from a man.
We do that as it is. In some asylums it would be easy and in others difficult,
according to the geographical position of the ward. But in a general way I wish
to enter an emphatic protest against the employment of women attendants
on men in asylums.

Dr. Morrison. —Fortified by the successes and failures of Dr. Turnbull and
Dr. Oswald, who very kindly placed at my disposal their experiences, I placed a
new male ward of fifty beds entirely under female nurses. I selected a mixed class
of patients for that ward; they were not only seniles, but epileptics, general
paralytics, and cases of recurrent mania and melancholia—in fact, a well-assorted
class to test the system,—and there was no doubt that the general tone, the general
form of nursing and care, and the general results, compared with those in any
other section of the asylum, were entirely as favourable in this ward as in any
other ward in charge of female nurses. But more than this has been achieved.
Cases of melancholia, long since classified among the chronic unrecoverable cases,
after being placed in this ward not only showed a marked improvement in their
mental condition, but half their number have been discharged recovered. I
attribute this entirely to the mental stimulus which these men received by associa-

Digitized by ^.ooQle

640

A CASE OF DOUBLE CONSCIOUSNESS,

[Oct,

tion with the gentler sex. I have gone further, and in this ward of mixed cases I
have put a night female nurse in charge. She attends during the night just as a
male attendant would, and if assistance is required to attend to weakly and bed¬
ridden patients she receives the assistance of the night female patrol, who visits at
intervals. The patients in this ward are as substantially cared for in every respect
by the female staff as they would be by male attendants; and although it is only
eighteen months since we opened this ward, my experience leads me to say there
is a great future for the nursing of the male insane by female nurses. Of course
we do not expect acute homicidal cases, or the class of men who are given to ex¬
posing their persons, to be exactly a suitable class to place under female care, but
if you exclude such classes I am of opinion that every other class of cases can
be advantageously placed under female nurses.

Dr. Turnbull. —There is very little to reply to, especially after the way in
which you, sir, have introduced the discussion. I am glad you gave the system a
trial, and I recommend Dr. Thomson to give it a trial before condemning it out¬
right. With regard to what Dr. Jones said on the question of expense, that did
not enter into my calculation. At the Fife Asylum it was not done on such a
scale as to greatly affect the expenditure, either one way or another. At the
same time I have heard Dr. Robertson say that it does work out better,
and that for the same expense you can double the number of the staff. Dr.
Jones rather gave the impression that the good effect was simply a mental
or a moral one produced by the nurse upon the patient. I think it goes much
further than that, and it was what you yourself indicated, that they can do
those little touches of nursing and attention to patients and the details of manage¬
ment in a way that few men can. Dr. Howden, of the Montrose Asylum,
used to say if he were ill he would not have a female nurse; he would have

a man. And one allows for the personal equation; but nursing cannot gene¬

rally be done with anything like the same deftness and tact by men as by women,
and I think we are doing quite right in taking advantage of the feminine
faculty. It struck me very much in Meerenberg that it is not a good thing to

mix the staffs. It is better to secure the best points in each, and not run either

side to the extreme. Dr. Thomson says he might not have more than a dozen cases
ill in his asylum of 450. We have 270 males, but we have six general paralytics
in bed, besides our other sick cases in the ordinary work of the asylum. And if
you admit that bodily sickness is as well nursed by women you must also admit
that general paralysis is a form of bodily sickness in addition to its mental
symptoms. I was very pleased to hear what Dr. Morrison said, because he did
me the honour, before he introduced the system, of writing and asking my ex¬
perience. He gave me the impression that he was going to introduce it at one
fell blow all over the male side, and I was afraid that might prove a failure. But
I am delighted to learn of his success on the scale on which he has actually
employed it. The system has given me much satisfaction, and I think every one
who tries it on right lines will find it a success.

A Case of Double Consciousness, By Albert Wilson, M.D.

This remarkable case of double consciousness was under my
constant observation for about four years.

It involved chiefly mental phenomena, and though I could
find no evidence by any physical signs of alternating action of
the two halves of the brain, yet the status should be kept

Digitized by v^.ooQLe

BY ALBERT WILSON, M.D.

1903-]

641

in view by experts in determining a possible causation for these
events.

For the purposes of classification I will call her normal
self A and her abnormal condition B, subdividing it into
B 1 to B 12, as she exhibited not merely one abnormal state but
more than a dozen such sub-stages.

At the beginning of her illness the abnormal appeared for
short periods, from a few minutes to an hour; but as time went
on the normal decreased in time and frequency, occurring only
for two or three minutes, and at intervals of days, until it has
finally completely vanished, and she has now been living in the
abnormal condition for years, making her own way in the
world.

There are three conditions about these several abnormal sub¬
stages which are constant, and should be kept in view through¬
out the history:

1. Each sub-stage appears and disappears at quite irregular
intervals.

2. Each sub-stage has its own special characteristics.

3. Each sub-stage is continuous with itself,—that is, when
any particular sub-stage appears it commences where the
previous attack of the same sub-stage left off. Therefore any
particular sub-stage has its memories limited to its own events,
and knows nothing of the life or incidents of any other sub-stage.
Each sub-stage or personality is, then, complete in itself.

But the abnormal had a faint glimmer of the normal.
Perhaps this might be aided by overhearing conversation about
herself. In the normal, however, she was absolutely ignorant
of what happened in the abnormal. This applies also to 1
physical suffering, for in one abnormal stage she was liable to
toothache, and if she returned to the normal the toothache
likewise disappeared.

These separate personalities were “switched” on and off
without apparent rhyme or reason. Yet there was always some
physical disturbance. It might be pallor and exhaustion of
passing duration, or she might fall off a chair, becoming cata¬
leptic or paralysed in the legs, or there might be loss of con¬
sciousness approaching coma. There never were epileptic fits,
though about three times she had convulsions, and once or twice
complete coma.

Among the varying personalities, there was to begin with

Digitized by v^.ooQLe

642 A CASE OF DOUBLE CONSCIOUSNESS, [Oct,

more or less complete loss of all previous knowledge; whilst
her character or Ego was much modified. Thus she might
become an amiable child, or cruel and wicked, or a hopeless
imbecile, blind and paralysed, a deaf mute, a maniac, or finally
lose all sense of moral tone and responsibility, either to thieve
or even to try to kill.

The patient was a bright, intelligent girl twelve and a half
years of age at Easter, 1895, when first taken ill with influenza.
There is no history to record except that there was great
trouble shortly before her birth, when the home had to be
broken up.

Though the influenza passed off in a week, yet she was left
with an attack of meningitis, and remained in a serious
condition for six weeks. There was a high temperature, intense
headache aggravated by light and sound, and great weakness.
In the third week she was delirious and maniacal. She had
intense fear, chiefly of imaginary snakes. During the attacks,
though so weak, she developed great strength. She was
ravenous for oranges, and this detail indicated later that this
was the first of the abnormal personalities. She was mentally
blind in that she could not recognise people, yet a hand or any
crease in the counterpane became to her a snake. In the fourth
week fits occurred; first choreiform jerkings, then opis¬
thotonos with lividity followed by coma. These fits would
occur ten to twenty times a day. In the fifth week recovery
set in and intelligence returned. In the sixth week catalepsy
developed with paralysis of the legs, and quite suddenly she
developed this double consciousness. It occurred in this way.
Whilst in bed reading or playing with her dolls she would com¬
mence shaking, and clear a space around. Then she would
say, “ It is coming/' turn a somersault, and sit up on the bed
in this new personality. Often she would call out “ Holloa ” as
if unexpectedly greeting those around her. Her facial expres¬
sion was altered; it became childish. She also clipped her
words like baby talk. She did not know the names of things.
If asked about her legs she would say, “ What dat?” “What
legs mean? ” and if touched would say, “ What? dese sings
legs ? ” and so on. On the other hand, if one touched her nose
she might call it her ear; so that she had a store of words,
only not the proper associations. She also reversed qualities,
calling white, black; black, white; red, green; and so on.

Digitized by v^.ooQLe

I 9°3-]

BY ALBERT WILSON, M.D.

643

When asked to read, she would misname letters, or call them
alternately N and O; but she learns quickly. As to writing,
she can copy, but cannot write to dictation, as if some word-
deafness. She always writes backwards; not mirror writing,
but commencing at the tail of the last letter of a word. She
applies nicknames to her family and friends, but this had
happened for two or three days before the first somersault,
when she showed a gradual change in her whole manner. Thus
she called her father “ The Tom ” or Tom, her mother “ The
Mary Ann,” the nurse “The Susan Jane,” her sister F. “The
gigger,” her sister A. “Sally,” her brother F. “George,” Dr.
H— “ The Jim,” Dr. T— “ The Sam,” and others. During the
attack she says she is “ a thing ” and not a girl, and she refuses
her proper name. Using her correct name, she says she is very
cross with that person for going and leaving her. She also
says she hates that person, for every one likes that person but
does not like her, meaning in her present abnormal state. So
the abnormal B has some conception of the normal A; but
when the normal A returns she knows nothing of B the
abnormal, yet knows that there is some sort of attack which
she describes as “ going to sleep,” and says she feels as if she
were dying. There is inability to stand, but she can move her
feet and crawl. Cataleptic attacks occur. Sometimes she is
drawn up like a ball, so that one can lift her en masse by one
limb. They last about ten minutes, and any sudden noise or
start will bring them on. It was not until July 20th, 1895,
that I saw her in her normal state. She suddenly changed to
the normal, and was very modest and well-behaved for a child
of her age. In the abnormal she was noisy and very familiar
in her manner. She told me she knew nothing of these attacks,
and she said she had not seen me before. This is very remark¬
able, for I had seen her nearly every day for ten weeks, and
she had heard my voice, so that in her abnormal condition she
and I were very old friends. In about five minutes she
changed back to the abnormal. She put on a very annoyed
expression, pouting and frowning. In a minute her features
relaxed, she smiled, and began chatting in her usual way.

I have kept a chronological record of the various sub-stages,
which would fill a small volume; but I propose only to deal
with the chief sub-stages, leaving out five or six which were ill-
defined. As a rule she gave herself a name in each sub-

Digitized by v^.ooQLe

644 A CASE OF DOUBLE CONSCIOUSNESS, [Oct.,

stage, or, if not, we suggested one. Thus in the last described
she was called “a thing.” We have now seen two sub¬
stages :

B i y the mania, with fear of snakes and great thirst.

B 2, “a thing.”

Whilst admitting the intricacy and dense obscurity of this
and similar cases, yet I wish to advance a theory for considera¬
tion. It seems to me poor fun to label this hystero-epilepsy
and toss it aside, shutting one’s eyes to the vast issues which
such a case raises in oursocial economy, especially in the question
of the day, Individual Responsibility, whether viewed from
the legal or the moral aspect. I think the tendency of to-day
is to regard hysteria and its many manifestations as a disease
of the sympathetic system. We all know the patches of flush¬
ing that occur on the face and neck of certain persons; while
in opposition to the local hypersemias we have local anaemias
and lividities as in Raynaud’s disease, chilblains, so-called
44 dead fingers,” and allied diseases. We have also local hyper-
aesthesia and local anaesthesia.

Are not all of them dependent on vaso-motor changes ?
These we might term the coarse manifestation of disturbance in
the sympathetic system. If we instead apply the same vaso¬
motor changes to the delicate cortex of the brain, must we not
be prepared to find aberrations from the normal brain functions ?

There is exaggerated ideation and motor explosion in cases
of cortical hyperaemia or congestion. Such might be the case
here during the maniacal attacks B i. But where loss of
memory occurs as in the B 2 sub-stage, is it not possible to con¬
ceive that the blood-supply may have been shut off in the
Broca area, or part of it ? The microscope reveals to us only
some of the finer blood-vessels and capillaries of the cortex, but
it has not yet shown us the most delicate system of channels
which bathe the individual cells and fibres in lymph or serum.
The spasm of one arteriole which we can see may curtail
functions in a group or layer of cells or association fibres with
very surprising results. Nor have we as yet traced the terminals
of the sympathetic vaso-motor fibres in the cortex. Yet the
same must exist; Nature would never leave her work imperfect.
Therefore, while we must not dogmatise, yet we may speculate,
and speculate with reason on aa unknown physical condition
which may have a vast influence on psychical phenomena.

Digitized by v^.ooQLe

BY ALBERT WILSON, M.D.

645

I903-]

B 3, or the third abnormal personality, was called “ Old
Nick/’ and was a very frequent and prolonged visitor. It first
appeared on July 24th, 1895, two months after B 2 (“ a thing ”)
had occurred. B 3 (“ Old Nick ”) stayed till August 8th and
then disappeared for a year, returning July 12th, 1896, when it
stayed for ten weeks. “Old Nick” had a very violent
temper, but was always very sorry afterwards and said, “ It is a
naughty man that comes.” “ Old Nick ” could as a rule walk,
and could read and write from the first, so there was not the
same amnesia for names and objects as in B 2. “ Old Nick ”

also had the best health of any of the personalities, which
perhaps throws a side-light on the etiology of neurasthenia.

The following incidents illustrate some of the special features
of the case:—Whilst in this “ Old Nick ” state the patient’s
mother was ill in bed. The patient attended carefully to her
mother, whom she styled “ Mary Ann.” One day she returned
suddenly to the normal, and was both surprised and distressed
to find her mother ill; and could not understand it, for her
mental association was with the last normal period when her
mother was up and in good health. The patient had several
times been at the sea-side, but when taken in this B 3 stage to
Maldon it all came as a new and surprising experience. She
returned normal once or twice, and in a particular road, so her
father conceived the idea of calling her persistently by name
when she walked down this road. She would then return to
normal, and after some time as soon as she entered that road
she would, without any aid, return to her normal state, passing
back to “ Old Nick ” when leaving it. The day after coming
home, having been “ Old Nick” on the journey, she returned
to normal, and was very puzzled to explain her arrival, being
unconscious of the journey.

The following event illustrates the continuity of the sub¬
stages:—On Sunday, September 20th, 1896, “ Old Nick” left
about 2 p.m. in the middle of her dinner. She stopped eating
and fell off her chair dazed; when this passed off she had changed
to another sub-stage. “ Old Nick ” next returned on a Sunday,
April 4th, 1897, about the same time, that is during the
dinner-hour. She was ill in bed in an imbecile state when she
suddenly called to her sister, “ What am I in bed for ? I am
quite well. You have been quick in getting my nightgown on
me. Don't you know me ? I am Nick.” She smelt the dinner

Digitized by v^.ooQLe

646 A CASE OF DOUBLE CONSCIOUSNESS, [Oct,

and asked to go down and finish her dinner, thinking it was
the same dinner she had left on September 20th.

B 4 was a deaf mute, and first appeared on August 8th, 1895,
at the end of “ Old Nick’s ” first visit. It returned five times
during the illness, for a few days only at a time. It comes and
goes quite suddenly. She makes her thoughts known by writing.

This brain area ought to be easily localised—namely, the
centre of speech and hearing with their association fibres.
Arterial spasm or anaemia of these convolutions might explain
the phenomenon.

B 5 was a personality which only came once and lasted about
three weeks. It arrived on December 1st, 1895. In this sub¬
stage she says she was only three days old, and knew no one at
first. She understands everything in the house, and is very
good in helping her mother. She writes in the ordinary way,
but if asked to spell a word does so backwards. She complains
of pain in the left temporal and parietal regions.

B 1 arrived again on December 20th, 1895, when the last
sub-stage disappeared. This I described as occurring in the
third week of the illness. The features were violent mania,
fear of snakes, great thirst and craving for oranges and
lemonade, and headache; in fact, she was constantly asking for
the water coil she formerly had for her head. This sub-stage
and B 2 (“ a thing ”) alternated until the beginning of
March, 1896.

B 6 was a personality very like B 2 (“ a thing ”), but was
gentler, more modest, and more refined. It appeared first on
May 6th, 1896, and became a very constant visitor; in
fact, she is now living in this sub-stage and supporting her own
livelihood. The normal personality A was now a rare visitor,
perhaps not appearing for a week or more, and possibly for only
three or four minutes at a time.

B 6 we named “ Good thing,” or “ Good creature,” or
“ Pretty dear.” It was not the same person as B 2 (“a thing ”),
because while “ a thing ” had now learned to read and write
“ Good creature ” could not do so, and had to be taught. B 6
was more intelligent than any of the others, and learned French.
A striking feature is that no other personality could understand
French. B 6 also replaced B 2, which till now had been the
common visitor.

Another instance of continuity of the different sub-stages was

Digitized by v^.ooQLe

BY ALBERT WILSON, M.D.

647

I 903 -]

shown in the following circumstance:—B 6 (“ Good creature ”)
suddenly left at 9 p.m. on December 29th, 1896, returning
on the evening of May 13th, 1897, and was excited and
disturbed because she could not explain her surroundings.
She had jumped suddenly from December to May, from
winter to early summer. She asked how the cut flowers
were there, as it was winter according to her memory, and
being lamp-light she could not estimate the season.

On this occasion in May she changed from “ Old Nick ” to
“ Good creature ” at about nine in the evening, and returned
back to “ Old Nick ” in daylight on July 1st. She was again
much disturbed to find it was daylight, for when she was last
“ Old Nick ” the lamp was lit, and her father, whom she called
“ Tom,” sitting beside her having his tea. She expected to see
him, whereas he was in the City.

A more remarkable illustration is found in connection with
her two visits to the sea-side. In August, 1896, she went as B 3
or " Old Nick 99 and bathed and learnt to swim. In 1898, two
years later, she visited the same place as B 6 or “ Good
creature ; ” she then was quite ignorant of the place, and had no
memory of being there before, nor having bathed. Two letters
written to me, one at each visit, illustrate this conclusively.

B 7 named herself “ Adjuica Uneza,” and came suddenly in
May, 1896, and stayed for about a fortnight. She could not
walk, and at first was very dazed. She had a remarkable
memory for the small events of her childhood up to the date of
her influenza, but she knows nothing that has happened since.
Her memory of events which happened when she was between
two and three years of age was very remarkable. As it has
been shown by Bolton that the more superficial layers of
small pyramidal cells of the cortex develop later than the
deeper layers of larger pyramids, is it possible that the deep
pyramidal layers were now called into activity by some stimula¬
tion, vascular or otherwise ?

It commends itself to common sense that the deeper layers
precede the more external and superficial in development and
evolution. The converse I have seen in the brain of an
alcoholic wreck, with mental enfeeblement and degeneration
even of the lower nervous system. In this case the superficial
layer of small pyramids was distinctly atrophied. The associa¬
tion fibres did not show a corresponding amount of degenera-

Digitized by v^.ooQLe

648 A CASE OF DOUBLE CONSCIOUSNESS, [Oct.,

tion and disappearance as if they were hitched on to deeper
strata of cells. The point that I wish to raise is that the vaso¬
motor changes would first affect these more distant cortical
areas rather than the deeper strata, producing more psychic
disturbance.

A sharp line of demarcation caused by the influenza and
meningitis shut off the more superficial and external layer of
developing pyramids with its mental pictures and memories.
We may regard these higher psychic areas as damaged, for we
see the ravages of meningitis, especially among the children of
the poor. While many appear to recover and grow up to
adult life, may not their whole personality be altered, as in this
case ? How many criminals and lunatics are handicapped in
this way from childhood! The law, while keen for justice, is
aptly personified as blind to mercy. Is it not for our profession
to collect evidence which might lead to a better protection for
society and a different principle on which to deal with the ever-
multiplying criminal population ?

B 8 was a short-lived personality, lasting only four days.
On June 20th, 1896, she had convulsions, and was very lost.
The following morning she knew no one, and said she was only
bom last night, so how could she know anything ? However,
she could read. Perhaps this is more a confusional or lost
condition, post-epileptic. Still she was quite ignorant both of
her normal self (A) or of any other sub-stage.

B 9 was, however, a most important sub-stage and a very
persistent visitor. In this she was imbecile, blind, and at times
deaf, and usually paralysed in the feet. The striking feature
in this case is that when blind she could draw, while at no
other period of her life, either normal or abnormal, had she any
ability in drawing. Is not this some ancestral devolution or
throw-back ? She would call out for 44 picters ” and 44 pencil/*
and set to work drawing the fashions which one sees in the
illustrated papers. She was guided entirely by touch. We
proved this by moving the paper when she was not touching it.
She at once discovered the error and commenced feeling for
the pencil marks, resuming the drawing in a correct manner.
I also proved the blindness by holding a book between her
eyes and the paper. Her eyes were, however, normal, and Mr.
Tweedy kindly confirmed this opinion. Once or twice when
examining the retina, the stimulation of the light brought her

Digitized by v^.ooQLe

BY ALBERT WILSON, M.D.

649

1903.]

to the normal condition. In this state she was a pitiable
object, the vacant face expressionless, the eyes protruding as
if the ocular muscles were paralysed, and the pupils widely
dilated. Usually she understood nothing, and there often
seemed no way of communicating with her. Sometimes for
hours she would roll beads on a tray; at other times she wrote
verses from memory, or the names of persons she knew; or she
would copy, only in this she was guided by touch and not by
sight. This seemed the most remarkable feature in the whole
case. To what was the blindness due ? It appeared to be
organic, all the ocular apparatus paralysed. The calcarine
area would probably escape. Dr. Bolton has shown this to be
the visual area, in the sense of the recording sensitised plate,
but here there was no psychic blindness, for her visual ideation
persisted. It was the photographic apparatus which was dis¬
organised. In seeking an explanation, there may have been
paralysis of the roots of the second, third, and fourth, ciliary
portions of the fifth and sixth nerves. Perhaps all was con¬
nected with superactivity of the cervical sympathetic, shutting
off vascular supply in these ocular districts which must be con¬
nected. Other opinions might incline to a paralysis of Bolton’s
visual area.

Was the imbecility due to the blindness, or did it coincide,
due to a shutting off of higher psychic centres, as the pre¬
frontal ? How, also, can we account for the extra keenness of
touch and hearing, as with those who are blind for years ?
This mental darkness lasted for three to four weeks from
December 29th, 1896; but she returned suddenly to the normal
on two occasions. On January 3rd, 1897, she suddenly re¬
gained her sight and became her normal self for about two
minutes. She was quite her ordinary self, and called to her
sister, “ I can see you,” and asked some questions. On
January 17th she also returned three or four times to the
normal, and told her mother she felt quite well, but sometimes
felt “ to be dying and to go right away.” When the normal
state occurs she can walk. I tried to rouse her out of this im¬
becility by beating a tea tray with a key; but she took abso¬
lutely no notice, though the noise was deafening and unmusical
in the extreme. As time progressed her intelligence improved
a little; she began to know people and things at more lucid
intervals.

Digitized by v^.ooQLe

650 A CASE OK DOUBLE CONSCIOUSNESS, [Oct.,

At the end of January she had some vision, but was short¬
sighted. She could discern colour and pictures four inches off,
but could not see about the room. This we proved by testing
her in various ways when she was able to walk and grope about.
Her hearing became very acute, compensatory for the more or
less complete blindness.

B 10 was a sub-stage showing decided moral degeneracy. She
herself was so conscious of her wickedness that she named her¬
self “ The dreadful wicked creature.” She was violent and cruel,
bullying her little sister, and on one occasion would have forced
her into the fire if help had not arrived. Does not this case
throw a side-light on the dangerous criminal ? Are not the more
rudimentary brain cells, which have to do with the lower animal
functions, let loose in fury and without control or guidance ? To
what extent, then, are such responsible ? Ought not the State
to care for uncontrollable unhealthy beings the same as for
lunatics ?

Another moral delinquency was shown in the sub-stage Bn,
but of a more harmless type. This sub-stage was rather mixed.
She could walk, and resembled B 2 in that she wrote and spelt
backwards, but also resembled B 6 in that she understood
French. Her chief characteristic was that she was bent on
stealing, and defended it partly on so-called Socialistic principles.
Thus she argued, “ If people don’t give you things, why, nick
them. Quite right too, if you are not found out.” She also
carried her object into practice, and one day took an orange
from a shop door, but seeing a policeman approach went back
and replaced it and made off. Here is exhibited also the pro¬
tective instinct after the act.

I stated before that pain might occur in one sub-stage and be
absent in the normal. This was demonstrated in the case of
toothache. Whilst in B 2 sub-stage (“ a thing ”) she had a good
deal of toothache. It always disappeared when she became
normal. On one occasion we gave her chloroform during B 2
stage and extracted the tooth. She was very unwilling at first,
but most pleased to be free from the pain afterwards. Her
father coaxed her to the normal state (A), and this lasted for ten
minutes. She at once detected the gap and the blood, and was
quite surprised, and asked how it was she never felt any pain
or knew anything of the chloroform.

A nerve specialist, the late Dr. Althaus, witnessed this perform-

Digitized by v^.ooQLe

1903 -]

BY ALBERT WILSON, M.D.

651

ance, and was greatly interested in it. About a year later, when
B 3, or “ Old Nick,” she again had toothache, but the toothache
left her if she went into any other condition.

Another illustration of the isolation of different sub-stages was
shown by the following occurrence:—Once, whilst showing me
a toy wigwam which had been given to her in the B 3 or “ Old
Nick ” stage, she being then in that state, she suddenly dropped
the toy and passed into a new stage, a variation of “ Good thing ”
or “Good creature” (B6). In this new personality she com¬
menced talking, but could not be induced to take any interest in
the wigwam, which she declared she had never seen or handled
before. As soon as she returned to B 3 she resumed her interest
in the toy.

Another minor detail bearing on the same point was that
some sub-stages feared thunder, others did not, and so on.
When she grew up to be about sixteen, the normal stage
(A) had practically gone for ever. She was sometimes B 3 (“ a
thing”), but more usually B 6 (“good creature”), a very nice docile
child. I instructed the parents as to careful training, and they
had broken the habit of baby talk and the forward free manner
which belonged to almost every abnormal personality. They
also called her by her proper name, and she would say, “ I sup¬
pose such is my proper name;” “I know I have been ill and
done funny things, I have been told about it.” Her general
health had all through been attended to, and when crippled she
rode in a bath-chair. She was by no means helpless or stupid.
Often in these abnormal states she did errands and made calls,
or went to church alone. Menstruation, which was irregular
at first, never made the slightest difference so far as we could
detail.

When about seventeen she developed another modification,
perhaps a personality, B 12; in it she was very self-willed, and
would not listen to her parents. She had a great affinity for
the opposite sex. She announced that she wanted a young man
and would have one. She carried her point, leading the
attack. However, by careful supervision and tact all went well.
Perhaps this may not be considered an abnormal stage, but the
uncloaking of the normal. This difficult stage of affection for
the opposite sex seemed to be paroxysmal, and fused into B 6
or “ Good creature.” It did not persist. As B 6 or “ Good
creature ” she gradually took her place as an ordinary individual.
xlix. 45

Digitized by v^.ooQLe

652 A CASE OF DOUBLE CONSCIOUSNESS, [Oct.,

No one would suspect any alteration, yet one who knew her
can see that the original Ego, the sum of personalities, is gone.

This case would suggest that whereas heredity and an¬
cestry form the basis of mind and modify the type, ex¬
perience and education form the superstructure. Education
and experience must equip various groups or districts of cells
and association centres. The more groups so developed, the
higher the state of memory and intellect. Thus each life, or the
true Ego, is made up of so many active mental centres or
personalities, some good and some bad according to circum¬
stances, inherited or acquired. Where the binding cement is
weak, we get the mentally unstable as here, and this opens the
very serious question which constantly affronts us—that of
Responsibility.

Resume of Sub-stages.

B i. Mania, fear, thirst. Rare visitor.

B 2. “A thing.** Writes backwards, amnesia, childish,
catalepsy.

B 3. Often paralysis of legs, ignorant. Very constant visitor
for the first year.

B 3. “ Old Nick.*’ Bad temper, can read and write. The best
health of any of the sub-stages. Frequent visitor for three years.

B 4. Deaf mute. Made five short visits.

B 5. “ Only three days old.” Came once.

B 6. “ Good thing ” or “ Good creature.” Like B 2, but
more refined and more intelligent. Had, however, to learn
reading and writing afresh. She learned French, and was the
only one who did so. Gradually replaced B 2, and after two to
three years became permanent.

B 7. “ Adjuica Uneza.” Only came once. The features are
a remarkable memory for the events of her life previous to this
illness, extending back to when she was two years old.

B 8. One visit for four days. “ Only born last night.”
Mentally blank.

B 9. Imbecile, blind, sometimes deaf, and motor paralysis;
could draw beautifully, the only time in her life.

B 10. Moral degeneracy. Cruelty and violence.

B 11. Allied to B 2 and B 6. Tendency to steal and
Socialism.

B 12. In adolescence. Fond of the opposite sex. Self-
willed. Resented control.

Digitized by

Google

1903 ]

BY ALBERT WILSON M.D.

653

Discussion

At the Annual Meeting in London, July 17th, 1903.

The President. —I am sure we are very much indebted to Dr. Wilson for this
very excellent and very fully described case of double consciousness; a more
interesting case it would be very difficult to find. The manner in which the facts
are stated is excellent; the varying mental phases of his patient are so accurately
described and are in such full detail that they leave us no doubt as to the com¬
pleteness of the case. There was one point which struck me, namely, that to
which I alluded in my address yesterday—the question of re-education. We are
finding at the present time that many cases of insanity drifting to the chronic
type can be re-educated back to mental life, and I have been very much surprised
by the possibilities in this direction. That is surely a point which a paper like
this brings to one’s mind, and I hope the discussion which is about to open on this
excellent case will bear out the views that I hold.

Dr. Lloyd Tuckey. —1 would like first to congratulate Dr. Wilson heartily
upon his paper. It is a particularly interesting subject to me. I was introduced
to it by Dr. Myers, who wrote upon it as far back as 1886 in an article in the
Journal dealing with the history of a case of double personality. Since that time
I have came across a number of cases. The most interesting lately has been
reported in Brain , and also in the Journal of the Society for Psychical Research , by
Dr. Morton Prince, one of the physicians of Boston. There are many of these
cases, but I have never come across a case so interesting as Dr. Wilson’s, and
never one so fully reported. There are two or three little points which I might be
allowed to comment on. One was with regard to the memory. In the other cases
I have read, No. 1 (normal) personality was not aware of what happened in No. 2,
No. 3, or No. 4 states; but generally the more advanced personalities were aware
of what happened to Nos. 1, 2, 3, and so on. This condition was very often
assigned, especially by French observers, to the double action of the brain, one
side of the brain functioning and the other being in abeyance. But when one came
to deal with three or four personalities of the same body I do not see how that
theory could any longer be held. I have myself come across four or five cases of
double personality. The only case I was able to follow up thoroughly was that of
a bank clerk who was rather addicted to drinking—not to great excess, but he got
drunk occasionally. On one occasion, a Friday, he disappeared from the bank and
did not come back. He was suspended from the bank, and his family was greatly
distressed. He turned up the following Monday, not knowing what he had been
doing, only saying he had found himself at an hotel at Southampton on Saturday
night, but he did not know how he got there. He took train back to London, and
finally got home to his wife and family. I knew one of the directors of the bank,
and approached him with the view of being allowed to hypnotise the man. I did
so, and though he had no recollection of what happened up to the time at which
he came to himself at Southampton, yet in the hypnotic state we were able to tap
that level of unconsciousness, and he very slowly, in answer to our questions,
disclosed exactly what had happened during the thirty-six hours of apparent
unconsciousness; and I was able to corroborate the statements, because he called
on various friends at Clapham Common and Guildford, and they were good
enough to come and see me. They told me he had called, and that though he
seemed rather dazed, and they thought he had been drinking, still he was rational,
and able to get about by himself. The idea on his mind was that he was on a
holiday, and was going by sea from Southampton to Dublin. He had made the
trip once before, and he thought he would repeat it. He had no sense of responsi¬
bility ; he left his wife and children without any news of him, and he seemed not to
realise the necessity of letting the bank know where he was. The other case I
heard of, but have not been able to get into contact with. The subject was a
highly educated Oxford man, who had on three occasions gone off into a state of
double personality. The last time he was reading for the Indian Civil Service,
and had a prospect of passing well, but he disappeared. His sister saw him into the
train when he was going to Folkestone for the week-end. He disappeared, and
nothing was heard of him by his family for ten days, when a telegram came from
Malta. He had passed into his natural state at Tunis when getting on board a

Digitized by LjOOQle

654

A CASE OF DOUBLE CONSCIOUSNESS,

[Oct,

French steamer. He knocked a man down, and the violent effort seemed to bring
him back to his normal consciousness. He heard from the people around
that the man had tried to rob him and snatch his portmanteau from him, and
he knocked him down for it. He despatched a telegram to his people, and
they sent him money by which he was able to come home. The idea was that he
should be hypnotised, and that while in that state we should try to unravel what
took place; but he objected, and nothing came of it. What made me think of
hypnotism in these instances was the well-known case reported by Professor
William James and Dr. Hodgson. Dr. Wilson was kind enough to show me his
case some years ago, when I, and Dr. Bramwell also, tried to hypnotise her, but
unfortunately we did not succeed.

Dr. Mickle. —I am sure, sir, we are all charmed by the case which Dr. Wilson
has brought before us. Indeed, some of us have seen the case in the flesh,
through tne courtesy of the author. When this paper is published, as I suppose
it will be, it will be one of the most celebrated cases of the kind which we have.
Of course the question as to what may be the condition which gives rise to or
permits this secondary personality, or multiple personality, as in this case, is one
which, in the present state of our knowledge, it is impossible to definitely answer.
One can evolve a dozen theories on the matter, but perhaps the theory which Dr.
Wilson brought forward is one of the most plausible. But I do not think that any
of us can prove it scientifically in the present state of our knowledge. These cases
are extremely important to us as physicians attending on the insane. I think that
among our patients there is a good deal more of this kind of thing than is usually
recognised, if one may judge by the text-books. I think if we study cases carefully
we may find a whole range among the ordinary insane at asylums which would
give a very large amount of light upon this subject when properly interpreted. In
relation to that I would mention the change which occurs in the deluded insane
where the patient, after a period of manufacture, so to speak, gradually arrives at
the conviction that his personality is changed. For example, take the average
common cases of paranoia, where the patient's identity gradually undergoes a
change. At last he believes himself to be some person—human, or Divine, or
devilish—entirely different from his original self, which still co-exists more or
less; and although those personalities are co-existent, they throw light more
or less on the successive personalities and alternations, such as we have had
placed before us to-day. indeed, in the very same patients one may trace at
one time simply a change in the personality, at another the simple co-existing
double personality, or, it may be, multiple personalities. In the case I hare
referred to, that follows upon a long train of reasoning. But there are cases in
which those changes occur rapidly and suddenly—cases in which the person is well
to-day, then passes into a state of delirium, ana is two, or three, or four persons all
at once. That same person, at another phase of his disease, may have successive
stages of personality and alternation, one after another. Only the other day I
observed a case in which there was a double co-existing personality at the same
time; and then the patient successively thought himself to be not his usual
self, but a sort of glorified usual self. And in alternation with that he was a
personality who was under the influence of the devil—in fact, was himself con¬
verted into a devil. The language in the one showed he was in a state of glory and
happiness. He was in a heavenly state, although he did not imagine himself in the
heavenly regions. In the other state he thought himself a devil, and his language
was of the foulest and most filthy description, full of blasphemy, imprecations, and
all sorts of sexual nastiness. Here, therefore, within a short space of time one had
a patient who manifested both a double co-existing personality, and personalities
existing in succession. In the latter case he simply identified himself at one time
with the one personage—we will call it, for convenience, the heavenly personage,—
and in the other he was a devilish personage; and he showed the two extremes that
a human being can go to in relation to that particular point. One might go on
speaking of the different forms of insanity, and discuss the subject from that point
of view; but I merely desire to draw attention to the cases of co-existing
personalities which may come on suddenly, may come on with medium rapidity, or
may come on as the termination of a long subterranean process of morbid thought;
as having important bearings on, and relations to, the cognate subject of successive
dual or multiple consciousness or personality.

Digitized by LjOOQle

BY ALBERT WILSON, M.D.

1903 ]

655

Dr. T. D. Savill. —I would like to add my congratulations to Dr. Wilson for
the lucid though somewhat abbreviated account of the case which he has narrated.
It was one which I had the pleasure of seeing in consultation with him some eight
or ten years ago, and I very distinctly remember the point which he emphasises in
his paper, how each of these different states took up the thread of the memory of
the previous occasion. For instance, this child, when I first saw her, was
in a particular state, I forget which; she was then changed into a state which
had ceased previously during the dusk of the evening, when the gas was about to
be lighted. And, although it was broad daylight when she returned to that state, she
picked up the thread of that condition, asking if the gas was not going to be lighted.
It was very instructive, and I think these cases would very well repay a committee
or sub-committee of investigation at the hands of this Society. One very remark¬
able case was that of a lady, a painter, who went to a neighbour of mine in the
same street. The last time she was seen was when she turned round the corner of
the street in which my house is situated. She was found somewhere in the north
of England. Of course it is quite admitted that it is a psychological phenomenon
which we are dealing with, and therefore it properly comes within the scope of this
Society. But, as a general physician, one comes across many cases where dual
consciousness is only a subordinate feature of the case. I had the pleasure of
seeing—in consultation with Dr. Meredith, who is here to-day—two years ago,
the case of a young lady who went to the Queen’s funeral, and in whom the
excitement, assisted perhaps by alcohol, brought on what was evidently a hystero-
epileptic seizure. As she came to out of it she was practically in the con¬
dition of a child, and she had renamed herself, much in the same way as
Dr. Wilson’s patient did; and she presented other features ’altogether different
from her former self. It was some long time before she resumed her normal
condition. She then remained normal for a time, and later, without very much
provocation, she again assumed this childish state, associated this time with
contracture of the left lower extremity and a certain amount of anaesthesia.
Of course the pathology of these cases is very obscure. That hysteria is due to
changes in the sympathetic system is a view which I have held for many years.
But perhaps I might remind Dr. Wilson of Dr. Leonard Hill’s researches.
Dr. Hill holds that he has disproved the existence of the sympathetic mechanism
in the cerebral vessels, and therefore we are at sea again. I think we must
approach the subject from the clinical aspect in the first place. All these cases
appear to have two leading psychical features connected with them. First there
is a sudden loss of memory, or part of memory, and they do not use the know¬
ledge and experience gained in their past life. In the second place there is a very
distinctive alteration of character, not always for the worse, but generally so;
there is a backward movement in the evolution of character. In these cases one
is more inclined to adopt Myer’s term, disintegrative personality, rather than dual
consciousness. In investigating this subject I think that one ought to include those
cases of sudden loss of memory, such as that extraordinary case which Charcot
records in the third volume of his Clinical Lectures , where a man of very excep¬
tional intelligence, and highly educated, suddenly lost his memory for forms and
colours—for instance, he could not remember the colour of his wife’s hair. In
other respects he was all right. Secondly, in a certain proportion of the cases
there is in association some physical phenomenon, some vaso-motor, motor, or
other change which is manifest to the careful observer. The cases of dual
consciousness are now fairly numerous, and I think this Society could usefully
investigate them.

Dr. Scott. —The point which interests me is one of legal responsibility. When
I heard that the question of double consciousness was to come on for discussion I
was afraid that a new terror was to be added to life. We have kleptomania and
all the other manias, and alcoholism, and degeneracy; and it is frequently very
difficult to give a definite opinion in the case of a person whom one only sees for a
short time, and as to whose antecedents one knows nothing. And I can imagine
that if we are to go before a sceptical judge and an enlightened British jury and
plead that a person should not be held responsible because his consciousness was
in aJekyll-Hyde condition, in a state of mental alibi, we would find our position
a difficult one to establish. One of Dr. Wilson’s remarks, I think, mav perhaps
convey a wrong impression as to what exists nowadays. He says the law, while

Digitized by v^.ooQLe

656

A CASE OF DOUBLE CONSCIOUSNESS,

[Oct,

keen for justice, is amply personified as being blind to mercy. On the contrary,
nowadays I think that our judges are almost too ready to accept the plea of
insanity, and in most cases, I can say from my own experience, they do take
a very merciful view. So far as the individual’s responsibility is concerned,
I think that we may regard double consciousness from the same standpoint as we
do the recurrent insa. Hies. If there is a want of motive, and all the other indica¬
tions point to an abnormal state of mind at the time, the judge and jury
will always be careful to consider these factors and to give due weight to any such
evidence.

Dr. Andribzen. — I believe a good deal of insight into the nature of
double and multiple personalities might be gained from the study of epilepsy, and
particularly cases we see in asylums. There we see instances where the sense of
personal identity and individuality alters suddenly and profoundly in an epileptic
fit. The new personality continues for days or weeks, and, as we know, it has
various characteristics. Then, as the result of the occurrence of another fit, or
some other event, the old personality returns and the new personality disappears.
The ordinary epileptic insane patient forgets his name, and does not remember
who or what he is. And if he is not insane, but a sane epileptic, like many who
are at large, a sudden attack mav make him wander about till he finds himself
stranded somewhere. He may live thus many days, till his old personality
comes back, and recalls him to his old life. A few months ago an under¬
graduate of Cambridge became a victim of this change of personality. He used to
suffer slightly from epileptic fits ; on one occasion he was out in the afternoon for
a walk, and did not return. Some one met him, but when he was asked who he was
he did not know. Finally he found himself in a village fourteen or fifteen miles
away. He lodged there at an inn, and stayed some days without any particular
incident occurring. At the end of that time his memory suddenly came back to
him, his old personality returned, he knew who he was, and returned to the
University. Such cases are not uncommon in medical literature of recent years.

I remember reading of a case in America of a man who was an epileptic, lost his
sense of personality, went to a far-off town, took up the occupation of carpenter,
and lived and worked there for many years. He forgot he had a wife, and lived as
a bachelor. After many years had passed he had a fit, his old personality returned
to him, he remembered who he was, and returned to his old town and to his wife.
How is it that epilepsy produces such a condition ? We know that in the epileptic
discharge every part of the brain is not universally affected ; the epilepsy affects
certain parts to the exclusion of others. What more likely than that in cases of the
nature that I have quoted, an epileptic discharge occurring in certain parts or
psychical areas of the brain should put certain centres out of action, the rest of the
brain continuing to act ? In that case the individual acts as though he had
another brain, and therefore acts as a new personality. When the old centres come
back into action that personality is restored. I do not think it is at all necessary' to
invoke the two hemispheres theory as proof of double personality. No satisfactory
evidence has been given to show that one hemisphere represents one personality
and the other hemisphere the other. The idea of Hughlings Jackson that one
hemisphere is more voluntary and the other more automatic must be given up as
wanting sufficient evidence. But others, of the French school, have taught that
below the cortical level there is a whole series of centres which have to do with
personality, and especially with automatic actions of various sorts; these
they have described very fully. One is very glad to note that Myers and others of
his school have come to practically the same conclusions. The fact that small
portions of the psychical centres in the brain may be thrown out of gear from time
to time would explain the large number of personalities which Dr. Wilson has
reported. For instance, it struck me with regard to personalities Nos. 6, 7,
and 10. One was intelligent and learned French, whereas the other had no
knowledge of the language; and, of course, certain psychical centres connected
with hearing and speech must have been involved in the one condition and been
released in the other. There is no doubt about the throwing out of gear of certain
parts of the brain. But why that occurs is altogether a different matter. This
clinical and pathological way of looking at the matter, 1 think, must once and for
all give the blow to the metaphysical theory that the mind is one and indivisible—
a view which used to be taught us by our classical tutors, and which even in

Digitized by

Google

BY ALBERT WILSON, M.D.

657

1903 ]

psychological medicine is still largely held. It seems to me, from experience
and observation day after day for the last ten years, that every new fact which has
been added to our knowledge on the brain gives a blow to that theory. The
reference which Dr. Mickle made to paranoia is a particularly happy one. The
long-continued conflict between the hallucinations on the one hand and the normal
integrity of the ego on the other hand comes to this in the long run—that the
integrity of the ego in the brain is destroyed, and a new personality of some form
takes its place, generally grandiose. The same thing occurs, in a speedier way, in
the development of hypochondriacal insanity, where also the entire personality
sometimes alters; and large numbers of cases can be quoted from classical
literature—the lives of saints, and so on. All stages from hypochondriasis to
hysteria occur. It is eurious to notice in modern literature that many individuals
who are abnormal in mind, show evidence of abnormal personalities, and who have
led extraordinary and eccentric lives, should be held up as great philosophers and
saints, as has been done. I was thinking especially of that famous visionary
Swedenborg, who certainly had more than one personality. I would add a few
words upon the vaso-motor fibres in the brain cortex. It is said they have not been
observed, and all sorts of theories have been built upon it. There is no question but
that they can be demonstrated in the cortex, and I am ready to produce microscopic
specimens of my own to prove that there are vaso-motor nerve-fibres in the blood¬
vessels of the cortex, at any rate of the pia mater. In 1894, at our Congress
held at Dublin, I showed some specimens; but since then many observers have
shown this condition on a much more complete scale, especially by staining with
methylene blue. Observers from France and Germany and America have
demonstrated under the microscope that there are vaso-motor fibres in the
cortex. So Dr. Leonard Hill’s theory, whatever it may be supported by, cannot
negative the fact that a vaso-motor system exists in the cortex. If it does exist
there, then this or that centre may be thrown into greater activity, or may be
diminished in activity, by vaso-motor disturbances, such as may take place in any
other part of the body. I simply mention this fact to show that in building a theory
of " multiple personality ” the presence of vaso-motor nerves would show that
irregular action of the vaso-motor system may also have some effect in bringing
about this disturbance of personality.

Mr. Vincent Pantin. —Dr. Wilson mentions that the colours yellow and green
were reversed. If observers take certain mediums as subjects and study their ways
they will find that many things get absolutely reversed—their writings, their ideas
—under their other personalities, of which they have many. I think these are
bond fide, whatever their origin may be.

Dr. Robert Jones. —I would like to add a few words of congratulation to Dr.
Wilson on the way in which he has correlated these sub-stages into one of the
most interesting cases that I have ever listened to. I had the privilege, through
his courtesy, of seeing this case some years ago, and I have been reminded since
of what Dr. Clouston said at one of the meetings of the British Medical Associa¬
tion many years ago at Birmingham—that the tendency of these shifting personali¬
ties was eventually towards absolute disintegration. He mentioned the case of a
student at Edinburgh who was frequently hypnotised, and who could be made, by
suggestion, to change from one state of personality to another. He ended his days
at Morningside. Mr. Pantin spoke of the reversal of sensation, and it is within
the experience of every one that when we speak of a straight line we imply that it
is not a curved one. This is fully apprehended in the theory of vision promulgated
by Hering. In Dr. Wilson’s case white was mistaken for black, and when one
form of sensation is brought before our consciousness the opposite is immediately
suggested at the same time. The interesting thing in regard to the pictures,
which form so valuable a supplement to this paper, is the fact that the patient
selected, as a predominant colour, that from the blue end of the spectrum. In the
language of some ancient races there is no word for green, but the word in Welsh,
for instance, which indicates the colour of grass is blue , and colloquial Welsh
describes the grass as blue. It is curious that this patient should have selected by
preference this elementary colour—although I admit others were also used,—indicat¬
ing, if one may suggest it, a reversal, or a throwing back, as it were, to a feature
characteristic of an ancient race. The whole of the ground has been traversed so
ably by Dr. Mickle and Dr. Andriezen in regard to the phases of multiple conscious-

Digitized by v^.ooQLe

658

A CASE OF DOUBLE CONSCIOUSNESS.

[Oct.,

ness seen in various forms of insanity, that I need sav nothing further about this
aspect of the case ; but, in addition to paranoia already referred to, the first stage
mentioned by Dr. Wilson is, to a certain extent, closely allied to what we see in
asylums in cases of premature dementia of young persons,—that is, an apprehen¬
siveness or fear, such as the delusions of snakes and the cataleptic states already
referred to. I think the best solution of these cases of multiple consciousness is to
view them from the standpoint of evolution, t. *., from the comparative anatomy
standpoint, as suggested by Dr. Andriezen. The brain is not one organ, but a cor¬
relation of a series of organs which have gradually evolved from the simplest forms
of animal life. In the nervous system of the Annelida you have all of these
organs in separate segments. In the brain of man you have the various segments
with their functions correlated into one organic whole—the visual area, the audi¬
tory area, the olfactory and other areas. Perhaps it is not surprising that occa¬
sionally these should be fundamentally disintegrated and tending to act one
independently of the other. Furthermore, in this correlation characteristic of the
healthy mind there seems to be a something, an “ ego,” which has a higher
" apperceptive ” power, and which appears to dominate the whole of the various
parts, but which appears dislocated in some of these cases. It is interesting, in
regard to the visual phase, that the report of Mr. Tweedy showed that nothing
abnormal could be found in the retina or the transparent media of the eye,
and he himself confirms Dr. Wilson’s statement that upon examination nothing
could be seen by the patient more than two feet away. I think we have had an
extremely interesting communication, and I also think that the suggestion made
by Dr. Savill is worthy of being taken into consideration bv our President.

Dr. Wilson. —Mr. President and Gentlemen,—I can only thank you heartily for
the very kind way in which you have received my paper, which I felt was rather a
long one, although I tried to condense the facts as much as possible. Dr. Savill’s
suggestion is, I think, a very good one, and it would be a splendid thing if,
especially in the great subject of our relations to the criminal world, we could have
this subject more deeply investigated. I did not mention in my paper that Dr.
Tuckey, Dr. Jones, and Dr. Savill had seen this patient, as also have one or two
other medical friends, and that this girl always resisted hypnotism. When it was
attempted she became what we term hysterical; she began to sigh and gasp, and
was upset, and wanted it stopped. With regard to reversing things, that was very
marked in the first stage, but not in all. I remember showing her two horses, one
black and the other white, and she always reversed them. When this was done
the colours were complementary. With regard to Dr. Andriezen’s remarks, I am
very glad to learn from what he says that the sympathetic fibres have been
demonstrated in the cortex. Of course, when we see a very fine vessel in the brain,
the very finest we can see, that does not represent the finality of the circulation,
because that fine vessel surely spreads out like a fan, and probably feeds a whole
group of cells. With regard to the dual action of the brain, split up into centres,
it has sometimes occurred to me in reference to comparative anatomy that we
might get some idea of dual brain action from the lower animals. In our own case
our vision converges; we only look at one object at a time; but most other
animals have divergent vision, so that they nrfay really be seeing two pictures in
their brain at once. If we take the hare, which has its eyes at right angles, it must
see two pictures at once—in their case there is no optic chiasma, but I believe the
optic nerve crosses to the opposite hemisphere direct. So it is rather an interesting
point how the brain of the animal does act when it sees safety on one side
and danger on the other, for it has got to analyse things and bring in both
mechanisms.

Digitized by v^.ooQLe

1903-]

THE TEACHING OF PSYCHOLOGY.

659

The Teaching of Psychology in Universities of the United
States.Q) By Charles S. Myers, M.A., M.D.

A SEVEN weeks* visit to seven principal universities in the
eastern States of America is a sorry qualification for talk¬
ing to you upon this subject. Nor, indeed, is it easy during
the brief time at my disposal to give you a satisfactory account
of the impressions which I formed during my visit. I can only
hope that the shortcomings and inaccuracies of this paper do
not exceed what may be called their normal number under
such circumstances, and that you may be induced some day to
repeat for yourselves experiences which I have been the first
to enjoy with such pleasure, interest, and profit. Nowhere
will your colleagues extend a warmer welcome to you, nowhere
will they take greater trouble in displaying and explaining to
you their institutions.

A true estimate of the position of psychology in the curri¬
culum of American universities can hardly be formed without
a brief survey of the general system of education which pre¬
vails there. In earlier years, one need hardly say, the training
was far narrower and less liberal than it is now. The candidate
for the B.A. degree had his educational career as carefully
prescribed for him as if he were still at school, and he had little
or no opportunity to deviate from it. At the present day the
various universities of the United States offer every gradation
between relatively elective and relatively non-elective systems
of study. In most universities the undergraduate will find his
course of work strictly defined during at least his first or fresh¬
man year. Little by little, however, the elective is gradually
replacing the non-elective system. Quite recently Harvard, for
example, determined to allow a very considerable measure of
optional subjects, from which the student has to make his
choice from the moment he is admitted to the university.

The danger of such a system, patent as it is to all, is increased
by the absence of a special ad hoc examination for the B.A.
degree. As a rule the degree is conferred solely on the results
of the terminal examinations held biennially, so that, unless
proper precautions were taken, it would be possible for a student,
after having passed his three or four years at college, to take

Digitized by ^.ooQle

660 THE TEACHING OF PSYCHOLOGY, [Oct.,

his degree on the basis of a superficial and very elementary
knowledge of many subjects and a detailed knowledge of none.
This drawback American universities have largely succeeded in
overcoming by a series of appropriate regulations concerning
the relative number of elementary and advanced lectures at
which attendance is required, and concerning the conditions
of admission to advanced lectures. At Yale, for example, under¬
graduate studies are ranged under three heads : (I) languages
and literature; (2) mathematics, physical and natural science ;
(3) philosophy, history, and the social sciences. Every student
is required to have attended advanced courses in at least one
of these departments, and to show at least an elementary
knowledge of subjects in the two other departments.

It will now be evident to you why subjects, which in English
universities are studied by the few, are in America taken up by
the many. Take Yale, for instance, with her department
of philosophy, history, and the social sciences. Every under¬
graduate has to show at least an elementary knowledge of
some subject in this department, t. e. t of philosophy, psychology,
ethics, pedagogics, logic, ancient, mediaeval, and modern history,
economics, politics, or sociology. A great number of American
students take a course of economics. At one university I was
told that on an average every student takes two courses of
economics during his undergraduate career. This fact may be
ranged beside another, viz. % that there are twenty-four professors,
lecturers, and instructors of political economy and government
at Harvard.

And so also it comes about that a great number of students
take up psychology, either by itself or with allied subjects. Two
hundred and fifty students, chiefly in their second or sophomore
year, attend the year’s course at Harvard, which is equally
divided between the study of logic and the study of elementary
psychology. At Yale a similar year’s course on ethics and
psychology was attended this year by 225 students. At Cornell
the year’s course on psychology, logic, and ethics is attended
by 200 students. Princeton goes so far as to make psychology
a compulsory subject, without which the B.A. degree cannot be
obtained. The popularity of psychology is also shown in that
it is taught in the upper forms of some of the better schools.

Of course such introductory courses in psychology are
delivered for the most part to students who later will take no

Digitized by v^.ooQLe

I903-] BY CHARLES S. MYERS, M.A., M.D. 661

direct interest in the subject. The scope of the teaching at
Harvard is narrowed to the range of James's smaller book ; a
few lectures on the anatomy of the nervous system are also
given. With so large a body of students laboratory work is
impossible, but in nearly all universities demonstrations are
performed during the lectures. The optical lantern is largely
used for this purpose. By the ingenious device of rotating a
smoked glass disc in front of the lantern, reaction time and
other chronometric experiments are carried out before a large
audience. Experiments in colour-vision and binocular vision
are demonstrated by the aid of twin lanterns. At Harvard the
lectures of the introductory course are supplemented by short
talks held periodically several times a term between small
bodies of students and their instructors. At Princeton similar
classes are held, but mainly, as I understood, to assist the
duller and less diligent students.

Experimental work in the laboratory is only performed by
students who intend to proceed further in psychology. Their
number is a very small fraction—from one tenth to one fifteenth
—of those who attend the preliminary course. At Columbia
they are expected to have attended either a general course on
experimental psychology or a special course, in which no less
than eight lecturers take part, each being responsible for a few
lectures in their own department of psychology, be it physio¬
logical, genetic, comparative, pathological, experimental, his¬
torical, or philosophical. By this means the student comes
into relation with most of the teaching staff of the department
in which he is interested. Later, more advanced courses are
open to him in analytical psychology, educational psychology,
the philosophy of mind, genetic psychology, and so on. At
Pennsylvania the student spends two years at psychology,
devoting the first half-year to analytical psychology, the second
half-year to physiological psychology, the third half-year to
synthetic psychology, and the fourth half-year to experimental
psychology. Each of these half-courses comprises lectures and
practical work of an hour and two hours' duration respectively
per week. In the study of physiological psychology brains
are dissected (there being no professor of physiology at Penn¬
sylvania, save in the separate medical school); careful drawings
are made; blue ferro-prussiate photographs are distributed to
each student, illustrating the coarse and minute structure of the

Digitized by v^.ooQLe

662 THE TEACHING OF PSYCHOLOGY, [Oct,

central nervous system. He pastes them in his note-book,
affixing names to the various structures.

It would be wearisome to follow out at further length the
various lines of undergraduate study pursued in psychology at
the several universities which I visited. You will, however,
hear with interest that men are offered at Yale a course of
recent German psychology in their fourth or senior year, the
class reading extracts from the works of Brentano, Wundt,
Stumpf, Kiilpe, and others, while the different attitudes of
these psychologists are explained by the instructor. At
Harvard a half-year’s course on the mental life of animals is
offered, accompanied by lectures and demonstrations. At
Cornell a course on the history of the psycho-physical work of
Weber, Fechner, and others is given.

This brings me to the more detailed consideration of experi¬
mental work in the United States; and here you will expect
something from me on the general equipment of their psycho¬
logical laboratories. The laboratory in Harvard University
has eleven rooms, in Yale it has seven, in Columbia nineteen,
in Princeton five, in Cornell ten, and in Clark ten ; these
numbers generally include all public and private rooms of the
department. Cornell has undoubtedly the best equipped
laboratory, so far as human psychology is concerned. Two
rooms here are devoted to vision, one to acoustics, one to
touch, one to taste and smell, one to chronometric apparatus,
one is a special research-room, and there is a lecture-room and
a workshop. Both Clark and Harvard have rooms devoted to
experiments on animals. Partly for this reason the Harvard
laboratory suffers from lack of space ; a new one will be built
in the near future. Most laboratories have a departmental
library, or at least a seminary in which the students can read
or meet for discussion. Practically all have a workshop and
employ a trained mechanician who is able to turn out even
complicated and expensive apparatus.

The methods of conducting experimental work naturally
differ in the various laboratories. At Harvard and Columbia
lectures are given in connection with the experiments, but at
other universities lectures and practical work are wholly inde¬
pendent. At Yale, Harvard, Princeton, and Cornell students
work together in pairs, each member of a pair serving alter¬
nately as subject and as experimenter. At Pennsylvania

Digitized by v^.ooQLe

190 3 .] BY CHARLES S. MYERS, M.A., M.D.

663

students work together in groups of three, the third recording
the results obtained by the two others. Stress is laid in most
laboratories on the careful keeping of note-books. Many of
those in Cornell are models of neatness and diligence; there
they are inspected, marked, and initialled monthly by the
assistants. At Princeton the times are so arranged that only
a single pair of students is working in the laboratory at any
one hour; they thus secure the undivided attention of the
instructor. At Harvard and Pennsylvania the entire class is
engaged upon the same kind of experiment at any one time ;
the Pennsylvania students are each provided with lockers con¬
taining the simpler apparatus they are likely to use. At Yale
and Cornell, on the other hand, students are engaged simul¬
taneously at different experiments ; one pair, for instance, is
working on colour-vision, another on reaction times, another on
tactile sensibility, and so on. Save at Cornell, the students
are each taken through all the laboratory experiments com¬
monly described in the text-books. But at Cornell it is held
sufficient for the student to devote himself to the investigation
of a single sense, working over perhaps fifteen experiments
therein, and then to proceed to one or two experiments on the
expression of the affective states, thence to some of the experi¬
ments in attention and reaction, and so on, whereby he acquires
a practical experience, less extensive but probably more
thorough than that usually obtained. He works four and a
half months in qualitative and four and a half months in
quantitative experimental work during his third year. His
fourth year is devoted to some special problem, and he writes
an essay upon his results.

If, having taken his B.A. degree, the graduate determines to
pursue his studies further, he enters the post-graduate school
in order to proceed to his doctor’s degree. After two or three
years’ post-graduate study he may present himself for examina¬
tion in a chosen division, e . g ., philosophy; and within the
division he must name some special field of study, e . g t
psychology, in which he is liable to minute examination, and
must offer a thesis showing evidence of independent research.
In psychology, as in all subjects, advanced lectures are delivered
to suit his requirements. At Cornell, during his first year of
post-graduate study the student does not start any special
research work ; he reads and roams about the laboratory,

Digitized by

Google

664 THE TEACHING OF PSYCHOLOGY. [Oct.,

observing what his senior fellow-students are doing. A very
large proportion of post-graduate students at Yale and Harvard
consists of graduates from smaller universities. At Harvard I
found no less than sixteen students engaged in the psycho¬
logical laboratory at original work for their Ph.D. degree.
They attended there at fixed times in the mornings only,
working in pairs alternately as subject and as experimenter.
Weekly seminary meetings are held at Harvard, Yale, and
Clark for post-graduate students. At Harvard three papers
are read at each evening meeting by the students, and are
discussed by themselves and their professor. At the Yale
seminaries a post-graduate student presents a paper weekly,
dealing with the system of some well-known mental philo¬
sopher. At Clark the students meet each week at the pro¬
fessor’s house to narrate and to criticise their progress in
research work.

A very large proportion of thesis work written for the
Ph.D. degree in psychology sees light in the pages of American
psychological journals. In many instances this must turn out
to be the one piece of original work such men have performed
in their lives. They drift away in various directions. The
best are chosen by their professors to be laboratory instruc¬
tors for a year or more. Thence they go to become
assistant professors in other universities, or depart earlier to
teach educational psychology in the State normal schools or in
other teachers’ training colleges. Mainly through lack of
leisure, they put forth little in the way of further and maturer
research. There is a strong tendency, too, for the most eminent
psychologists in America to turn to editorial or literary work,
or to deal with purely philosophical, ethical, or religious
problems.

But apart from such drawbacks, which are the result rather
of American ways of life and character than of deficient
interest or training, I have said enough, I hope, to show what
a living subject of education psychology is in the United
States. It is becoming recognised there that a man of culture
should know something not only of the works but also of the
working of the human mind. Psychology in the United States
is not a subject of the philosophical few, as it is in our country.
If it pays the penalty for, it also reaps the advantage of its
position. I have shown you what numbers of undergraduate

Digitized by v^.ooQLe

1903.] EPILEPSY AND TOXEMIC CONDITIONS.

665

students acquire a notion, however dim and imperfect, of the
range and importance of psychology, so that if ever they be¬
come successful business men, as many of them do, they are
prepared to lend it financial assistance in later life. Future
medical students take up psychology during their academic
career, and turn their knowledge of it to account when they
come to deal with the problems of insanity. Zoologists pass
from their museums to study it, and return to work out the
psychology of animal life. Teachers obtain a useful smattering
of it, sufficient to interest and improve them in their arduous
career; at Pennsylvania, for example, they have the oppor¬
tunity of attending a pedagogical clinic at which children with
various mental disorders are brought before their notice, so that
they may recognise them hereafter.

Surely, then, I may forbear to indicate at further length what
a lesson America offers us, and what an example it has shown
us in the organised teaching of a subject the welfare of which
we have so much at heart.

(*) A paper read at a meeting of the Psychological Society held at Cambridge,
July 25th, 1903. It has been published in Nature.

That Epilepsy cannot be caused by Toxcemic Conditions .

By W. Hamilton Hall, L.R.C.P.Lond., M.RX.S.Eng.

From time to time one meets with the opinion, or with
expressions and general phrases indicating the unavowed
opinion, that “ idiopathic ” epilepsy results from a toxaemic
state,—that is to say, that epilepsy the disease is caused by
poisons circulating in the blood ; or less positively that epilepsy
the paroxysm is determined, the attack precipitated, by the
transient presence in the blood of such poisons ; and in both
cases the unexpressed idea seems to be that these poisons get
there, in the manner of other auto-intoxicants, by reason of the
inefficient performance of the digestive function in some respect
A most learned and brilliant worker in another field has
wittily expressed his experience that “sometimes ... a
theory . . . needs only to be clearly stated in order to break

Digitized by

Google

666

EPILEPSY AND TOXEMIC CONDITIONS,

[Oct,

down by its own weight,” ( x ) and that this expresses true wisdom
is unquestionable, though it may not be practicable to apply
it effectively in this case of the causation of epilepsy. But
baldness of statement has always at least the merit of exposing
the true nature of the proposition one is invited to accept; and
what is this toxaemic proposition, in fact ? We know of great
numbers of epileptics who are, for a certainty, fed with the
utmost care, upon diets carefully thought out, by physicians
whose principal object in prescribing such diets is unquestion¬
ably the avoidance of dyspeptic troubles, inasmuch as that is
the only conceivable object they could have. If they should
say they desire to build up the patient’s strength, if they should
say they desire that the diet may obviate the use of purgatives
and clysters, if they should say that their aim is to modify the
incidence or the quality of the nocturnal or matutinal attacks,—
it all amounts to the same thing: they desire to facilitate in
every way, and as far as may be by perfectly natural means,
the performance of the whole digestive act

That is very good practice undoubtedly, but what effect does
it produce upon the epilepsy? Does it prevent fits? Does it
modify to any extent the incidence of the fits, the number, the
time, the severity, the variability in severity ? Does it have any
recognisable influence at all upon the fits, as distinguished
from the patient ? Hardly any, perhaps, if one looks only for
amelioration ; but much, one quite believes, if one looks chiefly
at the contingencies reasonably likely to attend the neglect of
such obvious precautions. The plain conclusion would appear
to be that in these well-cared-for patients the toxaemia is not a
result arising immediately from the ingesta. That conclusion
might, indeed, have been attained off-hand, by consideration
that the patient often is known to have had fits while still at
the breast, though others suckled by the same mother are not
so affected. If we cannot quite go the length of believing that
the maternal breast is sometimes for months together a source
of toxic or potentially toxic food, sometimes not, then we need
not greatly boggle over rejecting the proposition that a care¬
fully designed diet, which will provide most children with per¬
fectly healthy food, may nevertheless provide one of the number
round the table with the noxious factor.

But if it cannot be maintained that poison enters with the
food, it may nevertheless be manufactured out of the food,

Digitized by ^.ooQle

1903.] BY \V. HAMILTON HALL, L.R.C.P.LOND. 667

granting that to be in itself innocent. Thus to express the
opinion, however, really begs the question, for it predicates of
the epileptic that he has possessed himself of the habit of pro¬
ducing his toxins, which caused his epilepsy, from his nutri¬
ment, which is an absurd statement. Some of the latest asser¬
tions on the full nature of the digestive process are really
alarming in their complexity, but stated in its crudest terms
this proposition is that the epileptic is enabled to get out of
his food something which the non-epileptic cannot get, and
to make himself an epileptic with it. No vicious circle argu¬
ment can be brought to bear, since it is plain experience that
some are epileptics from the first, wherever that may be taken,
and it is impossible to imagine a food-derived toxin which can
make one person an epileptic but not another, other things
being equal ; it would be as rational to imagine a condition in
which twice two is sometimes four, sometimes not. Merely for
the sake of argument granting the toxin to be a demonstrated
fact, the next fact that it makes an epileptic of one but not of
another demonstrates a personal difference, that the other
things are not equal; for the only alternative is that this toxin
can be produced by all, from any food ; therefore we are all
epileptics potentially, whether we know it or not, and the
apparent freedom of the healthy is mere neglect of oppor¬
tunity.

If, then, some patients are in actual fact epileptic and dys¬
peptic, as a great many of course are, these two conditions
cannot truly be regarded in any way as cause and effect,
mediately or immediately, until it is shown that the dyspeptic
condition, the toxin-producing condition, is actually a pre¬
cedent and not a consequent condition ; and still taking that
toxin for a demonstrated fact, it has yet to be shown that
the toxin stands to the disease in a causal relation ; alternatively
that the toxin stands to the paroxysm in a causal relation.
That this has never been attempted is but natural, since the
toxin itself has not as yet been discovered ; it is as mythical
as the spiritual cause of the medium’s vagaries. Not to be un¬
fair, the proposition may be stated thus :—A toxin, not yet
isolated, may be the cause of epileptic conditions. Its action
is presumably effectuated through the agency of the circulation,
and its origin may possibly be in some product of undigested
food. If that can be allowed to pass for a rational imagina-

XLIX. 46

Digitized by v^.ooQLe

668

EPILEPSY AND TOXEMIC CONDITIONS, [Oct,

tion, what follows ? The results of indigestion are reasonably
common, they are absolutely the commonest manifestation of
ill-health ; therefore the opportunities for the production of this
toxin are on every hand. Is epilepsy equally common, as a
mere matter of counting noses ? Do any vast majority, or any
constant proportion, of dyspeptics manifest epilepsy sooner or
later? It is difficult to formulate a proposition more at
variance with the observed facts. On the other hand, do all
epileptics suffer from dyspepsia in the first place ? That
certainly is not so, for some epileptics, a minority no doubt,
are entirely free. Are we, then, to suppose that these get their
toxin by an easier process, without the intermediate stage of
gastric putrefaction ? These, then, are the patients who have
the most fatal facility for auto-intoxication—the patients of the
worst and most hopeless type ? But in fact the epileptic who
is not dyspeptic is the happy exception, the comparatively
fortunate of his class, the case in which the chances of relative
improvement, or of delayed deterioration, are most hopeful. To
state the matter shortly, no one has yet shown any good grounds
whatever for believing either in the existence of this toxin, or
in an origin for this toxin, or in the causal nature of any casual
toxin which may perchance exist. The whole idea is, in fact, a
putting of the cart before the horse.

When we regard epilepsy from a general point of view,
free of any beliefs or theories or imaginations, rejecting all
ideas or dogmas which are plainly inconsequent, and looking
simply at the facts before us, what do we see ? Well, we see a
patient with abnormal symptoms. These symptoms are fairly
constant in type, but protean in form. Searching for a general
feature of these protean details, at last we find mainly a con¬
dition of over-activity, of preposterously exaggerated function.
That is seen in many different manifestations. Some patient
who has usually, perhaps, a slight degree of salivation, during a
fit has such excessive action of the same function that the
saliva may be seen streaming as clear fluid from the mouth.
In like manner the normal tear solution is seen during the fit
as profuse lachrymation. Both conditions are sometimes seen
in paroxysmal degree, when no general convulsions actually
supervene. Similarly enuresis is often present; and, moreover,
the same patient will show different manifestations of this kind
at different times. These simple instances are selected because

Digitized by v^.ooQLe

1903.] by W. HAMILTON HALL, L.R.C.P.LOND.

669

here is the result of exaggerated function manifest, capable of
being estimated in the increased output. It is not more diffi¬
cult to recognise a like extravagance of muscular action. The
very interesting variability of the unconscious pupil, oscillating,
under the influence of involuntary muscular fibres, quite slowly
between comparative constriction and wide dilatation, can be
seen going on throughout the course of most epileptic fits ;
as a matter of fact this is very rarely, if ever, absent,
and a useful little point is that this symptom cannot be
imitated by the malingerer. Turning to slightly larger move¬
ments, there is the nystagmus which may precede or accom¬
pany the general convulsions, and other illustrations will readily
occur.

When we come to consider coarse movements in this light
we are getting near to the actual conditions of “ convulsion ”
as that word is commonly applied. The same exaggeration of
normal function is plainly recognisable. We may first regard
a case which admits of ample time for leisurely consideration.
Most will admit that the mere incidence of the body-weight
upon the feet provides sufficient stimulus to induce “automatic”
walking. Space does not serve to argue out the precise mode
in which these semi-reflex acts are effectuated, but this par¬
ticular reflex is not commonly disputed; whatever may be its
actual nature, it is a normal condition of the healthy. But the
epileptic frequently shows the next stage, and on being started
to walk overdoes the action, adopts the spastic gait, even to
the extent of walking entirely on his phalanges, as a horse does
normally. That shows distinct points of resemblance with the
exaggeration of the normal tone of those muscles concerned in
maintaining the erect posture, into the tonic extension move¬
ment which ushers in the convulsive movements of the ordinary
fit. As a minor point, one of the very commonest symptoms
among the defective, who are so frequently also epileptic, is the
habitual over-extension of the digital phalanges on the meta¬
carpus. All this misdirected energy is to be seen with a
frequency so great as to be virtually constant, and every
observer can furnish other examples, since epileptics of every
shade and type have some or other form of it.

The stomach is an organ which frequently displays such
over-excitability, as might be supposed from its relative im¬
portance in the economy; and accordingly the patient with the

Digitized by

Google

670

EPILEPSY AND TOXEMIC CONDITIONS, [Oct.,

spastic gait may now and then also illustrate the habit of food-
regurgitation. It is interesting to notice that whenever any
such symptom is rather more marked than ordinary, the inci¬
dence of general fits may be anticipated ; and also that when
one patient displays two or several of these manifestations, a
plurality may be worse than average together; or his whole
attention, so to speak, may be concentrated on one only. In
the matter of regurgitating the food it will be found that, so far
as diet is concerned, changes from the present suitable diet to
another equally suitable will have no sort of effect in altering
this condition, which is not to say that indiscretions of diet
might not make it much worse, though that at times would
appear an impossibility. The heart is another organ of which
the functional activity is easily observed. Many epileptics
show great changes in this respect, and some perfectly intelli¬
gent epileptics, perhaps a small matter, refer the aura to
cardiac sensations. In this connection it cannot be without
significance that the “ fit ” may at times take the form only of
a sudden, often alarming rise in the temperature; from normal
to 107°, for example, has been observed. It is impossible to
overlook that the vast majority of epileptics, both in and
preceding, and also to all appearances independently of fits,
show marked disturbances of the vaso-motor apparatus. Here
is perverted energy visible in the areas of pallor and blush.
The commonly received explanations of the turgid to livid
countenance during a fit may be questioned for their absolute
accuracy; but if their general accuracy be granted they fail to
explain those fits in which this extreme congestion of the facial,
and presumably also the cerebral circulation, is entirely absent,
although the struggles are equally violent. It is easy to notice
that this congested circulation of the face and brain cannot be
entirely mechanical, but must be largely of a process common
also to emotional states. The blush is distinctly emotional,
and if one observes a child, especially a fair child, in a violent
passion of screaming, one can see precisely the same turgk)
countenance, the colour often sharply marked off at the supra¬
orbital ridge and just above the zygoma, unembarrassed by any
doubts that here is superfluous and misdirected energy obvious.

Keeping, however, to the main proposition, the toxin-produc¬
tion, we cannot call that a normal function, nor an exaggeration
of a normal function, of the stomach. We can, however, after a

Digitized by ^.ooQle

I903.] BY W. HAMILTON HALL, L.R.C.P.LOND.

671

fashion, see a perversion of the stomach’s true office if we look
for it. The patient who at one time, in one fit that is, pours
out tears literally by the drachm, at another time may very
possibly furnish a salivary flow measurable in ounces. When
we see such plain evidence of profusion in the flow of one
secretion assigned to the digestive function, it is not unreasonable
to assume that a like profusion may occur in another,—for
example, in the proper gastric secretion. No one who has seen
an insane or a more or less idiotic epileptic vomiting fluid,
apparently of his own mere motion, literally by pints, and to the
extent of losing body-weight by pounds, several pounds in two
or three days,( 2 ) can have any doubt that such action may occur ;
and that similar discharges in less degree are frequent is certain,
therefore that they occur in a degree not admitting of ready
observation is practically certain, and in this lesser degree they
may be very frequent. That, however, would amount to per¬
version, gross excess of normal function ; and the stomach
which has thus, so to speak, been squandering its resources,
may very possibly be unable to resume its normal function
immediately. A period of “ dyspepsia ” would very probably
follow, entirely independent of any article of diet; and the
evidence that something of the kind does actually happen
arises, or may be plausibly inferred, from the observation that
artificial feeding with self-digesting food does shorten the
period of recovery after such a phase of extreme over-action.
The extent, of course, to which a few days’ peptonised feeding
has facilitated repair must be in great measure a matter of per¬
sonal judgment; but by giving ample attention to the scales the
judgment is greatly fortified, and where weight rapidly lost has
been almost as rapidly replaced we may be very sure that
something out of the ordinary has been achieved. It might be
somewhat fanciful to compare the condition of a stomach which
can only inferentially be called exhausted, with the muscular
paresis which is called post-epileptic paralysis ; but one may be
permitted to observe that the latter condition has not been very
satisfactorily explained, and “ paralysis ” of an evanescent
nature must be of the nature of exhaustion in some way, either
functional or central.

But to say that the stomach, misdirected to these extreme
degrees, is to be held guilty of producing the cause of all the
trouble is most unfair, since the calf muscles or the iris might

Digitized by v^.ooQLe

672

EPILEPSY AND TOXEMIC CONDITIONS. [Oct.,

with equal justice be accused of the mischief. They behave
with the same functional irrationality, and the stomach does
nothing worse than we see the lachrymal and salivary glands
doing. Exhaustion for their true office has not, indeed, been
proved of these organs, but it may be remarked that inexpli¬
cable conjunctivitis is not rare among epileptics, and rapidly
disappears without treatment. There is little doubt that the
theory of “ peripheral irritation ” has much slovenly thinking
to answer for. The teething infant has a fit. Peripheral
irritation in the gums. Or the little child has a fit, and
ascarides. Clearly peripheral irritation. But some of those
who pass through dentition, and even endure ascarides, escape
the fits unquestionably. Or perhaps a long prepuce. Plainly
still peripheral irritation, therefore off with it But does he
not continue to have fits nevertheless ? Undoubtedly he does,
very frequently. And where is peripheral irritation in the
matter of pediculi ? Shall we regard the irritation of dentition,
and disregard that of the carious tooth? or ignore the renal
calculus, while reviling the frequent nematode? Not very
logically, perhaps, so long as renal disturbances are closely
associated with rigor, which in turn is in infancy expressed in
the form of convulsion. Very possibly the infant is seldom
troubled with renal calculus, but equally epilepsy often does
not develop till adolescence, or even middle life.

Shall we further disregard the strictly comparable case of
traumatic epilepsy ? Why has this sufferer no need for a
haemic toxin ? We know that a cranial injury is sufficient to
serve his turn ; we have the clearest evidence that irritation of
the meninges and cerebral surface is a prime factor in the cause
of his condition, not merely by the traumatic sequence, but
demonstrated by the surgical cure of many cases. Though
the “ idiopathic ” variety is obviously something different, it is
absurd to suppose it to differ toto ccelo i so long as we must
acknowledge that it is also obviously something similar. It
must be an assumption the most natural, even if eventually
shown to be erroneous, that the central instability is the con¬
stant, the peripheral irritation the accident—very frequently, no
doubt, merely the coincident. So of the symptoms. The
excessive over-action is the constant; the form in which it is
manifested is most uncertain and most variable, whether it be
pure matter of chance what the form is in fact or not. The

Digitized by v^.ooQLe

1903.]

CLINICAL NOTES AND CASES.

673

only thing one can predicate of the epileptic is that he is almost
certain to exhibit this extravagance in some form or another;
even the slightest cases of epilepsia mitior may be found to
illustrate it in some way, on careful search.

We are reduced, then, to the admission that central insta¬
bility can be caused by a toxin of unknown nature, and one
whereof the manifestations are so variable that it might be
several. To put it shortly, however specious the theory of
auto-intoxication, the blessed word toxaemia does not explain
anything, and, indeed, has no real meaning in this connection.
An elementary step towards knowing something of this disease
is to be quite clear what we do not know; and the next step is
to discriminate closely between what we do know and what we
only think we know. We know that plenty of exercise in
coarse movements, such as walking and general outdoor labour,
has a beneficial effect, possibly by reason of directing sufficient
energy to proper ends. We know that the less severely
affected have their attacks mainly at night, when, in fact,
there is practically no demand for energy in beneficent
channels. We know that emotional states, which as a whole
may be called in this connection maleficent, are extremely
likely to induce untoward manifestations—fits, temper, dyspeptic
derangements,—and we know a number of equally simple every¬
day facts, since we see them in every epileptic. And we are
asked to explain all these notorious matters by the assertion
of the presence, or the ancient presence, of a toxin circulating
in the blood. It would be hardly less reasonable to explain
a fall in the funds by the circulation of spurious money ; not
necessarily now, any time. That that has existed can be
really proved.

i 1 ) Archcsologia, vol. lviii, p. 322.—(*) From 55 lbs. 2 oz. to 48 lbs. 4 oz. within
a week, to quote a concrete instance, via., a loss of one eighth of the total weight.

Clinical Notes and Cases.

Twelve Cases of “ Korsakow's Disease" in Women. By
John Turner, M.B.

FIFTEEN years ago the late Professor Korsakow described an
assemblage of symptoms met with most frequently amongst

Digitized by

Google

674

CLINICAL NOTES AND CASES.

[Oct,

chronic alcoholics. He claimed that they represented a dis¬
tinct disease, which he termed polyneuritic psychosis, and later
cerebropathia psychica toxaemica. The cardinal features of
this affection, according to him, were, besides the polyneuritis,
amnesia and pseudo-reminiscence. We in England, perhaps
wisely, are slow to accept new diseases; but as now a large
amount of literature has accumulated around “ Korsakow’s
disease ” from physicians in all parts of Europe, it may be of
interest to give an account of twelve cases among women which
I have met with presenting the symptoms of this affection.

Whether we regard “ Korsakow’s disease ” as an entity, or
merely as a syndrome occurring in divers affections, there is no
doubt that the associated symptoms he pointed out are met
with in a comparatively large number of cases of chronic
alcoholic insanity; and the mere fact that certain symptoms
cohere in certain cases lends these cases an additional interest
But, indeed, the recognition of such a coherence is a real gain
to our stock of knowledge, which after all is but a classification
and comparison of phenomena.

Before stating my cases I will mention very briefly some of
the opinions of Continental writers regarding this affection, and
for this purpose I shall make large use of a paper by S.
Soukhanoff and A. Boutenko, which appeared in the Journal
of Mental Pathology (vol. iv). Appended to this communi¬
cation was a complete bibliography giving a hundred and ten
references, only three from English sources.

Although alcohol is accountable for nearly three quarters of
the cases, it also follows after typhoid fever, childbirth, jaundice,
pyaemia, arsenical and, perhaps, lead poisoning. One writer,
however (Oppenheim), could find no cases with the character¬
istic psychic disturbances in others than alcoholics.

Many authorities do not consider that polyneuritis is a
necessary accompaniment of the special psychic disturbances
(Babinski, Gudden, Jolly, Bonhoffer, etc.). It is very generally
looked upon as a form ok mental confusion of toxic origin.
Some consider the speech as characteristic (Chancellay). A
common feature noted by many is the happy disposition and
feeling of self-satisfaction displayed by the patients. Some
(Wernicke, Chancellay, etc.) consider the prognosis unfavour¬
able, others (Rogues and Fursac) as favourable; Tiling says
the non-alcoholic cases are favourable, but not the alcoholic,

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

675

which always leave some mental defect. The intactness of the
intellect and judgment is insisted on by this writer and others.
Chotzen says that women are more susceptible than men, and
gives the recovery rate as 1 in 38 in both sexes. Some
consider delirium tremens as a slight form of the affection
(S. J. Cole also discusses this point); others consider that it
may be an exciting cause. Soukhanoff and Boutenko analyse
the total number (192) of cases collected, and find that 112
occur in men and 80 in women, and that nearly three quarters
are of alcoholic origin.

There is not much difference in the age of onset in either
sex; the greater number in both men and women occur between
thirty-one and fifty years of age. All the cases in women have
presented marked multiple neuritis, and in about 9 per cent.
only it was absent from the male cases. In men, in about
half the cases some psychic defect persists ; death is frequent
and complete recovery rare (2 per cent.). In women, 14 out of
76 recovered, 6 partly recovered, 20 were left with psychic
defects, 5 became demented, and 21 died. Eleven out of the
14 recoveries were of alcoholic nature.

No. 1.—E. A—, aet. 49, married, said to have been sober until nine
months ago. On admission she was quite unable to walk, her knee-
jerks were absent, her pupils reacted normally to light and on accom¬
modation. Her tongue was steady. She was very confused and had
no idea of the lapse of time, and two days after admission thought she
had only been here two hours. Was very badly orientated, and said she
was “ near the cemetery in Grove Road, close to your shop.” In a
little over three weeks’ time she could walk alone, but waddled with
legs apart and could not turn without support. Romberg’s sign was
present. She had a fair sense of the position of her limbs in space, and
could localise with her finger fairly accurately the places where I
pricked or touched her. Her feet and fingers were swollen and very
painful on pressure, and she said they felt numb. She was restless and
fidgety; thought she had known me a long time, and called me Dr.
Todd; her disposition was very cheerful. After the lapse of three
months she became noisy and excited, sat up in bed and rocked herself
to and fro, and sobbed ; talked in a silly hysterical way, and turning to
her nurse exclaimed with emphasis, “ Oh, she is a love, she is a love,
she is a dear ; oh, I could kiss her.” Remained in this condition for
two or three days and then gradually improved; her gait became
normal and her movements less tremulous; Romberg’s sign dis¬
appeared, but her knee-jerks remained absent; her muscle sense, tested
by weights and the position of her limbs in space, was normal. There
was some blunting of tactile sensibility and some anaesthesia (described
a pin-prick as pressure with head of pin); no pain or numbness. She

Digitized by v^.ooQLe

67 6

CLINICAL NOTES AND CASES.

[Oct,

was discharged as recovered, ten months after admission. Her memory-
remained defective, both for recent and remote events, though better
than when she was admitted.

No. 2.—E. F—, set. 46; married ; no children; previous to ad¬
mission had been in bed for two months, said to be paraplegic. The
certificate stated that she imagined she had a baby in bed with her,
and that she had been to Yarmouth that morning and had only been
in bed half an hour and had just finished her household work. I quote
these facts in full as they are so characteristic of the disorder, and as
illustrations of confabulation and pseudo-reminiscence. On admission
she was unable to stand, but could lift her feet from the bed and exert
considerable pressure against my hand with them. She was aware
when I touched them with my finger, and could tell me the number
of times I did so; and with her finger could localise correctly the
stimulated part. When she was pricked so as to draw blood she felt
no pain, but only the pressure. This condition existed from her thighs
to her feet. In the arms her sensitiveness to pain was much blunted,
but not entirely absent, and she localised here also well. In the face
her sensitiveness appeared normal. Her knee-jerks and plantar
reflexes were absent; her pupils equal: they reacted slightly to both
consensual and direct light, and well on accommodation. She lay
placidly in bed, and talked in a drowsy way ; did what I told her to.
Ejaculated short phrases with no relevancy to my questions ; e. g . 9 “ I
haven’t put it near me . . . Another miscarriage with myself ... I’m
reflecting to you ... I picked up this hand ” (lifted up her own hand)
“and pointed to you” (did so). “Now this leg is moving,” etc. She
did not know the day or how long she had been here. She was dirty in
habits. Ten days after admission she was able to walk in an unsteady
fashion. Romberg’s sign was present; she complained of “ rheumatics ”
in hands and feet, and that her hands felt “ so big and numbified,” and
also of a feeling of “ pins and needles.” These sensations were less felt
in her feet. She had no idea how long she had been here, and was
always referring to imaginary journeys to the pawn-shop and public-
house. Exhibited a characteristic feeling of self-satisfaction, and laughed
at nothing. Twenty months after admission she was neat and indus¬
trious ; her pupils were equal, and reacted normally to light and on
accommodation. Her gait was normal, but her knee-jerks were still
absent. Her sensitiveness to tactile and painful impressions appeared
normal. She still exhibited amnesia and pseudo-reminiscence. She
was discharged as recovered six years after admission with her memory
still impaired.

No. 3.—E. E—, aet. 45, married, a heavy drinker for years. The
certificate stated that she raved about her sins, imagined she saw
animals of all kinds, refused her food, and was very excited. On
admission her knee-jerks and plantar reflexes w-ere well marked.
She had apparently no use in her legs and could not stand. The right
pupil was larger than the left. She was emotional and irritable, and
returned generally irrelevant replies, but after a few days was able to
converse better, and it was then found out that she had no idea where

Digitized by CjOOQle

CLINICAL NOTES AND CASES.

677

1903 .]

she was, and thought she had been here six months. Imagined that
she was taken out at night to sleep in a room below, whereas she
was not moved, and was on the ground-floor. Recognised strangers
as her personal friends. Had visual hallucinations of animals. She
was able to get up after a fortnight and walk with a little support,
and at the end of two months her gait was normal and she was
discharged as recovered. No mention was made in the case-book as to
the condition of her memory when she left here.

No. 4.—M. P—, aet. 43, married, was admitted in an acutely maniacal
condition, noisy, abusive, and obscene; her knee-jerks were absent, her
pupils equal, and they reacted normally to light and distance. After
five days she became drowsy and extremely confused, with very impaired
ideas as to the lapse of time. She remained in this somnolent con¬
dition for a week, and then began to be more alive to her surroundings.
Was able to give her name and the place where she was born, but when
she is asked her age replies, “ Blowed if I know! ” Said she had
had five children, including twins. Her knee-jerks remained absent; her
plantar reflexes were of the flexor type. Her tongue was deflected
slightly to the right; it was free from tremor. She was unable to walk
without assistance. Six months after admission she had a seizure of
some sort, “ lost consciousness and went stone-cold ” (information
from nurse); her temperature was subnormal, and remained so for six
days, when it rose to M. 102*0°, E. 102*4°, but went down the next day.
In the course of a few days she became quite talkative and exhibited
characteristic pseudo-reminiscence; e. g., “ had been married that
morning in the church over there” (pointing). Called the nurses by
their wrong names and thought they were old friends of hers. She was
in bed and was unable to stand. A year afterwards she was stout and in
good condition, able to walk in a somewhat stilted way. She complained
of stiffness in her joints; Romberg’s sign was absent. Tongue still
deflected slightly to the right, and knee-jerks abolished. Looked after
herself, had a smiling aspect, and was self-satisfied and jocular. Her
memory was still very impaired as to recent events, but she no longer
indulged in pseudo-reminiscence, and was able to converse rationally.
Three years after admission she was still in good health, neat, cheerful, and
placid, and the only serious psychic defect was amnesia. She had no
idea of the correct date, and when I made her repeat it after me she
almost instantaneously forgot it again. At the present time, two months
later than the previous note, her memory has much improved, and is
now fairly good for both recent and remote events. Her gait is normal
but slow, and she easily gets tired. She complains of cramps and pains
in her legs; her knee-jerks are still absent She is silly and placid,
laughs without obvious cause, and gives no trouble.

No. 5.—E. S. B—, aet. 58, married. She was said to have had a “fit”
a few months before admission. On admission she could not walk, and
when I got her out of bed and stood her up her legs gave way,
and she fell down on the floor. Sensitiveness to painful impressions
was much blunted from the knees down; elsewhere it appeared normal.
Her knee-jerks and plantar reflexes were absent, her pupils equal—they

Digitized by CjOOQle

678

CLINICAL NOTES AND CASES.

[Oct,

reacted fairly well both to light and distance. Tongue straight and
steady. She had a silly smiling aspect, and gave very erroneous answers.
The day after her admission she had no idea how long she had been
here. She described herself as thirty, and said she was a widow with
three children, the eldest eighteen, and that she was only twelve and a
half when she was married. A month after admission she was able to
walk, but very unsteadily. Romberg’s sign was present; she told me,
“ As soon as I shut my eyes I feel I must go down.” Her knee-jerks
were still absent. She was very confused, said she had been here ten
years, and had been to the City that morning, and to Spurgeon’s
Tabernacle. Called me Mr. McDougall. She had a smiling aspect
and her speech was clear. She remained in much the same condition
till the middle of 1902, when she was removed to a branch establish¬
ment. Her legs occasionally gave way under her, she was always
cheerful and self-satisfied, and forgot things as soon as she was told
them. She still indulged in pseudo-reminiscence.

No. 6.—K. W—, set. 53, married. The certificate stated that she
had no memory, and kept getting out of her bed and looking under it
for her baby. On admission her knee-jerks were exaggerated and her
plantar reflexes of the flexor type, her gait apparently normal; her pupils
were equal and contracted, and either rigid to light and on acccommo-
dation, or else reacted very slightly; her tongue was steady and protruded
straightly. She was very restless during the first night, and kept
bumping her bedstead on the floor. The next day she was quieter but very'
confused, and did not know what day it was, nor how long she had been
here—“about a year,” she thought. Described her age as sixteen. Her
habits were very defective. She rapidly improved in all respects except
as to her memory and habits of confabulation ; she stated frequently
that she had been to Walthamstow and back in the morning (a
distance of over thirty miles). Forgot all about friends who had
recently visited her. She was neat and clean, and after ten months was
discharged as recovered. No mention was made whether her memory
had improved when she left.

No. 7.—E. C—, aet. 53, married. The certificate stated that she
was delusive—she was to be burnt aliv6, and fancied she had a baby
in bed with her. On admission she was unable to stand, and lay with
knees slightly contracted and “ dropt feet.” Her sensitiveness to
tactile and painful impressions was much blunted from the thighs
downward, and also in her arms and back of hands; her tongue was
steady and protruded straightly. She remained in bed for two months
with amnesia and ideas that boys came into her room and annoyed
her. After six months she was able to walk a little, was much less
confused, and was discharged as recovered but with impaired memory'.

No. 8.—S. W—, aet. 29, married, had been a heavy drinker for
years past. On admission she could not stand. There was some
hyperaesthesia in her legs and feet; otherwise no decided abnormality of
sensation was detected. She lay with her legs extended and with
“ dropt feet; ” her knee-jerks and plantar reflexes were absent; her

Digitized by CjOOQle

1903 -]

CLINICAL NOTES AND CASES.

67 9

pupils were equal and they reacted to light, but with a restricted range;
their reaction for accommodation was normal; her tongue was steady
and protruded straightly. She had a superficial ulcer on the outer side
of her right leg. She was very talkative and pleased with herself. The
next day she became excited, and saw rats running all about her room.
Was badly orientated and had marked amnesia, and was much given to
confabulation and pseudo-reminiscence; e. g., stated that she made
journeys to Highgate and elsewhere, and that she had a baby in bed
with her. If told the correct date and made to repeat it herself she
immediately forgot it again. Diarrhoea and vomiting set in three
weeks after her admission, and she died a fortnight later^ 1 ) An
autopsy was made ten hours after death. The body was well
nourished. There was excess of fluid beneath dura, arachnoid, and in
the lateral ventricles, and considerable atrophy of the convolutions at
the vertex; otherwise the brain, meninges, and vessels appeared
healthy. The right and left cerebral hemispheres (with meninges)
weighed 480 grms. each, the cerebellum 115, and the stem 30; total
encephalon, 1105 grms. The lungs were free from adhesions; they
were congested at the bases, otherwise they appeared healthy. The
heart weighed 385 grms. ; both it and the aorta were fairly healthy.
The liver was mottled and probably fatty, but it was not examined
microscopically; it weighed 1535 grms., the spleen 215, and the
kidneys 120 and 125 ; they all appeared normal. Transverse sections
of the posterior tibials of both sides stained in osmic acid showed
decrease of the myelin rings and increase of interstitial tissue.
Longitudinal sections, after hardening in Muller’s fluid and treatment
with osmic acid, showed breaking up of the myelin coat into drops
and small black droplets of recent degeneration. Sections from five or
six of the posterior root ganglia w^ere examined after staining with
toluidin blue. A very large proportion of their cells w r ere in a state
of axonal reaction. One ganglion, examined for the Marchi reaction,
showed no degenerative changes in the nerve-fibres. Sections of the
spinal cord taken at three levels, viz., cervical enlargement, mid-dorsal,
and lumbar enlargement, and stained with toluidin blue, showed only
a few cells of the anterior horn in the cervical region in a state of
axonal reaction, more in the dorsal, and nearly all in the lumbar.
Clarke’s column-cells and the Scattered cells seen in similar positions in
the lumbar and cervical regions were practically all similarly affected.
In the cervical region there was only slight recent degeneration in both
Goll’s and Burdach’s column scattered throughout, except quite at the
cornu commissural region. The crossed pyramidal tracts were slightly
affected. Elsewhere no recent degeneration w*as noted at this level. In
the mid-dorsal region a more marked condition of recent degeneration
in the same tracts was observed, and still more marked in the lumbar
region; and here some of the anterior nerve roots (intra-caudal) showed
recent degeneration. The posterior nerve-roots were unaffected except
at their entry into the cord in the lumbar region. The cells of the
hypoglossal nucleus and Purkinje’s cells did not show any signs of axonal
reaction or other alteration. The paracentral convolutions on both
sides were examined. The meninges were unaltered, there w*as no
obvious increase of spider elements in the first layer of the cortex, and

Digitized by CjOOQle

68o

CLINICAL NOTES AND CASES.

[Oct,

the vascular changes were insignificant. Every Betz cell seen was in a
state of axonal reaction, generally in a marked degree (nucleus affected).

No. 9.—M. A—, aet 39, married, a beer drinker. She was con¬
fined to bed for three weeks before coming here. On admission
her gait was unsteady, but she did not show Romberg’s sign; her
knee-jerks were exaggerated, and her plantar reflexes of the flexor
type. She had jerky movements of the arms and head, and her
legs were tremulous whilst she was speaking. Her tongue was also
slightly tremulous; it was protruded straightly. Her pupils were equal
and their reactions normal. She was a dull, heavy-eyed, restless woman,
wandering aimlessly about. She had marked amnesia and was badly
orientated. Forgot things as soon as she was told them. She could
hear her children talking to her (hallucination). After being here ten
days she became very excited and agitated, appeared frightened, and
thought the place was on fire. Her face was flushed and her tongue
dry and brown; she showed marked dropping over to the right side.
She was apparently quite lost to her surroundings, and kept uttering
short disconnected phrases having no bearing on her present circum¬
stances. When she got up, after being ten days in bed, she could only
walk in a very unsteady fashion, and had a small superficial sore over
the sacrum. She remained so feeble on her legs that it was necessary
to keep her in bed for the greater part of her time for another six
weeks. And when she was temporarily got up she would try to run
about, and fall and hurt herself. She could not turn without stumbling,
and had to be supported. She did not show Romberg’s sign, her
knee-jerks were normal, and her sense of the position of her limbs in
space was intact. She laughed or cried at suggestion, but had a sense
of humour, and was self-satisfied and very talkative. Amnesia was
present to a marked degree, and confabulation. Her speech was some¬
what thick. A week later there was an extraordinary improvement in
both her bodily and mental symptoms; her gait had become normal,
and her memory for both recent and remote events very fair; she was
neat in her appearance, bright and rational in conversation, and so she
remains awaiting her discharge.

No. 10.—C. N—, aet. 39, married. Patient was stated to be very
susceptible to alcohol. Mental disturbances and loss of power in her
legs have been gradually coming on for eighteen months. She was pre¬
viously an active woman. On admission she was unable to stand, and
there was apparently some anaesthesia and analgesia in her legs below
the knees. She described a prick as a blunt impression, and localised
the spot with her finger very incorrectly. Elsewhere there was no
marked abnormality of sensation noted. Her knee-jerks were absent,
and her plantar reflexes of the flexor type. In the class of patients
under consideration the testing of sensation is a very unsatisfactory
matter; their answers are often unreliable and their power of attention
very faulty. This woman, when tested a month later, had apparently
some hyperaesthesia in her legs, and screamed when very slightly
pricked, but when her attention w r as attracted from the examination she
paid no heed to sharp pricks. Her right pupil was the larger, and

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

68l

they reacted normally; her tongue steady and protruded straightly.
She was very loquacious and emotional, and although generally
jocular and well pleased with herself, could easily be made to weep by
suggestion. She had marked amnesia with almost instantaneous forget¬
fulness, and no idea of the lapse of time. Her orientation was very
defective, and she imagined that she was at Southend, and that she had
come here for a seaside holiday. She had actually been to Southend
for some time previous to her admission here. A month later she was
still in bed, cheerful and garrulous, and fabricated all manner of
shifting tales; one minute said her husband and children were in
bed with her, and the next declared they were all dead. She would
point to her knee or a bundle of bedclothes and say it was her baby.
A month later she had improved very much mentally, but was still
unable to walk, and complained of pricking sensations in her feet
and numbness in her fingers; her knee-jerks were still absent. Her
memory is now very fair for both recent and remote events; she no
longer indulges in confabulation or pseudo-reminiscence—in fact, she
converses rationally. In this condition she remains at the present time,
with no power in her legs.

No. 11.—E. H—, aet 35, married. No history of alcoholic indulgence
could actually be obtained in her case. The certificate stated that she
talked of going out shopping whereas she had not been out of bed.
On admission she was unable to stand, could not lift her feet off the
bed, and could only push against my hand with slight force. There
was some hyperaesthesia in the legs. Knee-jerks and plantar reflexes
were absent. Her pupils were equal and their reaction normal. Her
tongue was steady and protruded straightly. Her teeth were of
Hutchinson’s type. She talked in a husky voice, and was very confused
and badly orientated. Said she had been here a fortnight and that she
was in Cardiff. At the end of four months was just able to walk with¬
out support, and Romberg’s sign was present; her knee-jerks remained
absent. After nearly three years she was discharged as recovered, but
her memory remained very defective. In disposition she was quiet and
placid.

No. 12.—E. S—, set. 40, married. No history of alcoholism positively
ascertained, but highly probable. On admission she was unable to
walk, and lay in bed w’ith “ dropt feet.” There was no appreciable
alteration in her sensitiveness to tactile and painful impression,
and she localised fairly well (tested in legs, arms, and face). Her
knee-jerks and plantar reflexes were absent. The right pupil was
the larger; they both reacted to accommodation, but the left
seemed rigid to light and the right reacted very slightly (direct and
consensual). Her tongue was steady and straight, and her speech clear.
She was restless, jocular, and emotional; sang snatches of topical songs.
She could answer questions to the point, but quickly wandered to
irrelevant subjects. The following is a specimen of her chatter :—** I
love you, Bill; will you have me for your wife ? . . . I shall turn over,
I’m tired. . . . No, I wouldn’t, darling. . . . Yes, I wish you would. . . .
You can leave me now for a little time.” She continued in good

Digitized by

Google

682

CLINICAL NOTES AND CASES.

[Oct.,

spirits and very garrulous, laughed at nothing, and was often noisy;
said she had seven thousand a year. She was badly orientated,
and with marked amnesia. When tested after the lapse of three
months she had apparently analgesia in arms and legs, and went
on chattering quite unconcernedly when pricked so as to draw
blood, but would casually mention that I was pricking her. Her
habits were very dirty. Seventeen months after admission she could
walk, but with a waddling motion, and there was no Romberg's sign.
Her knee-jerks remained absent. Her right pupil was the larger ; they
both reacted slightly to light (direct and consensual) and fairly on
accommodation. She was fat, lazy, and impudent, collected rubbish,
and was untidy ; her amnesia w T as still present. She called me “father”
and “ uncle," and when questioned as to how long she had been here,
replied, “ Bothered if I know—about a week; ” and when asked to
name the day, said, “Blessed if I know—day after yesterday." She
remained here over three years in much the same condition, and was
then removed to another asylum, where she died a year later of colitis.

The preceding twelve cases, inasmuch as they all present the
cardinal features insisted on by Korsakow and others, viz.,
amnesia, disorientation, pseudo-reminiscence, and confabulation,
may without much question be taken as specimens of “ Korsa-
kow’s disease.” Certainly in ten, and probably in all, peripheral
neuritis was present; the existence of exaggerated knee-jerks in
some of the cases does not forbid this assumption. Some
time ago I examined the posterior tibial nerves in a woman
who died after a short residence here with symptoms of peri¬
pheral neuritis but with very exaggerated knee-jerks, and found
very marked degeneration present. Over-indulgence in alcohol
was ascertained in ten, and was highly probable in the other
two.

There did not appear to be anything characteristic in the
speech ; in two it is described as “ thick,” in one “ drowsy,”
and in the others it was normal. As to the pupils, the right
was the larger in three cases; in six they reacted normally to light
and distance ; in one the range to light reaction was restricted ;
in one they reacted slightly to light; in three they were
described on admission as of the Argyll-Robertson type ; but in
all these there may have been a very slight movement to light,
and in one the reaction improved, so that when she left they
reacted decidedly but slightly to light ; in one the reactions were
not mentioned.

Jolly, Bonhofifer, Sorey, and Cole look upon Korsakow's
disease and delirium tremens as very closely allied ; and Cole

Digitized by v^.ooQLe

1903-]

CLINICAL NOTES AND CASES.

683

points out how in cases of marked neuritis there is, in addition
to the confusion, a delirious condition with marked tremor and
jactitation, and often characteristic visual hallucinations (ani¬
mals), and with often a distinct element of fright or dread.
Others, again, regard delirium tremens as an exciting cause of
Korsakow’s disease.

It will be observed that four of my cases partook largely at
one period of their course of delirium tremens (Nos. 3., 4, 8,
and 9). Nos. 3, 4, and 8 were delirious at first, and 3 and 8
had typical visual hallucinations (rats and other animals).
No. 9 developed the delirious symptoms ten days after
admission.

Course .—Seven recovered sufficiently to be discharged, but
the memory remained seriously impaired in four ; in two no
mention of its condition is made at the time of discharge, and
in one it regained its normal state. Three of the cases remain,
and in all probability one of these will ultimately recover with
no very obvious impairment of her memory. Two died, one
after only a month’s residence and the other after four years.

Pathological anatomy .—A microscopical examination of the
nerve tissues has been made by several Continental observers,
but I have not had access to their records. Cole mentions that
he can find no record of any case in which the cord was
examined by Marchi’s method in which it is stated that the
posterior columns were free from degeneration. Soukhanoff
and Boutenko make very slight reference to the pathological
findings. In a case of Sorey’s they mention that, besides the
degeneration of the peripheral nerves, the cerebral cells were
markedly impaired, but they do not say in what manner ; and
in a case of Siefert’s they state that the most marked changes
in the brain were located in the central convolutions. Cole
gives a full report of two cases in both of which the patho¬
logical findings were similar, and they agree entirely with those
of No. 8.

The question as to whether we are to look upon Korsakow’s
description as applying to a distinct disease or merely to a
syndrome will largely depend on our connotation of the term
disease. An ideal definition of disease would necessitate our
insisting on the presence of certain symptoms, following a
specific cause and characterised by a definite pathology. We
cannot with the evidence at our disposal say that “ Korsakow’s

XLIX. 47

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

684

[Oct,

disease” fulfils all these requirements; but neither do many
other fully recognised diseases.

It is well known that the injurious effect of alcohol on the
organism is of the most varied nature. Sometimes it plays
havoc chiefly with the hepatic functions, at others with the
renal, and again at others with the nervous. A form of
insanity may ensue from the renal disturbance which has
distinct features from that which is due directly to the toxic
action of the alcohol on the nervous system. Apparently, also,
even when the nervous system is primarily attacked the
symptoms vary according to the part or parts implicated.
For reasons which are obscure, sometimes the vascular and
supporting tissues of the brain are chiefly affected, at other
times the nerve-cells themselves in one or another region, or
sometimes it would appear as though the prolongations of the
nerve-cells are the parts especially picked out; and the variations
in the psychical disturbances will obviously depend upon the
respective parts affected.

I am inclined to agree with Jolly that the symptoms we are
considering constitute a syndrome, and are one of the mani¬
festations of the action of alcohol and other toxins on the
nervous system ; that they are the expression of a neuritis
affecting different portions of this system at different times.

I believe that the specific action of these toxins is on the
nerve-fibres, and not directly on the nerve-cell. If the
peripheral fibres are implicated, then we get the manifestations
of peripheral neuritis; sometimes these structures are not
seriously affected, and the toxic action expends itself chiefly on
the prolongations of the cortical cells which pass down the cord
in the pyramidal tract, or, again, on those which pass up the
cord in the posterior columns, in either of which cases we have
to deal with a central neuritis. Probably in all cases there is
more or less grave implication of the association nerve-fibres,
especially those of the tangential system.

The most usual form of nerve-cell change met with is one
that can adequately be accounted for without suggesting any
direct toxic action on the cell bodies. It is the form known as
reaction a distance , or axonal reaction. Experiments show
conclusively that it can be produced by severance of axons
from their cells, or by influences which injuriously affect the
axons (< e . g ,, haemorrhage); and in the condition described by

Digitized by v^.ooQLe

1903.] CLINICAL NOTES AND CASES. 685

Korsakow we have, so far as I know, invariably the necessary
factors for setting up this change. But there is also another
factor present which will supplement and assist the primary
action of the disordered motor axons on their cells. We have
considerable evidence to show that deprivation of those normal
stimuli which pass to the efferent cells (stimuli, that is, pro¬
ceeding from afferent or sensory cells, and impinging on motor
cells) is also capable of setting up this form of change; and in
every case, so far, where a microscopical examination of the
cord has been made, very marked evidence of degeneration has
been found in the posterior columns.

As regards the genesis of the peculiar psychic troubles, whilst
the serious interference with cortical association fibres, espe¬
cially of the tangential system, enables us to form some concep¬
tion as to why the memory and the time and space ideas
should be so seriously interfered with, and account for the
confusional nature of the insanity, it seems to me also possible
in the cases where there is wide-spread polyneuritis that this
factor also to some extent assists in fostering the peculiar
mental troubles.

Consciousness depends upon the integrity of the periphery ;
more or less interference with the nervous currents passing from
the periphery to the central nervous system will correspondingly
impair consciousness. If we cut off entirely this supply of
currents, as, e.g., in chloroform narcosis, consciousness is quickly
abolished. A case is on record of a deaf man with practically
total anaesthesia of his skin, in whom it was only necessary
to close his eyes and he immediately went to sleep, t\ e. f became
unconscious.

Our time and space perceptions depend upon the due
appreciation of the sequence or simultaneity of impressions. If
we interfere with these to any extent, if they are blunted or
perverted, we shall get perversions of time and space ideas ;
and if the abolition of these impressions is very wide-spread,
then not only will the subject be unconscious of his environ¬
ment, but his ideas of present time and of space will also be
annulled. Under these conditions, not receiving an adequate
supply of sensations from the periphery, he will draw on the
ideas already stored up in his central nervous system, and the
result will be pseudo-reminiscence and confabulation. Patients,
it will be observed, imagine themselves still to be in the place

Digitized by v^.ooQLe

686 CLINICAL NOTES AND CASES. [Oct.,

where they were before their consciousness was seriously
impaired. But although the peripheral trouble may take a
share in forming the peculiar nature of the psychic disturb¬
ances, this share can only be a supplemental one. There can
be no doubt that the confusion of mind is essentially due to
disorder of the central nervous system, for when patients have
to all intents entirely recovered from their peripheral defects
they often still present very marked disturbances psychically,
e.g, ,, amnesia and pseudo-reminiscence.

References.

Serge Soukhanoff and Andre Boutenko, “ A Study of Korsakoff’s
Disease,” Journal of Mental Pathology , vol. iv, 1903, pp. 1—33.

Sydney J. Cole, “ On Changes in the Central Nervous System in the
Neuritic Disorders of Chronic Alcoholism,” Brain y vol. xxv, 1902,
pp. 326—363.

(M The pathological features of this case are reported more fully in Brain ,
Spring, 1903. It is No. 32 in the article entitled “ An Account of the Nerve-cells
in Thirty-three Cases of Insanity, etc.”

Notes on Two Cases illustrating the Difference between
Katatonia and Melancholia Attonita.() By W. R.
Dawson, M.D., Farnham House, Finglas.

One of the most interesting points connected with the
concept katatonia is its relation to the morbid phenomena
included under the older term melancholia attonita. Many
modem exponents of the former, especially in Germany,
would deny the existence of stuporose melancholia altogether.
Yet it seems to me that cases occur conforming to the
descriptions of the latter which cannot be included in the cate¬
gory of katatonia without the merest straining of terms. In
this connection I think the following two cases are instruc¬
tive :

Married woman, aet. 30, admitted in June, 1902. It was ascertained
that her brother had been alcoholic and had committed suicide, and
that her sister had met her death in a manner that left no doubt that
she had also taken her own life. The patient herself is said to have
behaved in a peculiar manner some years before the present attack.
She had no family, and sexually was out of health, menstruation being

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

687

1903 .]

very profuse. Shortly before the present illness she became connected
with one of the more emotional religious sects, and about a year previous
to admission she took an inexplicable dislike to one of her clergymen,
whom she believed to be preaching at her. A few weeks later, while at
the sea-side, she suddenly became acutely insane; but this phase was
very transitory, and during the summer of 1901 (in the course of which
she underwent an operation) she was depressed and solitary, with fears
that her soul was lost. She was at this time in poor physical health.
By October she had greatly improved, but she then became nervous,
flighty, and restless, lost her sleep, and showed a preference for men's
society. On November 3rd she suddenly began knocking on doors,
saying that God had called her, and became violently excited. This
subsided, but two days later she had another attack in which she bit,
kicked, tore, beat her head upon the floor, and the like. This gradually
passed off, and she then became perverse and mischievous, and at the
same time developed a high opinion of her saintliness. Later still she pre¬
tended to be lifeless, passed her motions under her, and had to be tube-
fed. I saw her in consultation about this time, and found her unwilling
to speak and full of somewhat exalted and mystical religious delusions.
She then had a period of mutism for some weeks, but did what she was
told. During the spring she was variable and rather depressed, and
as she did not seem to be making progress she was sent to Famham
House. She is said to have been suicidally inclined. On admission
she was in a state of resistive stupor, lying still and silent, often with
her eyes shut, until she was wanted to do anything, when she at once
resisted. She was muscularly strong, and showed no physical ab¬
normalities except poor circulation, with somewhat livid skin, rapid pulse,
and high arterial pressure, and also a trace of sugar in the urine, which
proved only temporary. There was a tendency to constipation. Sleep
fairly good. Temperature was slightly subnormal.

On a few occasions during the first nine months after admission she
talked a little, but in the main lay silent and quiet with her eyes shut,
and resisted violently when anything was done for her, spitting, biting,
and striking. She had almost invariably to be tube-fed, had to be
washed and dressed, was dirty in her habits frequently, and generally
refused to wear any night-linen, though she usually allowed her clothes
to remain on in the daytime. In the summer she was subjected to a
course of thyroid feeding, but was only partially roused by it, and soon
relapsed; and of the other drugs tried the only one which produced
any marked effect was trional in 10-gr. doses thrice daily. Under this
she always roused and showed improvement, but it soon lost its effect.
Almost all through she seemed, so far as could be judged, to retain her
perception of what was going on around her; and once (in February
last), when frightened by another patient’s screaming, she left her room
(albeit in a nude state), and was more rational for the rest of the day.
In February the menses, which had been in abeyance, reappeared, and
she showed some improvement, but in March she relapsed, and, indeed,
for a few days the stupor deepened into a condition resembling coma.
After this, however, it began to pass away, and some elevation took its
place, and in the course of the last three months the stupor has alto¬
gether disappeared. The patient is now usually cheerful and slightly

Digitized by v^.ooQLe

688

CLINICAL NOTES AND CASES.

[Oct,

elevated, but is inclined to be touchy and unmanageable, and sometimes
loses her temper without any external reason whatever. She is fairly
sensible, enjoys visits from her friends, and is beginning to be anxious
for her discharge. On the whole, improvement is still progressing, but
a certain element of mental weakness is still present, though this may
not prove permanent.

We have here a succession of melancholia, mania, and
stupor, followed by slight maniacal elevation and mental weak¬
ness, in an hereditary neuropath. The whole attack has
lasted over two years. There were delusions and probably
auditory hallucinations of a religious type both in the melan¬
cholic and maniacal periods, and at times also in the stuporose.
The latter period was marked by many temporary and incom¬
plete remissions, and the stupor was of a resistive type, with a
tendency to negativism. Upon the whole, therefore, the case
is a fairly typical example of katatonia, notwithstanding the
absence of some symptoms (especially verbigeration and cata¬
lepsy) to which great importance is attached by many authori¬
ties. On the other hand, the following case, though showing
these symptoms, cannot, in my opinion, be so classed :

Case 2.— The patient, a married woman aet 33, comes of a nervous
family, though no neuropathic history has been elicited. She had sus¬
tained a severe fall on her head when out riding some fifteen years before,
and had frequently suffered from headaches since. Just before the present
attack she had had an abscess in one of her fingers. She is said to be
naturally rather sulky and obstinate, but very nervous, and a gynaecologist
has pronounced her to be sexually ill-developed. For about two years
she has been worrying unnecessarily about a certain action on the part
of a relative. Early in 1902 she became parsimonious, and then acquired
delusions of having no money (even when she had ^7 or in her pocket
at the time), and grudged necessary expenses. Next she thought that
the police wished to arrest her for starving her household, and then
began to dislike her husband and to refuse food. On one occasion she
is said to have attempted suicide. Various measures, such as change,
Weir-Mitchell treatment, etc., were tried without avail, and finally she
was sent to Maryville. On admission she was very emaciated, looked
much older than her years, and was stuporose and somewhat resistive,
but no organic disease could be detected. Her physical condition has
considerably improved under treatment, but mentally she remains much
the same. Her state varies frequently between a quiet stupor, in which she
sits or stands motionless and silent (mutism) and often allows her limbs
to remain for a short time in any position in which they are placed
(catalepsy), and a state of more or less acute restlessness and resistive¬
ness, in which she looks intensely miserable and is very noisy, repeating
one cry for hours in an automatic sort of way (verbigeration). Even in

Digitized by ^.ooQle

CLINICAL NOTES AND CASES.

689

1903 ]

the latter state, however, there is still a great deal of stupor. She has
frequently had to be tube-fed, is wet and dirty in her habits, and at
times wakeful at night. Occasionally she recognises her relatives when
they come to visit her, and seems glad to see them, but not always.
Various forms of special treatment—thyroid feeding, lavage, morphia or
opium hypodermically and by the mouth, and latterly over-feeding—
have been tried without much apparent result, at least on the mental
side.

It will be seen that this case, although showing a sometimes
resistive stupor, with mutism, verbigeration, and a tendency to
catalepsy at times, differs from the type of katatonia in the
absence of marked heredity, of a maniacal stage, of exalted and
religious delusions, and of any tendency to real remissions,
while there has been marked depression all through. For
these reasons (although I admit that further observation is
required) it seems to me that this case cannot justly be set
down as one of katatonia, but is a genuine instance of melan¬
cholia attonita, as distinguished from the former. If this is
correct, the case is further interesting as showing that ver¬
bigeration may occur in an acute form of melancholia—a fact, if
it be one, which has been expressly denied.

( x ) Read at the meeting of the Irish Division at Enniscorthy, July 3rd, 1903.

Notes on the Treatment of A cute Cases . By R. R. Leeper,
F.R.C.S.I., Medical Superintendent, St. Patrick’s Hospital,
Dublin.

If we trouble ourselves to look back and study the treat¬
ment of insane persons in olden times, we cannot but be
struck by the fact that our forefathers regarded insanity as a
disease which needed active treatment, and it generally received
such at their hands; and that, however much the weird and
sudden outbursts of religious frenzies, sudden seizures, and mad
impulses were regarded as evidences of demoniacal possession,
or God-inspired action, the patients so affected, and rendered
conspicuous by their conduct, received at the hands of their
fellow-creatures treatment which, however curative in intention,
must have tended rather to elimination than recovery, and in

Digitized by ^.ooQle

690

CLINICAL NOTES AND CASES.

[Oct,

this respect differed little from that meted out to the physical
illnesses, wounds, and accidents of the patients of bygone times.

Yet the treatments which were carried out were largely
thought to be curative; and we find men as assertive of the
benefits to be derived from a diet of apples, from frequent
scourgings with sticks, and rapid revolutions in specially con¬
structed chairs, of the administration of hellebore and borage,
and many other means regarded by us as either useless or
ingeniously cruel, as men are to-day of the benefits to the insane
of costly and home-like surroundings, freedom of action, the
use of organotherapy, and all our modem methods of treating
the insane which we daily put in practice.

One of the first difficulties in dealing with an acute case of
insanity presented to us is that it is often impossible to
promptly classify an individual case so as to place it under a
distinct heading, and much valuable time may be lost in the
mere contemplation of the case by the most energetic of us
before we can decide to commence that active treatment which
is demanded of us if the patient is to owe his recovery to our
intervention—time which may mean the coagulation necrosis,
and chromatolysis of the nerve-cell, and the death mayhap, of
the infinitely complex organ whose mere functional disturbances
are so alarming, whose comparatively slight organic changes
mean physical wreckage and an intra vitam mental death.

What, then, can be done to remedy the evils of vague and
excessive classifications so as to more quickly develop the
dark negative and bring out the clear picture of the mental
state of our patients ? Can we as yet but empirically treat a
disease which we can but also vaguely, symptomatically, and
empirically classify ?

I think it may be possible ere long for those of great ability
and with scope for their labours to select one acute and sharply
defined mental disease and devote all the annual work of our
laboratories and hospital wards more directly and particularly
to it and its therapeutic and clinical aspects. Let all in
asylums give the selected disease a steady and continued
investigation. If this were done it would focus the work of
many able men on this one object, and it seems to me would
be more productive of advance in knowledge than the more
largely conceived and varied investigations by individual
workers, no matter how productive of good such work has

Digitized by

Google

1903-]

CLINICAL NOTES AND CASES.

691

undoubtedly been in the past. Let us never forget that the
barbarisms of the past were thought to be curative. Men have
recorded their opinions of such treatment in eulogistic terms,
and they undoubtedly were credited with effecting cures in
their day.

“ All roads lead to Rome” and in the estimation of the
value of one particular treatment it must be ever borne clearly
in our minds that recoveries have so far resulted from many
apparent causes (as treatment in asylums is very varied), and
that the good result may possibly be due to time, opportunity,
or individual peculiarity more than to the course of treatment
we are inclined to attribute it to.

In writing this paper I have not brought anything new before
you, nor do I intend to announce to you the successful applica¬
tion of some new remedy followed by the hasty enumeration of
a series of recoveries by its use ; but I wish to frankly acknow¬
ledge the personal difficulties of one who is, like those whom
I address, daily seeking through comparative darkness for
more efficient weapons wherewith to treat an ever-present
mischief, for a more certain and efficient means to cure the
diseased minds of those who are daily entrusted to his care.

With an increase of knowledge professional differences of
opinion as regards the value of treatments must die out, and our
art and science must gain in public esteem and usefulness.
Let us, then, do something more than heretofore to produce
this unanimity, so that each one may feel a confidence in the
carrying out of a remedial course which has received the un¬
qualified approval both of the scientifically and clinically minded
of the psychologists of to-day. If we regard the noisy restless¬
ness, verbigeration, and incoherence of the maniac as we regard
the dulness on percussion, and rusty sputum, of a patient
suffering from pneumonia—merely as the symptoms which
enable us to classify and promptly treat their respective diseases,
—surely there is as much reason to treat with uniformity the
mental as the physical disease; and in securing the best and
most successfully uniform treatment our best efforts must be
used in the interests of our race. Each new suggestion for
the application of new remedies ought to receive as much
attention, and record, and investigation by different hands and
different minds in our mental as in our general hospitals ; and
I think that uniformity on lines of recognised treatment is as

Digitized by

Google

CLINICAL NOTES AND CASES.

692

[Oct,

imperative, and will undoubtedly be as practicable with us in
asylums as it is in general medical and surgical practice.

At present, if it were asked of us what drug or medicinal
means we used to treat our last twenty acutely maniacal or
melancholic patients, we would be puzzled to find an answer.
Yet a goodly number recovered, and one is ever inclined to
attribute the recovery to one or other of the therapeutic
measures we adopted ; but what ultimately effected the change
we are loth to say. Even of the patients chained to the walls
of the old asylums it is recorded that some recovered and were
discharged as cured. And we who are faced with the treatment
of the insane of to-day can but say that, however uniform our
treatment is as regards kindness and the provision of amuse¬
ments and comfort of our people, we have yet much to do in
the provision for them also of a more systematised medicinal
treatment.

I fancy that it has been the feeling of most of us at times that
we were engaged in a very unequal and single-handed contest,
and the feelings of a psychological therapist might not inaptly
be described as similar to those of a naked fencer with an
armoured adversary who responds to his most furious onslaught
by a calm indifference, or some unlooked-for and outlandish
response to his attack, which leaves him almost bewildered, or
helpless and dismayed. He must, however, again think out
some new line of treatment, some new method of attack ; and
happy is he if he can discern a joint in the armour, or secure a
response to his efforts.

I have selected a few of my cases as being of sufficient
interest to bring before you as examples of the somewhat
bewildering difficulties of treating acute patients. They are
intended to show you that recovery does occur apparently a s
the direct result of drug treatment, and that apparently some¬
what similar cases sometimes recover without any specialised
drug treatment at all, and that until our knowledge increases I
fear I shall be unable to increase my annual recovery rate
beyond its present average, viz,, 53 per cent, on my annual
admissions.

The first case I wish to record is the remarkable case of A. D—,
admitted to St. Patrick’s Hospital August 1st, 1900, set. 33 years,
barrister-at-law, suffering from delusional insanity. This patient had
been deported to Scotland, and had been under treatment in the

Digitized by v^.ooQLe

1903 -] CLINICAL NOTES AND CASES. 693

Murray Asylum in 1898, and in the Crichton Royal Asylum in 1899.
He had been travelling with attendants in England prior to his being
admitted here. He was brought to the hospital with his legs tied
together with ropes, to facilitate his journey back to Ireland. His
present attack, which was of two years’ duration, began with the usual
symptoms of an on-coming melancholia—sleeplessness, restlessness,
—and he complained of a feeling of numbness of his skin, and a
great and irrational anxiety lest he should be unable to support himself
and his wife. I was told he masturbated frequently and shamelessly,
and he was treated for this condition by a Dublin practitioner, who cir¬
cumcised him. Being none the better for this proceeding, he was taken
to London, where another surgeon, presumably with a more artistic
sense of proportion, re-circumcised him. After these proceedings he
was removed to Scotch asylums, where he remained for two years. On
admission here he was in an apparently stuporose and partially demented
state, very resistive and violent if interfered with or made to move,
refusing to speak or answer questions, swaying his body from side to
side, chewing his clothes, and sucking his fingers. It generally took
four strong attendants to give him a bath or move him to the grounds
for exercise. He daily chewed the sleeve or collar off a coat, and
frequently destroyed both a coat and waistcoat a day. If asked to
cease destroying his clothes he denied doing so, and his condition
might be described as one of negativeness. If asked did he like
Dublin, he replied, “ This is not Dublin; ” and when shown the
well-known Wellington Monument in the park, which can be seen
from the hospital windows, he still refused to recognise his country.
If one bade him good morning, he replied, “ This is not morning; ”
if good night, “This is not night.” If asked to look at a flower
in the grounds his response was, “ That’s no flower.” If we pointed
out the sun to him we were told, “That’s no sun.” During this
stage of his illness he was exceedingly wet and dirty in his habits,
daily passing urine and faeces in his trousers, while standing swaying
his body from side to side. During the period which elapsed between
his treatment in Scotch asylums and his admission here, he had his
hands tied nightly to the bedposts in order to prevent his masturbat¬
ing, and for long after his admission here he slept with his arms raised
above his head as the result of this treatment. He never was observed
to masturbate after his admission here.

His pupils were normal and reacted to light and accommodation, his
organs healthy, and a small quantity of sugar was found in his urine on
admission, sp. gr. 1030. He was treated for this by 1 gr. codeia
being administered daily, and the sugar disappeared shortly after
admission and did not afterwards complicate the case.

His muscular system was exceedingly rigid and his reflexes slightly
exaggerated. His condition being unaltered on September 17th, 1900,
he was put to bed, and thyroid extract administered in 5-gr. doses,
gradually increased till he was taking 50 grs. per day. This treatment
was discontinued on October 20th, there having been no reaction what¬
ever or good results obtained apparently by its use.

The note on February 14th, 1901, describes him as standing all day
long at the ward door, rushing violently out whenever he could, and

Digitized by v^.ooQLe

694

CLINICAL NOTES AND CASES.

[Oct,

then standing aimlessly outside, refusing to either go on or go back,
rocking his body from side to side, and as wet and dirty in his habits
as a general paralytic; the note in the case book being that he shows
no sign of intelligence. He had ceased chewing his clothes fourteen
months after admission. It was observed in July, 1902, that a slight
change had occurred, that he would answer questions and speak
rationally, and showed a decided taste for riddles and conundrums,
which he always tried to answer if asked in a joking way by the atten¬
dants. He was again put to bed and treated with large doses of thyroid
extract, which seemed to produce no effect whatever, neither a rise of
temperature nor a more rapid pulse-rate being observed to occur from
its use, nor did it seem to reduce his weight His physical health con¬
tinued excellent.

On October 9th, 1902, the first noticeable change occurred. He
still stood about the doorways, but looked more intelligent and
increased slightly in weight He steadily and gradually improved, and
was completely recovered about May 1st, 1903, nearly three years
having elapsed since his admission to the hospital; and in the fifth
year of his illness his recovery took place. He has a distinct
recollection of all that occurred around him during his apparently
stuporose state, and he even recalled to my mind the efforts I had
made a year ago to draw him into conversation, and recollected the
very words I spoke to him, both then and afterwards. He has a dis¬
tinct and accurate memory of all his experiences both here and in
England and Scotland during his illness.

A short period prior to his discharge it was discovered that he
suffered from thread-worms in his intestines, which were immediately
actively treated and eliminated. Whether the presence of these
parasites was the fons et origo of the diseased state I cannot say. The
illness,—which commenced by peripheral nervous irritation of the genito¬
urinary tract, as shown firstly by the self-abuse and glycosuria, and sub¬
sequently by the chewing of the clothes and muscular rigidity,—may
have been the result of a visceral reflex irritation caused by urates.
The remarkable recovery in this case, the clinical treatments by
thyroid and codeia, and lastly, the exhibition of vermicides, may be my
excuse for reporting to you at such length a case which is the most
remarkable I have seen for some years.

Case 2.—M. C—, an unmarried girl set. 20 years, admitted to hospital
September 14th, 1901, suffering from acute melancholia. Father
committed suicide by cutting his throat. Brother believed to have
also committed suicide. Present illness of four months' duration,
and believed to be due to business worries and a severe wetting
during a menstrual period, which was supposed to have produced
araenorrhcea, from which she suffered, and for which she was taken
to a gynaecologist. She last menstruated six months prior to her
admission. The night after her visit to the gynaecologist, who examined
her pelvic organs, she started out of bed, broke the lamp, and made a
most determined attempt to cut her throat with the broken fragments
of glass. Her mother, who was sleeping in the same room, could not
prevent her severely lacerating her throat On admission she was

Digitized by v^.ooQLe

1903]

CLINICAL NOTES AND CASES.

695

found to have several deep lacerated wounds and one deep punctured
wound which was in very close proximity to her carotid artery, but had
not opened the large blood-vessels of the neck. She was in a semi-
stuporose state, her circulation very feeble, her hands blue; she was
sleepless at night, and answered questions very slowly. Her pupils are
very variable, at times widely dilated and a few hours later contracted;
constantly picking her finger-nails, and at times weeps and cries bitterly,
saying she is ruined and disgraced, and that everyone is calling her
names. Suffers from hallucinations of hearing. Her reason, she says,
for attempting to commit suicide was that she knew her mother was
going to kill her, and in order to save her mother from sin and
subsequent punishment, she decided to destroy herself. Examined
carefully, we detected distinct crepitation at apex of right lung.

She improved very much and did a good deal of nurse’s work in the
ward, and said she would wish to become a nurse. Says she suffers no
annoyance from voices now, two months after admission, and is bright
and cheerful in her manner.

In December she had a relapse, and seemed to be as melancholic as
on admission. Her catamenia, which had now been absent for nine
months, returned, and she suffered more from her old hallucinations
and depressing delusions than before. Towards the end of December
she again became bright and cheerful, and was occupied at house-work ;
grows worse towards evening.

In January she had another fit of depression, and seemed to be as
bad as on admission, saying she is to be killed, and imagining she has
brought some vague misfortune upon all belonging to her.

She again became bright, and again depressed, during February and
March. Menstrual periods are now normal as regards both time and
quantity. Her hands are blue and her general circulation feeble, but
her physical health is much improved, and her lung trouble has
apparently disappeared. Her condition of alternating between depres¬
sion and brightness continued, and on March 2nd I decided to put her
to bed and give her a course of thyroid extract. On March 15th, 1902,
whilst undergoing this course of treatment, she jumped out of bed
suddenly and rushed to the window, breaking the glass, and was pre¬
vented by the nurse, with difficulty, from injuring herself. Says she
has ruined her family.

She was still kept on the thyroid extract, and on March 22nd the
thyroid treatment was stopped, as her temperature was raised and her
pulse and respirations increased in frequency. Mental state very
variable, one day depressed and one day bright, but alternation more
frequent; she gradually lost the fits of depression, and left the hospital
almost recovered on March 31st, 1902. I have made inquiries recently
and find she is quite well, and has had no recurrence of her trouble
since she left us. This is a case in which the thyroid extract seemed to
produce a very desirable result, and to hasten, if not absolutely to cause,
her recovery.

The next three cases which I shall simply describe received no
specialised drug treatment at our hands, and yet recovered, and
have since leaving us done well, and have had no return of their
illnesses.

Digitized by

Google

69 6

CLINICAL NOTES AND CASES.

[Oct,

Case 3.— R. J. H—, male, aet 21, clerk and book-keeper, admitted
July 29th, 1901. Sister had been patient here and recovered. Whilst
on a fishing excursion this patient wrote out a dying statement for his
family’s benefit, and with a penknife opened his radial artery. Medical
help was at hand, and the patient was promptly admitted here.

His condition on admission was one of profound depression. He
said he had ruined us all, that he had contracted syphilis, which was
untrue, and that he would give us all this disease. He remained in a
semi-stupid, delusional state for three months after admission, when he
developed acute mania, became again suicidal, and required the padded
room at night. Noisy and restless. This condition was not long main¬
tained, and he again became melancholic and depressed.

He remained in this state for some months, alternating between exalta¬
tion and depression, and it was remarkable that as soon as he became
restless and talkative sordes appeared on his lips, and his tongue became
furred. I ordered him salicylate of bismuth, 10 grs., three times daily,
and again a course of calomel, 5 grs., and salol in 3-gr. doses during
his periods of gastric disorder and mental excitement. He gradually
recovered, and I had recently a letter from him saying he is well, and
has been employed in farming work, and is leading an open-air life in
one of the colonies. The only drug treatment used in this case was
the course of intestinal antiseptics, which may have shortened his
attack or hastened his recovery.

The next case I shall mention to you is one of some interest in
connection with the article by Dr. Bruce which appeared in the last issue
of the Journal of Mental Science . Dr. Bruce, you will remember, claims
to have discovered and isolated a bacillus which presumably causes
mania. By the hypodermic injection of turpentine, he produced an
aseptic abscess, which, according to his experience, seems to have a
remarkably curative action upon this disease.

M. W—, a stout lady, set. 50, was troubled with gouty eczema of her
legs for years. A “gamp” nurse was employed to look after her
in her own home. She was of temperate habits, and had never been
previously insane. Her father and mother had been insane; brother
eccentric. Admitted to St. Patrick’s Hospital from a private asylum on
February 2nd, 1903.

The history of her attack was as follows :—She rushed out of her
house into the street in her nightdress, pursued by her nurse, who
endeavoured to control her. Both patient and nurse were arrested by
the police and removed to the station, where the former was recognised
to be insane. She was subsequently sent to a small private asylum, where
her furiously maniacal condition was controlled by a strait-waistcoat;
she was there found by our nurses tied to a portmanteau and was admitted
here in a condition of acute mania. For a fortnight after her admission
she shouted and rolled on the floor, and was with difficulty prevented
from injuring herself. She tore her clothes and was violent to those
about her. On February 13th the note in the case-book states that she
is almost rational, quiet, and the excitement has passed off; is much
distressed by the recollection of her recent illness, and appears to have
suddenly changed for the better. It is most interesting to note that at

Digitized by v^.ooQLe

1903]

CLINICAL NOTES AND CASES.

697

this period of sudden recovery a small abscess formed on the sole of her
foot at the metatarsal phalangeal joint under the great toe, as the result,
I fancy, of the continuous dancing and jumping on the floor. Her foot
was much swollen, and after freezing the part I made an incision
into the abscess, evacuating a drachm or two of healthy pus. From
this time on her mental state cleared up, and she almost completely
recovered by the 25th of last month, and was transferred to St. Edmunds-
bury, and is shortly to be discharged. The old gouty ulcer on her leg
has healed, and she is in robust physical health. A microscopical
examination of her blood shows that her white blood-cells are lympho¬
cytes and polymorphonuclear leucocytes. No leucocytosis; a leuco-
penia, if anything, being noticeable. It will be interesting, therefore,
to note if the recovery will remain permanent. She was discharged,
and remained a month at home, but has relapsed and had to be read¬
mitted in a sub-acutely maniacal state.

M. A. S.—, set. 42 years, admitted March 13th, 1903. Unmarried.
Second attack. Duration previous to admission, three to four weeks.

Cause of attack unknown. Family history unknown.

Previous history .—She had acute rheumatism when about twenty
years old, which left no complications. Ten years ago she had an
attack of melancholia, which lasted about six weeks ; she was treated at
home and recovered perfectly, but since that she was subject to
occasional fits of extreme depression. The present attack began about
three or four weeks before admission, with insomnia, change in habits,
and depression.

When admitted to hospital she appeared to be in good physical
health, but was very silent and depressed. She answered questions in
a slow, hesitating, and incoherent way. Her memory, both recent and
remote, was a blank. Her urine contained a large amount of urates,
but otherwise was normal. She had hallucinations of sight and hearing.
She slept badly at first, and was treated as follows :—Potass. Bromidi,
3j; Mag. Sulph., 3j; Aq. Chlorof. ad ^vii] > Sig. 3ss ter in die.

After admission and during the month of March she remained in a
stuporose condition, with occasional outbursts of impulsiveness, during
which she broke windows and pictures and threw articles of furniture
about the wards. Her memory remained a blank, and her statements
in answer to questions were very irrational, such as that she had lived
at one place for 1000 years. In the beginning of April she showed
some signs of improvement; she attempted to do some sewing. She
was sent out for drives very often, but as yet she took little interest in
her surroundings. She was put on a tonic (Easton’s syrup). By April
nth she was greatly improved; she was bright, more active, cheerful,
and talkative; her memory for recent events was coming back, but that
for the time of her present acute attack was still a blank. A week
later she was apparently quite sane. She had no recollection of her
attack, or the events preceding it. She stated that she often goes over
two menstrual periods without being unwell, but that now she was more
regular than formerly. She was last unwell in February, 1903. She
complains of occipital headaches, for which she has been in the habit

Digitized by v^.ooQLe

698 CLINICAL NOTES AND CASES. [Oct.,

of taking antipyrine. She left hospital on April 18th, 1903, and has
made a good recovery and resumed her occupation.

J. M—, set 42 years, admitted April 21st, 1902. First attack.
Cause, business worry.

History. —Patient’s family were stated to be nervous, but no other
history of neuroses or insanity. Patient was of sober habits; he had
suffered from rheumatism seven years before admission. Duration of
existing attack, four months. He attempted suicide by throwing
himself from the Irish mail between Rugby and Holyhead, and also
threatened to end his life on different occasions.

On admission. —Patient’s bowels were constipated. Urine normal
except for presence of urates. Heart-sounds normal; pulse normal in
rate, but bounding and of high tension. Lungs normal. He was
silent and self-absorbed, with depressing hallucinations of sight and
hearing. He said he was being watched and followed by police¬
men, and was to be charged with some imaginary crime, that he was
ruined, and that his employees were leaving his service; he stated that
he was tired of his life, and would take measures to end it. During his
stay in the hospital he was usually in a state of depression, worrying
about his business, which he thought was to be sold out because he
saw some advertisements of auctions in the papers. He thought his
children were dead or not at home, and he stated that at night his
back was being burned with a red-hot poker, and that he was to be
burned alive or killed by me. Sometimes he got out of this mood and
was bright and somewhat cheerful and very talkative, taking part in
outdoor and indoor games and doing a little gardening; continually
pulling the hair out of his head and beard. Patient remained in this
condition till September 12th, being then quite as delusional as on
admission; very irritable and depressed during the day-time, but
sleeping well at night.

On September 27th patient was much improved mentally, clear in
conversation and rational and comparatively sane, and on October 3rd
he was removed home by his friends, being then quite well. He
called at the hospital in the beginning of this year; he was then in
perfect health, and had been working at his business for some months

E. A. S—, set. 39, admitted December 10th, 1901; unmarried. First
attack. Causation: predisposing, over-strain nursing relations; exciting,
love affair.

History .—No insanity or other nervous disease in family. Patient
had been ill about six weeks before.

Admission .—She seemed to be in good general health, a well-
nourished, intelligent lady. She was in a very restless and despondent
condition. She believed that the devil had taken possession of her,
and that her entrance here was the first step towards the infernal
regions.

Heart-sounds normal; pulse of high tension; lungs normal; eyes and
sight good, but pupils were dilated and non-contractile to light. Bowels
constipated; urine acid, abundant urates, but otherwise normal Patient
was stated to have a tendency to suicide. She was put on the following

Digitized by v^.ooQLe

CLINICAL NOTES AND CASES.

699

1903.]

mixture:—Potass. Bromide, Jj; Magnes. Sulph., Jj; Tinct. Hyos., Jij;
Spts. Menth. Pip., Jss; Aq. Chlorof., ad 5 viij; Sig. Jss ter in die.

During her stay in the hospital patient’s condition was variable up to
the first week in March, 1902. The day after admission she threw her
gold ring into the fire. She said it belonged to the devil. Usually
despondent and restless, with depressing delusions; sometimes she
brightened up considerably and chatted with those around her, saying
she wished she could resist her depressing emotions; and occasionally
she did some needlework. She was ordered an iron tonic on
February 1st. In the beginning of March she seemed to improve
very much. She was bright and cheerful, and rational in manner.
She stated that her former depressing thoughts had no effect on
her now. Her memory and powers of observation appeared to be
normal, and, having continued to improve, she left the hospital on
April 29th, 1902, perfectly well. This was a case of what one might
term an accidental insanity caused by the strain of anxiety and nursing
several aged and infirm relatives in their last illness. She has since
married and is perfectly well, and has had no return of her troubles.

These three cases are of interest as showing the recovery of three
patients who were treated in no very special manner, and who all suffered
from acute and recent insanity, and all of whom recovered.

I don’t desire to weary you with the stories of other patients
who have been treated in our old hospital, and who;affected in
somewhat similar ways, apparently often owe their recoveries to
different treatments. What I wish to impress upon those
engaged in similar work to my own, is the fact that we are
undoubtedly often prone to attach a fictitious value to some of
our curative means; and to hope that, in carrying out—as we
always will carry out—new and ever-advancing methods of
dealing with the mental diseases of our patients, we will not
hastily accept any fixed lines until we have found them to be
the best available in our present state of knowledge.

Let us endeavour to separate the drug of spurious from that
of real value. It seems desirable that we should more speedily
discard those drugs which we have weighed in the scales of past
experience and knowledge and found wanting, and be ever
more careful that whatever new drugs are substituted shall not
hold the field one day longer than their utility and effectiveness
entitle them to.

The great difficulties of solving the problems of psychiatry
are only rendered greater by a too hasty conclusion as regards
the actual and relative values of new drugs and new treatments ;
whilst on the other * hand it may not be uninstructive to
remember that personal respect for Galen and Hippocrates
xlix. 48

Digitized by v^.ooQLe

700

CLINICAL NOTES AND CASES.

[Oct.,

caused many disciples to follow blindly for centuries the
erroneous views of these great fathers of medical science,
thereby hindering the ever-onward march of true knowledge,
obtainable only as the result of personal scientific observation,
enterprise, and investigation, and an ever-widening school of
thought

Discussion

At the Meeting of the Irish Division at Enniscorthy, July 3rd, 1903.

Dr. Drapes said that Dr. Leeper had remarked in his interesting paper that
recovery was due sometimes to systematic and sometimes to special treatment,
while sometimes it took place with no treatment at all. He thought that it was
more difficult in insanity than in any other disease to say whether or not recovery
was actually due to the measures used. He regarded simple nursing, with
supporting and, where necessary, sedative treatment, as the principal remedial
agent in acute cases. Intercurrent bodily disease sometimes did improve the
mental state, as in a recent case admitted with wounds on the hands, in which
resulting septic abscesses seemed to have a favourable influence on recovery. Rest
treatment he regarded as one of the best at our disposal. He had lately had a
patient suffering from adolescent insanity who had become worse from being sent
into the open air, whereas rest in bed resulted in very considerable improvement.

Dr. Dawson, referring to the stress laid by Dr. Leeper on uniformity of treat*
ment, was of opinion that although uniformity of principle was desirable, as, for
example, the broad principle of seeking to influence the mental state by improve¬
ment of the bodily nutrition, every case should be treated on its own merits, and
not by any hard and fast method. Some cases did better with rest, others with
open-air exercise, while in others good results seemed to be got from the prolonged
bath; it was necessary to try method after method until the one to suit the
individual case was found. With regard to the case in which there was glycosuria,
he was coming to the belief that sugar in the urine, if transitory, was of little
importance, and he even had a patient suffering from persistent glycosuria who
was in good bodily health and actually putting on weight. Aspirin, as recom¬
mended by Williamson, ^ave good results in lessening the sugar excreted. The
effect of intercurrent febrile conditions, like that induced by thyroid extract, was
probably to be explained by the anabolic reaction which followed increased
katabolism; but the methoa of turpentine abscesses had been tried in Italy
and discarded. He thought the difficulty as to whether or not recovery was to
be attributed to treatment arose in other diseases as well as mental.

Dr. Nolan remarked that one most important method of treatment had been
overlooked by previous speakers, and that was the moral treatment, to which he
attached the highest importance, particularly with regard to chronic cases.

Dr. Norman desired to protest against the apparent distinction drawn in the
preamble to the paper between “ scientific ” and “ clinical ” observation. Clinical
observation is scientific, for science is knowledge and facts are facts whether they
are observed at the bedside or in the laboratory. They had heard of a recovery
rate of 53 per cent. % but such a ratio is only obtainable where cases for admission
are selected with a view to curability. He wished he could believe that the
practical results of modern methods would prove so very much better than those
which had been attained when the old-fashioned methods were in vogue, which are
now so contemptuously spoken of. He had been much interested in the first case
described, having been acquainted with the patient. Two important facts in this
case were the existence of a bad heredity (a brother bein^ insane) and the recent
marriage of the patient. With regard to the latter point there was perhaps a
moral as well as a physical factor, since the immediate apparent cause of the attack
was anxiety lest he should be unable to support himself and his wife. As regarded
glycosuria, he agreed with Dr. Dawson that it did not seem of much importance
in this case.

Digitized by LjOOQle

1 903-]

CLINICAL NOTES AND CASES.

701

Dr. Leeper, in reply, thanked the meeting for the reception accorded to his
paper, the main object of which was not to advocate the treatment of patients in
bulk, but to give such examples as might furnish tangible facts for the treatment
of cases individually. In treating pneumonia, for instance, one knew what
measures to adopt without delay, and it would be desirable that one should be able
to treat acute insanity as promptly. Rest was a very good treatment in certain
cases, but in many it was difficult to adopt. As regarded Dr. Norman’s remarks
with reference to nis statement about clinical and scientific observation, he had no
intention of creating the schism of which he had been accused. What he wished
to advocate was that clinical and laboratory research should work conjointly for
the elucidation of mental disease.

Notes on a Case of Graves Disease with Mania . By
J. P. Grieves, M.R.C.S.Eng., L.R.C.P.Lond.

T HE following case is one of chronic Graves’ disease suddenly
taking on an acute form with mania and resulting in death in
fourteen days, with pyrexia during the last week, there being
no pulmonary or other complications.

The patient, a married woman aet. 43, had never been treated for
Graves’ disease, but I had by chance noticed that she had very marked
proptosis at least twelve months before attending her.

About three months before the onset of the acute symptoms, the
patient, who had previously been rather an economical person, began
to spend money very freely, going out and ordering large quantities of
useless things, on one occasion ^17 worth of plated goods, including a
dozen butter knives!

When she had run up bills to the extent of ^150 she confessed to
her husband, who was naturally very angry, being a man of limited
means; and in the heat of the moment he remarked that they were
ruined, which appears to have made a great impression upon the patient,
and for at least a month she remained entirely indoors to avoid being
tempted to buy things. On April 24th I was called in to see her, and
found her in a state of great distress and excitement, pacing about the
room and exclaiming that they were ruined, that her child was starving,
and that it was all her fault. She declared there was nothing to eat in
the house, though they had just finished a meal.

On April 25th the patient was quiet but seemed very depressed, as if
brooding over things; in the evening she again became very excited,
rushing about the room and exclaiming that they had no money,
although to convince her her husband produced a handful of gold from
his pocket. This attack of excitement passed off in about an hour, and
she then discussed the matter with me quite rationally, and said she
did not know what she was doing when these attacks came on. During
the night she again became very violent, and could not be induced to
stay in bed.

On April 26th I kept her in bed and obtained a mental nurse for

Digitized by v^.ooQLe

702

CLINICAL NOTES AND CASES.

[Oct.,

her. Her condition then was as follows:—There was very marked
enlargement of the right lobe of the thyroid, very marked protrusion
of the eyeballs, which gave the face a most maniacal expression,
Stellwag’s sign being very marked, but Graefe’s sign slight. There were
no noticeable tremors. Pulse-rate 130 per minute. Temperature
subnormal. The patient was very restless, constantly turning from side
to side, would not answer usually when spoken to, but at intervals said

Tima

BovcLj

Urma

fi**

103 '

AM 1

P M. I

AX.

I.II1

123

WSmM

□1

□!

□1

□!

□

■

■1

■

□

■

□

■

□

■

■1

f—

U—

1—

—

—■

—

“

—

”

—

—1

—

P.l

■j

■M\

■ 1

■1

■■

■

r 1

—

10 V

101 °

—

1 'i

—

^ fl

■J

■«

—

p 1

—

■ V

1—

—

1 M

—

—1

—

■

—

100 *

—

p«

—

r«

—

r*s

—

QSj

98 *

Day JDtS

Pulse

R een

Dote

\wm

■1

■Bi

■1

□

■i

l mi

■

I j. M

■

■5

■

■i

■

■1

[¥

TT*

1 ol OD

ill

■

[ Sat Ind.

[ Sun 3 r«i.

[ non. U.H

| Tirov SlK.

1_1

that they were ruined and that everyone would very soon be dead. If
she was not constantly restrained she would get out of bed.

April 27th.—Patient in much the same condition, but it was so
difficult to keep her in bed that she was allowed to be up for a time
in a dressing gown, during which time she constantly kept carrying a
coal-box from one side of the room to the other. No coherent remarks
could be elicited from her, but she stared at one wildly when spoken to.
It became increasingly difficult to induce the patient to take food at
this time, and until the termination of the case it was the same.

On April 28th Dr. Rayner saw the case with me and recommended

Digitized by ^.ooQle

IJ 03 .] OCCASIONAL NOTES. 703

her removal to an asylum, and arrangements were made to have her
removed.

On the evening of April 30th the temperature, which had previously
been subnormal, began to rise, and on May 2nd had reached 103*4°. I
had the patient sponged, when it fell to 101*2°. On May 3rd I was
surprised to find that the thyroid gland could only with great difficulty
be felt at all , the enlargement of the right lobe having almost entirely
disappeared\ The protrusion of the eyeballs was also very much less , less
than it had been for the previous twelve months.

The temperature gradually declined from this time, on May 5 th
being only 99*6°. The mental condition remained about the same. The
patient was still very restless, and unless restrained constantly got out
of bed; there appeared to be very little physical weakness, and until
the end she got out of bed almost at one bound.

Between April 29th and May 3rd there was a good deal of diarrhoea,
and throughout the patient passed both urine and faeces in bed or
on the floor, without attempting to retain either. There were no
pulmonary complications at any time. The pulse-rate varied from 130
to 170 per minute, and at no time was it less than 128.

On the evening of May 5th the temperature again rose, reaching
io 3*4°> and the pulse-rate rose to 230 per minute. The patient died at
2 a.m. on May 6th.

Occasional Notes.

The Annual Meeting of the Medico-Psychological Association.

The annual meeting has again testified most strikingly to the
growing influence and activity of the Association. This is
evidenced not only by the increased number of members, the
large attendance, the number of communications, and the
vigorous discussions, but especially by the activity of the
various committees, whose reports represent persistent work
by a large number of members throughout the year. Lastly,
the stability of the Association is proven by the flourishing
state of the finances.

The President’s address, printed elsewhere, is sufficient evi¬
dence that the dignity of the office will be well upheld by the
ability of the present holder. If legislation is forthcoming
in the present year, the representative of the Association is

Digitized by v^.ooQLe

704

OCCASIONAL NOTES.

[Oct,

thoroughly acquainted with the needs of the insane and the
reasons by which they can be enforced on the Legislature.

The communications read and discussed at the meetings
were of exceptional value, and the demonstration by Dr. Mott
was of the greatest interest. Full reports of these will be
found in the JOURNAL.

The most important business of the meeting was the adoption
of the new rules, and the committee (presided over by Dr.
Urquhart), who have worked so long and arduously, are to be
congratulated on the success of their work.

The committee appointed to revise the statistical tables
have worked most sedulously during the year, but have not as
yet completed their task, which is the most important matter
that the Association has now on hand.

The least satisfactory matter in connection with the year's
work is probably the paucity of competitors for the Association
prizes. This, however, is no new thing, is but a repetition of
the experience of previous years, and suggests the desirability
of inquiring whether any improvement can be made in this
respect. The junior members of the Association, for whom
these prizes are instituted, can with rare exceptions possess
the experience or opportunities of study necessary to produce
a comprehensive monograph on any special subject such as
these prizes demand.

The faculty which it is specially desirable to cultivate in them
is that of observation and description. Would it not, therefore,
be more within their powers and more calculated to stimulate
their efforts to offer prizes for clinical reporting ? Such a com¬
petition would be within the reach of every junior physician,
and the competitors for such prizes would probably never be
wanting. Such a competition would also tend to rescue clini¬
cal work from the unfortunate position into which it has fallen
in English asylums. Our junior colleagues should be im¬
pressed with the indisputable fact that the finest laboratory
work is valueless to the physician and is essentially unscientific,
because partial and one-sided, if not carried out in collabora¬
tion with constant careful and minute clinical observation. If
we think of what has been done in the study of aphasia, and
of how unmeaning would be the attempt to investigate the
conditions of the function of language by investigations carried
on in the pathological laboratory alone, we can see how im-

Digitized by ^.ooQle

I903-]

OCCASIONAL NOTES.

70S

perfect our science must always be while clinical work is
neglected. In England, it must be confessed, we have been
backward in this respect for many years and have not con¬
tributed those exact and laborious clinical studies which are to
be found in the French and German psychiatric literature.
This may be due to the unhappy system by which case-books
have come to be regarded not as scientific records but as mere
items of official routine—not as serious medical work, but as
something to be compiled “ to satisfy the Commissioners.”
Whatever the cause, it is time to apply a remedy.

The Association dinner was numerously attended, and passed
off in the most satisfactory manner. The change of date of
the meeting unfortunately prevented the Lord Mayor from
attending as a guest of the President, as he would otherwise
almost certainly have done.

A large number of the members of the Association, on the
invitation of the President, visited the City of London Asylum
on the 18 th July. They were there most hospitably entertained,
and had the opportunity of seeing how an old institution had
been remodelled to meet the requirements of the modern treat¬
ment of the insane. An interesting account of how the change
was effected has appeared in a former number of this JOURNAL.

Sir Charles Bagot .

The retirement of Mr. (now Sir Charles) Bagot from the
Lunacy Commission has been followed by a due recognition
of his services in his promotion to the honour of knighthood.

The members of this Association attending at the annual
meeting expressed their appreciation of the services of Sir
Charles Bagot in moving a resolution to congratulate him on
the honour conferred on him, and the feeling thus expressed is
fully shared by those members who were not present.

Sir Charles Bagot, from the very outset of his joining the
Commission won the confidence of the Specialty, and as years
passed on this feeling has grown into the highest esteem and
admiration.

Apart, however, from the feeling of personal congratulation,
there is a strong feeling of satisfaction that such an honour has

Digitized by v^.ooQLe

706

OCCASIONAL NOTES.

[Oct.,

been conferred on a member of the English Lunacy Commis¬
sion. And we may express the hope that this may form a
precedent which will be followed on the retirement of other
members of the Commission.

No future recipient of such an honour, however, will ever
have more thoroughly earned and merited it than Sir Charles
Bagot. We sincerely hope that he may long enjoy his dignity
and rest.

The Temporary Treatment of Unconfimied Insanity .

The Commissioners in Lunacy, in their recently issued report,
make recommendations in regard to the temporary treatment
of unconfirmed insanity which are most satisfactory. These
will materially aid in passing the clauses in relation to this
matter contained in the Lord Chancellor’s Lunacy Bill, when¬
ever the Houses of Parliament recover their legislative activity.

The Medico-Psychological Association has done so much in
helping forward this means of treatment that it would seem to
be incumbent on it to consider whether it can do anything
to ensure the efficient use of these clauses when, if ever, they
become law. Their satisfactory working will depend on the
quality of the guardianship obtained ; and the question which
the Association might consider is whether it can aid the public
and the medical profession in the selection of persons and
homes best qualified or suited to the care of incipient and
unconfirmed insanity. This question is by no means easy of
solution.

The special qualifications for such guardianship are not to
be proven with facility. Experience of treatment in asylums
or elsewhere, although necessary, is not alone sufficient. The
personal qualities and special experience of treatment in home
life have to be otherwise acquired—usually, of course, by assist¬
ing in treatment of this kind. Although the special know¬
ledge thus acquired might be tested by examination, the more
important qualities, such as tact, etc., could only be arrived at
through the testimony of competent observers who had had
opportunities of noting these qualities in actual employment.

Hence the qualification for guardian of incipient mental
disease should not only consist of a proof of knowledge of the

Digitized by v^.ooQLe

1903]

OCCASIONAL NOTES.

707

ordinary treatment of such disorders, but of proof of special
experience and personal fitness. The latter qualifications could
only be satisfactorily evidenced by the testimony of medical
men who were themselves specially qualified to give such an
opinion.

Beyond the question of personal fitness of the guardian is
that of the suitability of other persons, if any, who would be
associated in the home life, and of the house being also adapted
to the reception of a nervous case.

A guardian to be efficient, therefore, should have special
evidence of knowledge of the treatment of the insane, special
personal recommendation of fitness, and a special recom¬
mendation for the household and home.

The difficulty is whether such qualifications can be tested or
evidenced so that a list of guardians could be available to the
profession and the public, or whether, as at the present time,
the medical man or the patient’s friends must be left to find a
suitable guardian as best they can.

A list of qualified guardians would be a great advantage, but
the difficulties of forming it are obviously very great. The
possibility of overcoming these difficulties is worthy of con¬
sideration, and this Association might well debate whether it
was within its power to take action in the matter.

The Pauperisation of the Insane .

Insane persons whose friends cannot pay a pound a week
for their maintenance, are compelled, under existing conditions
(with a few exceptions in the registered hospitals), to become
pauper inmates of pauper asylums. Bitter injustice is thus
inflicted on a numerous class who could pay from ten to sixteen
shillings a week if by so doing the pauper classification could
be avoided. Under existing conditions they are compelled to
accept the degradation, and soon become reconciled to shifting
their responsibility on to the shoulders of the ratepayers, be¬
coming pauperised de facto as well as de jure .

There is no greater or more urgent need in England than
the provision of similar accommodation to that which exists in
abundance in Scotland. That such accommodation can be
provided in England is amply proved by the very considerable

Digitized by

Google

OCCASIONAL NOTES.

70S

[Oct,

profits made by those county asylums which take cases at a
pound a week.

Rumours have been rife of county asylums which contem¬
plated taking private patients at very low rates, and it has
been said that some institutions which are making large profits
intend to apply a portion of their surplus to the assisting of
such cases; but we are reminded that though Milton tells us
hell is paved with gold, an earlier writer says it is paved with
good intentions.

This at least is certain, that if the profits of the private
annexes of the county asylums were applied in the direction
suggested, they would do more indirectly towards the relief of
the rates than when directly applied to that end, by stimulating
friends and relatives (who now shirk their responsibilities) to
contribute the major part of the maintenance of numerous
patients who are at present entirely rate-supported.

The Home Care of the Insane Poor in England\

The absence of anything like a system of home care (or
boarding out) in England is perhaps one of the most striking
anomalies of our lunacy administration, and it is astonishing
that, under the great stress of providing accommodation for the
ever-increasing accumulation of lunatics in asylums, no serious
or systematic attempt has been made to utilise this method of
treatment.

In Scotland, as every member of this Association knows,
this system has been in operation on a large scale for more
than forty years, with unqualified success, both in regard to the
welfare of the patients and to economy.

A contrast of the distribution of the pauper lunatics in the
two countries in the year 1901 will demonstrate the importance
of the difference.

Country.

Total pauper
insane.

In asylums.

Per cent .

In private
dwellings.

Per cent.

Scotland

•3.581

9.285

672

2631

193

England

100,779

78,028

773

5541

Digitized by v^.ooQLe

1903]

OCCASIONAL NOTES.

709

These figures show that in Scotland 19*3 per cent of the
pauper insane are provided for in private dwellings, while in
England the proportion is only 5*5 per cent If 19 per cent
of the English pauper insane were boarded out there would be
some fourteen thousand asylum beds vacant, and if the same
economy resulted as in Scotland this would produce an annual
saving of a quarter of a million sterling for maintenance, and
(for some years at least) of half a million in building.

Economy, however, is not the strongest argument in favour
of this system. The patients themselves are benefited ; they
are found to prefer unanimously the home to the asylum life,
and the beneficial effect on them is proved by a larger propor¬
tion being found capable of taking their places in the general
population than would be the case if they remained in the
asylums. It is, in fact, a better and more successful system
of treatment for suitable cases than that provided by the
asylums.

The boarding out of these patients in poor agricultural
districts has been found to be a distinct advantage to their
guardians, and the work of those patients is probably much
more valuable than when confined in institutions.

That home care has not been carried out in England, in
spite of these well-known advantages, is due to a variety of
causes, the principal of which are :

(а) The capitation grant of 4s. per week to the inmates of
asylums.

(б) The utter inadequacy of the English Lunacy Commission.

(r) The density of the population has also been adduced as

a cause.

The capitation grant is probably the obstacle most difficult
to overcome. The average weekly cost for the maintenance of
patients in English county and borough asylums in 1901 was
1 or. 4 \d. per week, so that the parochial authorities, after the
deduction of the 4 s. grant, contributed only 6s. 4 \d. y which is
probably less than the patient would cost in an ordinary work-
house, and is not so great as the cost of the boarded-out
patient, which in Scotland amounts to about 6s. lod. Under
existing conditions, therefore, boarding out is not to the monetary
interest of the parishes, and until this difficulty is removed there
is no hope of obtaining their co-operation in extending home
care.

Digitized by

Google

7 io

OCCASIONAL NOTES.

[Oct.,

The total cost of an asylum patient is probably about
13 s. per week (allowing less than 3s. for the cost of buildings
and repairs); hence, if a patient were boarded out from the
asylum even at a cost of 9 s. per week, the charge to the parish
could be reduced by is. 4id?., whilst the asylum authorities would
save the cost of the bed (say 2 s. 8 d, per week). Such an
amount of saving, it might be imagined, would predispose both
the asylum and the parochial authorities in favour of home
care.

The Lunacy Commission, in order to cope with home care,
would need to be very largely strengthened. In Scotland the
home care cases are distributed in upwards of two thousand
homes, every one of which is visited and inspected by a
deputy commissioner at least once a year ; if boarding out
reached the same extent in England twelve thousand such
visits would have to be made, but there are no deputy commis¬
sioners to perform the duty. If the English Commission had
the same proportion as the Scotch to the number of patients
supervised, it would possess eleven senior medical commissioners
and eleven deputy medical commissioners in place of the three
who are now supposed to be adequate. Can astonishment be
felt, in face of this obvious inadequacy of the English Commis¬
sion, that home care and other equally important matters are
sedulously avoided ? The existing skeleton commission must
be recruited to fuller strength of numbers before it can under¬
take the work which it ought to perform, not only in this but
in many other directions.

The argument has been advanced that home care is not
possible in England on account of the density of the popula¬
tion. Many districts of England, however, are not more
densely populated than the Scottish localities in which a large
part of the boarding out is effected, and it has been found to
be practicable even in such densely populated towns as Berlin.

If any county council would employ a suitable agent to
search out in any given district the number of homes in which
such patients could be received, it is probable that this difficulty
would be found far less than has been imagined.

That some county council would have the public spirit to
exercise the powers which are conferred under the fiftieth
section of the Lunacy Act of 1890 is devoutly to be wished.
Better than this, however, would be a combined action of

Digitized by

Google

1903-]

OCCASIONAL NOTES.

7 II

unions, county councils, and Lunacy Commissioners, especially
if the movement were prompted by the initiative of the last-
named body.

That home care is so utterly neglected is, we fear, a standing
reproach to all who are entrusted with the provision of accom¬
modation for the insane in England and Wales.

Dr. Chapman's Revision of the Tuberculosis Report.

The result of Dr. Chapman’s investigations is stated in the
forefront of his report to the Council, a report which is now
being circulated with the same publicity as was afforded to
the original document. He “ does not in any way traverse
any conclusions and recommendations contained in the report
of the Committee on Tuberculosis, but, on the contrary, in
several directions supports them more strongly.” This finding,
which we indicated in an occasional article in April last,
cannot fail to be most gratifying to the Committee, and to
every loyal member of the Association. It is late in the
day to write in appreciation of Dr. Chapman as a past master
in the science of vital statistics, and it was felt that a
revision at his hands would assuredly place the questions
involved beyond all doubts. This feeling he has entirely
justified. The Association is greatly indebted to him for the
labour he has bestowed upon the marshalling of these figures,
and the lucid results of his inquiry. The whole of the docu¬
ments and the returns originally made to the Tuberculosis Com¬
mittee have been examined by Dr. Chapman, and the result is
an independent, competent audit in which the vouchers have
been compared and the final results published. It is again
brought to notice what a vast amount of work Dr. France
accomplished in the service of the Committee, and it is again
to be observed that the conclusions and recommendations pro¬
ceeding from his secretarial labours were not adopted by the
distinguished physicians who formed that Committee without
due care and consideration. Practical men are less concerned
with methods than results, and the broad facts evidently pointed
to the conclusions and recommendations so thoroughly endorsed
on reconsideration of the minutiae by independent critics.

Digitized by v^.ooQLe

7 12

REVIEWS.

[Oct,

Of course we must all regret that certain arithmetical errors
were found in the original report; but these mistakes did not
justify the exaggerated language of abuse and detraction, the
charges of deliberate malversation which have been so freely
made. The faulty decimals have not justified the methods nor
the insinuations of the critics, who failed to challenge the
original report when it was presented, and made haste to
amend the work of the Association from the outside. As yet
we have observed no indication of haste to acknowledge that,
after all, the Tuberculosis Committee have had their position
strengthened by the attack which failed.

Part II.—Reviews,

Archives of Neurology ; from the Pathological Laboratory of the London
County Asylums , Claybury , vol. ii. Edited by F. W. Mott, F.R.S.,
M.D., F.R.C.P. London: Macmillan and Co. Pp. 862 ; numerous
plates and figures in the text.

We propose here to pass under review a few of the articles contained
in the second volume of the Archives of Neurology ; and we shall com¬
mence with an article by Dr. A. F. Tredgold upon “ Amentia ” (idiocy
and imbecility). This covers ninety pages, and deals with the causes
(intrinsic and extrinsic,—that is to say, environmental), varieties, and
pathology of amentia. The material for this work was obtained from
the London County Asylums, Darenth, and Earlswood. Family histories
to the number of 150 were inquired into. It was found that a definite
history of abnormality of the nervous system occurred in the antecedents
of 82*5 per cent. of the cases, in 64*5 per cent, the abnormality was either
insanity or epilepsy, and in 65*5 per cent, it occurred in the direct line.
These figures are higher than the usual ones, but may be ascribed to
the particularly thorough nature of the inquiry. It was found that
alcohol in the parents was rarely the sole cause of amentia. Syphilis,
also, was directly responsible very rarely. The intrinsic causes are
discussed, such as consanguinity. As regards extrinsic causes; amongst
these are placed factors acting before birth (which in several instances
is, of course, perfectly correct), such as fright of the mother, maternal
impressions, and actual disease or ill-health on the mother’s part Can
these be rightly classed as causes extrinsic to the germ-plasm ? In
regarding such conditions as alcoholism, consumption, and other
diseases in the parents as factors causative of amentia in the offspring,
the author falls foul of the views of Weismann and others of his school

Digitized by ^.ooQle

REVIEWS.

713

1903]

In fact, as appears later, he expresses himself strongly against the
doctrine of non-transmissibility of acquired conditions,—that is to say,
against the wide meaning applied to that doctrine by the school referred
to. Apropos of this we may mention the statistical inquiries which
have of late years been carried out, which show the positive influence
of alcoholic indulgence in the parents in the production of disease and
degeneration of the nervous system (including amentia) and of tuber¬
culosis in the offspring. (Anton: Alkoholismus und Erblichkeit .
Ladrague: Alcoolisme et Enfants . DeLavarenne: Alcoolisme et Tuber -
culose.) But undoubtedly in the great majorityof the instances of extrinsic
causation of amentia—and in this Dr. Tredgold agrees—there are
hereditary influences bringing about a deterioration of the germ-plasm.
In antagonism to what is commonly believed, the author considers
that the importance of abnormal labour as a cause of idiocy has been
much over-estimated. And his figures do not bear out the statement
that a large proportion of idiots are first-born children.

The supposed causes of amentia which act after birth are shown—as
would be expected from what has been already stated—to be nearly
always contributory only, heredity being the main factor. Dr. Tredgold
considers that every day medical experience (to which argument, how¬
ever, we do not think those in antagonism to him attach much weight)
is against the view of Weismann that the germ-plasm is not, or is only
to a very small extent, influenced by the environment

Referring to the question of the training of imbeciles, the author
evidently doubts whether the results achieved are worth the expenditure.
We are inclined to agree with him. It is all very well to pat that long-
suffering pack-animal, the ratepayer, on the back, and applaud him for
his “ humanitarian ” sentiments. But the time has come when he may
well call for protection against the ignorance, callousness, and unheeding
lust which propagate imbecility and leave the care of the victim to
others. There are some sensible remarks upon the marriage question.
The section on the pathology of amentia is based upon the micro¬
scopical examination of twelve cases—a small number, though the
appearances are carefully gone into. In the twelfth case we are
expressly told that there was no amentia ; it is nevertheless classed as
one of two cases of “secondary” amentia. Imperfectly developed
nerve-cells were found to a greater extent in the frontal and parietal
regions, and especially in the layer of small pyramidal cells. The
horizontal nerve-fibres, too, showed greater diminution in these regions.
But it would be desirable to have more work done upon these
points. The results confirm previous observations, and go to prove
that amentia is due to numerical diminution, imperfect development,
and irregular arrangement of the nerve-cells. Nevertheless we require
more information as to the rdle of the nerve-fibres.

A list of references and some plates conclude this useful article.

Upon the above article follows one by Dr. J. S. Bolton, assistant
pathologist at Claybury, upon “ The Histological Basis of Amentia and
Dementia.” This covers 192 pages. The title hardly expresses the
wide scope of the inquiry, though it denotes the main object thereof.
Thus, Part I of the two parts comprised by the paper deals, among
other matters, with the morbid anatomy of mental disease, the influence

Digitized by ^.ooQle

714

REVIEWS.

[Oct.,

of heredity upon the development of mental disease, the effect of
gravity on the intra-cranial contents in the cadaver. Part II chiefly
deals with the results of microscopic examinations of the pre-frontal
cortex. The first part of the paper is based upon conclusions derived
from clinical and pathological study of 200 cases of mental disease
which appeared consecutively in the Claybury mortuary. A mere
notice such as the present can convey no adequate idea of the immense
amount of work which the author personally carried through in the way
of case-taking, clinical and pathological observation. The 200 cases
upon which Part I is based are divided into five groups, the first com¬
prising those without appreciable dementia, and the others cases of
dementia in ascending degrees to gross dementia. In passing, the
value of Dr. Mott's cold chamber, into which deceased patients at
Claybury are placed as soon as possible after death, is again empha¬
sised ; it made this research, amongst many others, possible. Notwith¬
standing the absolute necessity of such a chamber to secure the
constancy of the post-mortem conditions, we do not think it would be
rash to assert that the asylums possessing such might be counted on
one hand, and that one need not possess the conventional number of
fingers.

The cases in each of the five groups are classified and described, and a
pathological summary follows for each group. Then follows a general
summary of the morbid appearances in tabular form. From this and
from the results given in the succeeding pages it appears that the
naked-eye morbid changes existing within the skull-cap in insanity vary
in degree directly with the amount of dementia present, and are other¬
wise independent of the duration of the mental disease. Further, the
severer the degree of dementia the more extreme the vascular degene¬
ration ; the latter is independent of age. These facts are demonstrated
in two tables. Gross vascular degeneration may exist without dementia,
but in a cerebrum in which the cortical neurons have begun to
degenerate the presence or incidence of such vascular degeneration will
cause gross dementia.

Discussing the pathology of subdural deposits, Dr. Bolton describes
experiments which cause him to conclude that many recent subdural
films may occur at the time of death.

In a chapter on the “ Etiology of Paralytic Dementia ” it appears
that syphilis was certain in 15 out of 19 private cases (79 per cent.), and
in 82 percent, of 72 pauper cases [we find certain recent continental
writers put the percentage at anything between 40 and 80 per cent],
and psychopathic heredity was present in 82 per cent, of 72 histories
amongst the pauper class, and in 85 per cent, of 13 histories (a small
number from which to draw percentage conclusions) in the private
class. Such are the facts, amongst many others of like interest and
value, brought out in the course of Dr. Bolton's painstaking personal
investigation. These two factors, psychopathic heredity (resulting in
neurons of decreased durability) and syphilis, are essential to the develop¬
ment of paralytic dementia, in the author’s opinion ; though we cannot
see that his figures prove as much. “ Stress," in the widest sense, is
important as determining the onset.

In remarks upon the regions of wasting, speaking generally, of the

Digitized by v^.ooQLe

1903]

REVIEWS.

715

cerebrum in mental disease, the author confirms, by observations on
several hundred cases, the conclusions of others. The greatest amount
occurs in the pre-frontal region; for further conclusions the original
work may be consulted. As the same region shows under-development
in the greatest degree in primary amentia, the conclusion is that the
pre-frontal region is the one concerned with the highest functions of
mind. For these reasons the author has chosen that region for the
purpose of histological investigation, the results of which are embodied
in Part II of his article. Accurate micrometric examination was made
of regions of convolutions adapted for such in twenty cases, embracing
normal persons, aments, and degrees of dements; and the results are
embodied in a series of tables. The following general conclusions are
reached:—In the pre-frontal cortex of congenital amentia degrees of
under-development exist which vary inversely with the mental power
of the individual. In the same cortex in chronic insanity without
dementia there is under-development of the pyramidal layer of nerve-
cells, the other layers being approximately normal. In the same part
in dementia and dementia paralytica degrees of wasting exist, varying
directly with the amount of dementia present. In extreme dementia
all the cortical layers are approximately in the same condition as in the
new-born child. This is strikingly shown in a table.

From concluding remarks upon the functions of the cortical cell-
layers we select the following, in support of which cogent reasons are
given:—“The pyramidal layer (No. 2) subserves the psychic or asso-
ciational functions of the cerebrum.” Twenty-two photographs illustrate
this article.

Dr. Bolton’s contribution is a piece of sound reasoning based upon
a mass of observations laboriously collected and handled in a masterly
fashion.

Dr. Mott has an article upon “ The Prevention of Dysentery in the
London County Asylums.” He lays down four essentials for securing
prevention: (1) a knowledge of the clinical symptoms of the different
types (the atypical cases are often unrecognised); (2) systematic post¬
mortem examination of the bowels in all deaths ; (3) the recognition of
the importance of isolation and disinfection ; (4) notification of all
cases of diarrhoea and dysentery, and supervision of all suspected cases.
An account is given of the various clinical phenomena and the clinical
types met with in asylums, with illustrative charts. Morbid anatomy
and pathology receive attention, and there is a series of instructive
plates showing the naked-eye and microscopical lesions.

There never was any proof of the hypothesis that dysentery is due to
nerve-degeneration dependent upon insanity, and in that view we see
nothing tangible to discuss. But we consider that there is nothing
improbable in the view that the normal control exercised over bacterial
growth by the intestinal wall (in what manner is obscure) is impaired in
states of insanity with their attendant lowering of trophic power, as
evidenced in various ways. Such disturbance of the regulation of
bacterial growth would manifest itself earliest in the region of the ileo-
caecal valve, and then in the large intestine^ 1 ) A causative organism
would under such conditions have greater licence, and would con¬
ceivably be aided in its morbid activity by the unchecked proliferation

XLIX. 49

Digitized by v^.ooQLe

716

REVIEWS.

[Oct,

of normal and usually harmless bacteria of the intestine. In this way
mental disorder might be instrumental in promoting the morbific action
of the organism causing the disease. As Dr. Mott observes, the disease
is not confined to the insane. Nevertheless it is very rarely that those
attending on them are attacked. That there is a predilection for
asylums as compared with other (often overcrowded and no more
sanitary) institutions is clear ; and the ordinary arguments adduced to
account for this are not, to our mind, adequate.

An instructive account is given of the outbreak and mode of spread
of the disease in various wards of the London asylums. Dr. Mott has
the satisfaction of showing that since the adoption of the views put
forward by him as to the nature of this disease, and the methods of
dealing with it, there is evidence of marked diminution in the Claybury
Asylum; and the number of cases reported from all asylums has con¬
siderably diminished since notification has been in practice. Certain
remarks upon the state of mattresses at some of the asylums, which
mattresses were supposed to have been cleaned after contact with an
infectious case, emphasise the need for steam-pressure disinfectors in all
asylums.

In connection with Dr. Mott’s instructive communication, the remarks
of the Commissioners in Lunacy in their report for last year upon
diarrhoea and dysentery in asylums are interesting. Amongst other
points it is shown that the severer types of dysentery and diarrhoea pre¬
vail more in the larger institutions.

Dr. W. G. Smith contributes an article upon “ The Range of Imme¬
diate Association and Memory in Normal and Pathological Individuals.”
This inquiry is based upon the experience that the attempt to grasp a
series of mental impressions demonstrates the fact that there are definite
limits to our capacity. A basis is thus furnished for a comparative
research on normal and pathological persons. The procedure employed
in the present investigation consists in the presentation of objects of
one kind or another to the subject, who is asked, immediately or at
some subsequent period, to recall what was presented The number
and character of the errors in recollection which are thus brought to
light form a guide to the nature of the associative and reproductive
processes involved. The author’s earlier experiments were made through
the visual sense (presentation of a series of letters of varying length),
but this method was found to present difficulty in the case of the insane,
and resort was had to auditory stimulation, with better results. Letters
were written upon cards and presented in series of four to ten letters each.
The letters were read aloud to the patient and reproduced by him
orally. Somewhere between four and ten letters the capacity of reproduc¬
tion appears to break down for average normal and for abnormal persons.
The analysis made took account of the following :—As to whether the
letters were rightly placed, transposed or inverted, wrongly placed,
omitted, inserted, repeated, etc. Normal results, for comparison with
results from patients in Claybury Asylum, were taken from eleven persons,
nine of whom were of approximately the same grade of intelligence and
education as the abnormal persons prior to their illness; the two remain¬
ing were of higher intelligence. After an interesting analysis of these
Dr. Smith proceeds to state the pathological results which were obtained

Digitized by

Google

1903-]

REVIEWS.

717

from thirteen patients suffering from general paralysis in early (though
varying) stages, and from “ some degree of dementia, confusion, and
loss of memory.” For an analysis of these results the article must be
referred to. The chief conclusions arrived at are that the method of
immediate oral reproduction of auditory impressions seems to be well
fitted to test the range and character of immediate association in
different mental states ; that with normal subjects the range of imme¬
diate memory has usually a definite limit, as a rule found to lie at five
letters. When this limit is reached the addition of one letter to the
series of auditory impressions produced a decided fall in the number
of series which were reproduced quite correctly. With abnormal
subjects the relations are similar but less clear. In abnormal cases
there is a marked diminution in the power of reproducing impressions
in correct order, and an increase of all the errors indicating the more
severe forms of associational disorder. The method permits with some
precision of the differentiation between the more permanent memory
and the power of immediate reproduction.

Dr. Smith’s article is an addition to the evidence for the practicability
of psycho-physical experimentation in insane subjects. It is desirable
that the limitations of such methods as that adopted by him should be
determined more precisely by extensive employment. We fear that at
present asylums in this country are, as a whole, totally unequipped, and
their medical staff untrained for work in the domain of psycho-physics.

Dr. Mott has a note upon “ The Choline Test for Active Degenera¬
tion of the Nervous System.” Readers of the Journal are doubtless
aware of the work of Dr. Mott and Professor Halliburton upon this
subject, by which they have shown experimentally that there is a pro¬
portional relationship between the presence of choline in the blood and
the amount of nervous tissue undergoing active degeneration. Dr. Mott
in the present note draws attention to the application of this test to
clinical purposes. He is desirous that others should test the validity
of his results. Mention is made of fourteen cases of organic disease of
the nervous system, in all of which choline was present in abnormal
amount. The method of applying the test is described, and it is
apparent that this presents no special difficulty, and might be employed
on a large scale in asylums and hospitals with a view to the accumula¬
tion of evidence. It is to be noted that whilst the test is applicable to
cases of organic disease, the latter must be active at the time the blood
is drawn. Among the fourteen cases we notice only two (tabo-paralysis)
which could be classed under mental diseases, though mention is made
of other cases of general paralysis in which observations were made.
Whether the essential condition of active degeneration of the nervous
system is to be found apart from paralytic dementia in ordinary asylum
practice is, as far as we know, undetermined. In any case there is
abundant scope for further observation.

As this volume contains some 860 pages it is impossible to deal with
all the articles. We have endeavoured to give an indication as to the
scope and quality of five out of ten of them. The other five consist of
a very lengthy paper upon “ Tabes in Asylum and Hospital Practice,”
by Dr. Mott (a demonstration of the etiological identity of tabes and
general paralysis); an article upon “ The Coagulation Temperature of

Digitized by

Google

7 i8

REVIEWS.

[Oct,

Cell-globulin and its bearing upon Hyperpyrexia ” (Drs. Halliburton
and Mott); and papers upon “The Pathology of Juvenile General
Paralysis ” (Dr. G. A. Watson); “ Changes in the Medulla Oblongata
in Diphtheritic Toxaemia ” (Dr. C. Bolton); “ An Examination of the
Central and Peripheral Nervous System and Muscles in Acute Alcoholic
Paralysis with Mental Symptoms ” (Dr. S. J. Cole). We trust enough
has been said to incite to the perusal of this valuable work. The
Editor’s personal contributions comprise a considerable section of the
work, and his inspiriting influence upon the contributors they would
no doubt admit as readily as they acknowledge his advice and guidance.

Why is not the laboratory licensed for animal experimentation?
Are we not entitled, nous autres , to ask this question? We cannot
believe it is because Dr. Mott finds it unnecessary, since he can get
experiments performed at the laboratory of King’s College. The
laboratory of the West Riding Asylum, Wakefield, was, and still may
be, licensed; and it is not to be supposed that there would be any
difficulty about obtaining a licence at Claybury if the governing autho¬
rities so desired. We must assume that they do not desire. We
recently asked the question of the distinguished professor of anatomy in
the medical school of a university town in Belgium, with only some
45,000 inhabitants and a strong priestly element, whether there were
any difficulty in the way of animal experimentation at his school. The
answer was, “ Certainly not; why should there be ? Such matters are
left to those qualified to judge.” What must be the reflection of the
intelligent foreigner who visits the laboratory at Claybury and learns
that for an institute so prominent there is no licence to experiment?
We may, however, assume that one of his reasons for being in this
country is to observe and muse upon those eccentricities of the national
character which he has heard so much of at home, and one of which,
under the designation of conscientious objection, has, perchance, already
been under his notice.

Dr. Mott makes it clear that it would be advantageous to have the
laboratory placed in London—a view which there is good reason to
believe had its representatives when the question of establishing that
institution was under consideration. We have heard of a technical
legal objection, stated with ponderous impressiveness, to the carrying
out of this idea. But even if this is sound, is it irremovable ? If so,
then we must subscribe to the opinion of Mr. S. Weller, sen., as to the
law. Edwin Goodall.

( l ) Vide Lorrain Smith and Tennant, “ On the Growth of Bacteria in the Intes¬
tine,” Brit. Med. Journ., December 27th, 1902.

Dissertations on Leading Philosophical Topics. By Alexander Bain.

London : Longmans, 1903. Pp. 277. Price 7 s. 6 d.

A new book by Bain seems almost an anachronism. When most of
us first began to interest ourselves in psychology Bain was already one
of the fathers of the British associationai school of psychology, and his
books were looked on as classics. It is, therefore, a pleasure to find that

Digitized by v^.ooQLe

REVIEWS.

719

1903 ]

the venerable author is still able to send forth a new book. The mis¬
cellaneous studies which make up the volume, it must certainly be said,
are not very new, some of them twenty years old, and have already
appeared in Mind or elsewhere. They represent, however, Professor
Bain’s latest thoughts on the questions to which he has devoted a long
life, and on this account alone they deserve attention.

The main interest of the book probably lies in its exposition of the
distinguished author’s attitude towards the critics of the associational
doctrine and towards the modem developments of psychology generally.
Thus in one essay he defends associational psychology against the
various attacks of Bradley, Ward, and Wundt. His attitude towards
Wundt’s apperception theory, which is now by many held to supplant
the associational doctrine, is moderate and conciliatory ; he sees no real
conflict, indeed, between apperception (though he thinks the word un¬
necessary) and association. In another notable paper he defends the
position of those who hold that physiology has a real bearing on
psychology, as against those who, like Stout and Bradley, take the side
of “ subjective purism ” in psychology, and deny that physiology can be
of any use in stating or interpreting psychic phenomena. Introspection
must certainly, he agrees, be the main resort in psychological inquiry—
the alpha and the omega : “It is alone supreme, everything else subsi¬
diary;” but among the subsidiary aids, he argues, physiology must still
hold a very high place. In other papers he discusses sympathetically
the modem experimental methods of mental research, and discourses
concerning the relations of psychology to anthropology.

Professor Bain has never been a daring initiator, and he is certainly
not a brilliant writer. But in reading this book we realise afresh that
daring and brilliancy are not the qualities most needed in laying the
foundations of so subtle and complex a science as psychology, and that
his special temper of mind—strictly empirical, distrustful of system,
always candid and open, anxious to see everything in a dry light and to
give due weight to every consideration—has deservedly won for Professor
Bain a position in the history of his science which he is not likely to
lose, however swiftly his work may be superseded. The book also
enables us to see how fruitful the English associational school has
been, and why it is that it has played so important a part in the evolu¬
tion of psychology. The associational doctrine has proved too narrow,
but it was produced by workers who clung very closely to fact and
experience, and hence it is that the modem developments of psychology,
though arising in Germany and France and America, have a true
historical continuity with the earlier English school. (Since this notice
was written Dr. Bain’s death has been announced.) Havelock Ellis.

Das Wachstum des Menscheti [The Growth of Man ]. By Dr. Franz
Daffner. Second enlarged edition. Leipzig : Engelmann, 1902.
Octavo, pp. 475. Price 9 marks.

Dr. Daffner (who no longer spells his name with a y) here presents us
with a new edition of a modest but useful little book, which he first sent
out some ten years ago. It is not intended as a complete manual of

Digitized by v^.ooQLe

720

REVIEWS.

[Oct,

anthropology nor as a mere collection of figures, but discusses in a
concise manner, and with close adherence to the most authentic sources,
many of the anthropological problems—notably those connected with
the brain and skull—which are most likely to interest the medical in¬
vestigator. The author has been in correspondence with many noted
anthropologists, and in various cases reproduces their unpublished
opinions. His own opinions are very modestly introduced, and he is not
anxious to formulate any theses or to pile up general conclusions. The
thoroughness with which the new edition has been revised is proved, as
is also the rapid development of anthropology, by the fact that the
present edition is double the size of the first. There is unfortunately
no index. Havelock Ellis.

Encyclopaedia. Medica. Edited by Chalmers Watson, M.B., M.R.C.P.E.
Edinburgh : William Green and Sons. Thirteen vols. Price 2or.
net each.

This colossal work has now been completed in thirteen large volumes,
and it reflects the highest credit on all concerned. It was a very
heavy undertaking to combine in one series a reference work on medi¬
cine and surgery to the extent of 600 subjects fully treated. The
collection of monographs thus presented to the profession is a marvel
of ingenious contriving; for it is now easy, with the Encyclopaedia
Medica at hand, to come by the most advanced knowledge. The
system of references and the combination of medicine and surgery
strike us as particularly valuable, and we must heartily compliment Dr.
Chalmers Watson upon the issue of his herculean labours. To take a
bird’s-eye view of the wants of the medical profession in regard to the
latest results of world-wide science and art, to keep the proportions, to
omit nothing of value, and to prevent irrelevant details, surely constitute
claims on our attention and on our support which are but seldom
manifest. But we must add to these considerations the indefatigable
energy which has secured the services of so many leaders of thought
and action in the profession. The summaries which preface all
articles of any length provide a clue to the immense labyrinth. It is
not only much knowledge, but accessible knowledge which is placed
before us, especially as a full index is in preparation.

Supplemental volumes are to be issued from time to time to keep
the work up to date, and arrangements have been made to permit of
purchase by easy instalments.

The production of this work has been admirably carried out by
printers and publishers, and nothing has been spared to make it of
first-rate importance in all branches of the profession.

It is impossible in the space at our disposal to summarise the
articles which deal with insanity. They have been contributed by
well-known physicians, and present the latest facts and opinions in
psychiatry with a conciseness, clearness, and authority which is credit¬
able to our specialty. It would be easy to give extracts and indications
of the scope of these articles, but we refrain in the hope that our

Digitized by v^.ooQLe

ANTHROPOLOGY.

721

1903]

readers will peruse them in their entirety, although the chief use of
such an encyclopaedia on the shelves of asylum libraries must be to
enable us to keep in touch with the great body of modern medicine and
surgery in the midst of our ordinary avocations. To elucidate cases
of difficulty and as a guide in the maze of contending opinions the Ency¬
clopedia Medica will prove invaluable.

La Dimence pr'ecoce. Par le Dr. G. Deny et P. Roy. Paris : Bailliere
et Fils, 1903. Pp. 96 ; eleven plates. Price 1.50 fr.

This little book gives an admirable rlsumi of the subject, and it forms
a volume of that practical series Lcs Actualizes Medicates. Dementia
praecox is now generally recognised as a definite clinical group of mental
diseases, and the authors treat of the group under three headings : (1)
the form of hebephrenia or mania; (2) the form of katatonia or
stupor; (3) the form of paranoia.

The authors recognise the first form as the most common, affecting
the character, the moral sentiments, and the intellect generally. The
clinical pictures are presented with much skill and sincerity, and the
illustrations are very helpful and characteristic. Following the usual
clear-headed methods of French writers, the whole of the questions
relative to the disorders considered are worked out precisely and briefly
—yet not so briefly as to obscure the authors’ meaning. They confirm
previous observers in stating that dementia praecox is slightly more
common in the male sex, and that they find about 70 per cent, of
the cases have an hereditary history of insanity. The results of organo¬
therapy would seem to leave the authors in doubt as to its efficacy.
They note that passive gymnastics are indicated in katatonia, and lay
stress on moral influences. We commend this work as a concise history
and practical handbook in relation to this group of maladies.

Part III.—Epitome of Current Literature.

1. Anthropology*

Anthropometric Variations due to Sex and Height [Zthomme moyen d
Paris]. {Bull. Soc. cTAnth. de Paris, 1902, fasc. 4.) Papillault ', G.

The appearance of this valuable memoir can be only briefly noted.
It is one of the most important contributions to an exact knowledge of
the body—the proportions of head, trunk, and limbs—which has been
made during recent years. Dr. Papillault, who belongs to the school
of Manouvrier, and is a teacher at the Paris Laboratory of Anthropology,

Digitized by v^.ooQLe

722

EPITOME.

[Oct,

carefully measured, in accordance with the best technical methods, two
hundred bodies (one hundred of each sex) belonging to the anatomical
department They were all French, between the ages of 24 and 50,
and markedly pathological cases were excluded. The author discusses
his results with much ability and with a wide knowledge of the literature.
He clearly shows that the differences between men and women, like
those between the infant and the adult, may largely be explained as due
simply to differences in size. In addition to secondary sexual cha¬
racters, he adopts the conception of tertiary sexual characters as brought
forward by the present writer, but appears to consider his own definition
of such characters as new and distinct; while possibly more precise, it
remains, however, practically the same. Havelock Ellis.

Considerations on Infantilism , etc. [Considerazioni antropologiche suit*
infantilismo , etc. J. (Monitore Zoologico Italiano, 1903, Nos. 4—5.)
Giuffrida-Ruggeri.

The author, who is one of the ablest of the younger Italian anthro¬
pologists, here brings together various facts and considerations bearing
on infantilism, the significance of sexual differences, and the question
of the origin of human varieties—to some extent founding his paper
on the recent elaborate researches of Manouvrier, Godin, and Papiflault.

Infantilism may be defined as an arrest of development between the
ages of thirteen and sixteen, not necessarily accompanied by any decreased
growth in mere size; owing to this arrest, however, whatever the
increase in size, the relative proportions of the body retain the same
youthful ratio as they possessed before the arrest took place. The presence
of such arrest may be shown by various indications. The author refers,
for instance, to the relative height of the nipple and the lower extremity
of the body of the sternum : in the child the nipple is considerably
higher in relation to the extremity of the sternum; in the adult the
difference is only a few millimetres. A relatively high nipple may thus
be regarded as an anthropometric stigma of infantilism. It has been
asserted that the relative height of the upper borders of the symphysis
pubis and of the great trochanter furnishes a similar indication, the first
being lower in the child, and the two points nearly level in the adult;
this, however, while asserted by Godin, is denied by Papillault.
Another infantile characteristic is the proportionately greater length of
the lower limbs as compared to the trunk ; until the age of fifteen, Godin
found, increase of height is mainly due to the lower limbs, afterwards to
the trunk. This, however, is not true of women.

At this point the author passes on to a theme which he has often
dealt with, the supposed infantilism of women. He proceeds to bring
forward a number of facts and arguments showing that, while there may
be in women either sexual divergence from men, or equality, there is
no evidence for morphological inferiority. It must be pointed out,
however, that the author has here been somewhat carried away by his
favourite thesis, and has fallen into a confusion of terms. Although at
one point he recognises that “inferiority” and “infantilism” are
perfectly distinct, he writes on the whole as though they were identical.

Digitized by

Google

ANTHROPOLOGY.

733

1903 .]

The distinction is important, because, so far from being identical, they
may even be opposed. A large brain is not a sign of inferiority, since
a progressively larger brain marks advance in zoological rank; but it is an
infantile characteristic. In the same way many human characteristics
mark the young ape, but are lost in the adult; they are in the ape infan¬
tile, but we cannot call them inferior. This confusion somewhat vitiates
Dr. Giuffrida-Ruggeri’s otherwise excellent argument. He warmly
repels the statement that women are morphologically inferior, but he
fails to see that in asserting unconditionally that women show no signs
of infantilism he may have become an unconscious advocate of the
inferiority of women.

The infantilism of the lower races is then discussed, and the author
points out that in dealing with such races the infantilism they exhibit is
rather comparative than real, and that we must distinguish between the
pathological infantilism found in the isolated individual of a higher race,
and the infantilism “ in a philosophic sense ” which we may trace in
various races of savages.

In a subsequent study on “the plasticity of human varieties,” the
author discusses the question whether, or in what degree, the skull form
is capable of modification. It is a point on which anthropologists are
by no means agreed; some consider that the skull shape of a race may
be indefinitely modified, others that it never changes and that inter¬
mixture can only lead to the production of the two varieties side by
side, failing to produce any intermediate forms. Starting from this last
standpoint, the author considers that it is no longer possible to retain
it quite absolutely. He brings forward more especially the case of Italy.
The northern half of the peninsula is brachycephalic, the southern half
dolichocephalic, but at the point of junction the mesocephals prevail;
this phenomenon is considered to be best explained by supposing a
mixture of the two races with tendency to convergence of the opposed
head shapes, in harmony with the conclusions of Nystrom in Germany,
according to which the children of parents with unlike cephalic indices
themselves in the majority of cases have unlike indices, but that in a
small number of cases they show an intermediate index. The cranial
invariability asserted by Sergi, Kollmann, etc., must not therefore be
understood in too strict a sense ; this invariability tends to persist, but
mixture produces a gradual modifying influence.

Havelock Ellis.

Artificial Deformity of the Skull [Les deformations artificielles du crdtie

enFratice\. {Bull. Soc. cTAnth. de Paris , 1902, fisc. 2.) Delisle y F.

Dr. Delisle has for many years been an authority on this subject, and
in the present monograph he treats it in a more exhaustive manner
than he has hitherto done, and also presents a map showing the distri¬
bution of deformity in the various departments of France. Although
the practice is slowly dying out, it still persists to a surprising extent,
and may be found, the author remarks, in many Parisians of intellectual
distinction. It is least prevalent in the eastern third of France. The
author concludes that it shows no tendency to become hereditarily
impressed on the race, and that there is no sufficient evidence to

Digitized by CjOOQle

724

EPITOME.

[Oct.,

support the belief that any arrest of physical or mental development is
caused by the practice, or that the individuals subjected to it show any
unusual tendency to insanity. Havelock Ellis.

Physical Anthropology of the Jews . (American Anthropologist , 1902-3.)

Fishberg, Maurice.

Dr. Fishberg, of New York, is publishing a valuable series of studies
of Jewish anthropology, and of these the first two, dealing with the
cephalic index and with pigmentation, have already appeared. America
is a good field for the study of Jews, on account of the large number
now reaching its shores from very various parts of Europe; and the
study is one of considerable interest, as it is calculated to throw light on
various important problems of general anthropology.

The cephalic index among 500 Jews was found to be, taking the
arithmetical average, 82*12, or, taking the median, 81*77, coming,
therefore, in the sub-brachycephalic class. In order to ascertain
whether his results show a homogeneous or a heterogeneous race, the
author arranges them in a curve; it then appears clearly that this
curve has but a single definite apex corresponding to the average and
the median, and the conclusion becomes probable that the Jews are an
unmixed race—unmixed, indeed, it would seem, to a degree not found
in any other civilised race. The Jews are usually looked upon as
Semites ; the other Semites are, however, mainly dolichocephalic, and
Fishberg seems to incline to the opinion of Luschan and others,
according to which there was originally a large Armenian element
among the Jews.

Pigmentation is the subject of the second study. The results here
obtained do not altogether accord with those reached in the study of
the cephalic index. There is much more evidence of mixture of race.
While 56 per cent . were of brunette type, having both hair and eyes
dark, 12 per cent, showed blonde hair combined with blue eyes.
Fishberg is inclined to attribute this, it would seem, in part to the
blending of races which there is some reason to believe took place at
an early period in Jewish history, and in part to modem intermarriage.
If this is the case, we have to suppose that the mixture of race has been
effective in influencing pigmentation, but has not succeeded in in¬
fluencing head form. It may be added that this apparent discrepancy
possibly gives force to an argument of Giuffrida-Ruggeri, who in dis¬
cussing Fishberg’s conclusions is inclined to attribute the presence of
a single apex in the curve of the Jewish cephalic index not to unity of race,
but to a phenomenon of convergence by which opposing head shapes
have slowly merged into a predominance of the intermediate sub-
brachycephalic form. In either case, however, some discrepancy would
remain between head form and pigmentation. Havelock Ellis.

A Consideration of Labour among Primitive People. ( Glas . Med.
fount., June , 1903.) Jardine.

In this inaugural address, Professor Jardine gives a short sketch of
some of the beliefs and usages prevalent amongst uncivilised peoples
with regard to parturition, dealing with the matter mainly from the

Digitized by v^.ooQLe

NEUROLOGY.

725

1903]

standpoint of the practical obstetrician. He points out that many of
the methods adopted by primitive races are superior to those in vogue
in civilised communities. For instance, the squatting posture for
delivery customary with a good many savage races is much more
rational than the conventional attitudes assumed by cultured European
women. Similarly, he would attribute the comparative rarity of uterine
diseases in savage life, in part at least, to the precautionary customs
which grow out of the idea of uncleanness during menstruation.

W. C. Sullivan.

2. Neurology.

Electrical Resistance and Muscular Contraction before and after the
Epileptic Fit [Resistenza elettrica e contrazione muscolare avanti e
dopo r accesso epilettico\ (II Manicomio, anno xix, No. 1.) Alessi.

After the epileptic fit, several functions of the organism are found to
be more or less modified; this has been noted, for instance, in respect
of the mental state, the body-weight, the temperature, the blood, the
urine. From a consideration of these facts the author was led to the
inquiries recorded in this paper. He investigated the effect of the fit
as regards three points: (1) resistance to the passage of the galvanic
current; (2) the minimum current that will produce a muscular con¬
traction ; and (3) the character of the contraction recorded graphically.
The experiments, which were made on sixteen epileptics, were carried
out with minute precautions to secure that the conditions should be as
far as possible identical; and note was taken in each case of the atmo¬
spheric state as regards moisture, pressure, and temperature. Verdin’s
myograph was employed, and the biceps of the left arm was selected
for stimulation. Notes of each case are given, and the results are
summarised m tabular form.

The conclusions drawn by the author are as follows :

1. In all the epileptics examined the electrical resistance was higher,
and the current required to cause muscular contraction was stronger
than in non-epileptics.

2. After a fit the electrical resistance was increased and the
muscular sensibility diminished.

3. But in those epileptics whose fits were followed by phases of
mental excitement there was, on the contrary, a lowering of electrical
resistance and an increase of muscular excitability.

4. The curve of muscular contraction taken after the fit differed from

that taken before in being irregular and lower ; the strength of current
that gave ACC before the fit hardly ever gave it in the post-epileptic
phase. W. C. Sullivan.

Specific Autocytotoxins and A n ti- a u tocy to toxins in Epilepsy [Autocitotossine
e anti-autocitotossine specifiche degli epilcttia]. ( Riv . speriment . di
Freniatr ., vol. xxix,fasc. 1, 2, 1903.) Cent.

In this preliminary note, Ceni states shortly the results of further
experiments which he has undertaken in the investigation of the

Digitized by ^.ooQle

726

EPITOME.

[Oct.,

properties of the blood-serum in epilepsy. His earlier researches,
which have been reported in the Journal, led him to the view that
the serum of the epileptic contained two active principles—roughly
speaking, a toxin and an antitoxin,—and that the inconstancy of the
effects of serum injections was due to the opposite properties of these
principles. In the inquiries which he now describes he subjected
guinea-pigs to a course of injections with epileptic serum, and then
injected the serum of these vaccinated animals into a number of
epileptics. As a constant result the patients showed phenomena of
reaction, local and general, the latter being of a clearly specific sort,
viz ., rise of temperature with a characteristic state of mental confusion—
an epileptic psychosis, often with increased frequency of motor attacks.
On the other hand, normal blood-serum of guinea-pigs injected into
epileptic patients gave rise to no such specific reaction; and the serum
of guinea-pigs previously treated with non-epileptic serum was almost
equally inert. Further, the serum which gave characteristic results with
epileptics had practically no effect on non-epileptic patients.

The inference, therefore, is that the serum of epileptics injected into
the guinea-pig is capable of determining in that animal a product of
organic reaction with a specifically toxic action to which epileptics alone
are susceptible. Assuming, then, for the cytotoxin of epilepsy a con¬
stitution similar to that assigned by Metchnikoff and others to cytotoxins
in general, it would contain a thermolabile alexin incorporated in the
leucocytes, and only set free by phagolysis; and a thermostable body,
also of leucocytic origin, but capable of entering into the circulation.
In epilepsy, therefore, the hypothesis supposes that a morbid tendency
to phagolysis exists in the related nervous elements, and that thereby
quantities of alexin are liberated which act on the cortical cells rendered
hypersensitive by the thermostable substance.

Now, since the serum of the vaccinated guinea-pigs acts only on
epileptic subjects, the cytotoxin which it contains must be analogous to
the thermostable substance and not to the alexin. To confirm this
view Ceni, in a further series of experiments, injected this serum after
submitting it to a temperature of 56° C., with the anticipated result
that its toxic action was unaffected. It is to be concluded, therefore,
that the phenomena of specific reaction produced in an epileptic by
the injection of serum from another epileptic, or from a guinea-pig
treated with epileptic serum are due not to a further dose of alexin,
but to the thermostable substance which renders the nerve-cells more
sensitive to the alexin already circulating in the epileptic subject.

To show the existence of the supposed anticytotoxin in epileptic
blood, Ceni resorted to the method of mixing normal epileptic serum
with a toxic dose of serum from a vaccinated guinea-pig, and injecting
it into epileptic patients. The result was that in the great majority of
cases the action of the guinea-pig serum was largely or wholly neutralising
This effect was not, however, obtained in all the cases. But in a second
series of experiments, in each of which the diluting agent was the serum
of the individual patient who received the injection, the neutralising
action was found to be constant. The author concludes, therefore,
that while the thermostable substance in the autocytotoxin is capable
of influencing all epileptics, the antitoxin has a much more specific

Digitized by CjOOQle

ETIOLOGY OF INSANITY.

1903-]

727

and individual action, being more effective for the organism which has
elaborated it.

The details of the experiments on which these ingenious views are
based will be awaited with interest. W. C. Sullivan.

3. Physiological Psychology.

Mental and Moral Heredity in Royalty. (.Popular Science Monthly,
August, 1 go2 — April, 1903.) Woods, F. A.

Dr. Woods, of Harvard, has in this interesting series of papers made
a careful study of an old problem—the heredity of mental and moral
characters, including insanity, in royal families. He deals with all the
chief royal families of modern Europe in succession, using the copious
material contained in Lehr’s Genealogy and applying to it some of
the methods of Galton. His main general conclusion emphasises the
influence of heredity as against environment. On the intellectual side he
considers that heredity accounts for nearly nine tenths of the phenomena,
on the moral side for rather more than one half. Variations in the
offspring are found associated with corresponding variations in the
ancestry, so that when good and bad blood is mixed the children tend
to show corresponding deviations in both directions, although they may
be all bred in the same environment. There is found to be a slight,
but only a slight, relationship between genius and insanity.

Havelock Ellis.

4. Etiology of Insanity.

The Geographical Distribution of Insanity in the United States. (Joum.
of Nerv. and Ment. Dis., May, 1903.) White, W. A.

When invited by the National Geographical Society to address them
on this subject, the author states that he had vague notions of the possi¬
bility of formulating laws that would express the relationship between
insanity and latitude and longitude, temperature, precipitation, etc., after
a diligent study of statistics. Confronted at the outset by the fact that
the proportion of insanity varies greatly in different regions of the
United States, what more natural, he asks, than that any scientific man
not especially acquainted with the statistical study of sociological
phenomena should ascribe such variations directly to the difference in
man’s physical environment in these localities ?

He then proceeds to explain why he found it impossible to present
such laws as he originally dreamed of, clothed in mathematical formulae
and demonstrating beyond doubt the precise effects of each climatic and
geographical factor upon the prevalence of mental disease.

The social organism (he says) is so extremely complex that any effort

Digitized by CjOOQle

728

EPITOME.

[Oct.,

to reason from the association of two or more conditions to the probable
causative relations between them is always dangerous, and when figures
are suborned for such purposes the results are notoriously inaccurate.

In this address, it is his object to inquire whether the prevalence of
insanity in the various regions can be shown to have any definite rela¬
tion to any one or more environmental conditions; whether insanity
is more prevalent at certain elevations above sea level, or between
certain degrees of latitude; whether it prevails more especially in regions
of a certain average temperature and barometric pressure, or, on the
other hand, where the mean humidity is high or low; and further, if
these conditions cannot be shown to have a causative effect upon its
distribution, what has ?

He then starts his inquiry by a study of a map of the United States,
upon each state or territory of which the ratio of insane to 100,000
population is indicated in accordance with the census returns for 1880;
and comes to the general conclusion that the variation in the propor¬
tion of insanity in the different states is regular and uniform, while both
geographic and climatic conditions are not, but, on the contrary, differ
greatly in different parts of the United States—as, for instance, in the
region of the Great Lakes. If, therefore, we would explain these figures,
we must seek a cause as uniform as its effects. This cause, or more
properly, these causes, are the same causes that make for civilisation;
the same that make for permanency and organisation of social institu¬
tions ; the same that make for concentration of population in great
cities; the same, in short, that make for progress in its broadest sense.

He does not wish to convey the idea that climate has no influence on
conduct, believing that Dexter has clearly shown that it has; but he
thinks with Berkley that climate and seasons have little to do with the
evolution of insanity. The effects of man’s physical environment upon
his mind must be only secondary—mediate, not immediate. If we
study, for example, the effects of temperature, humidity, or altitude, we
find them expressed in terms of respiration, pulse-rate, evaporation
from the cutaneous surface, blood-pressure, etc.—effects which he grants
are potent, but which nevertheless are not primarily mental. Therefore,
if we are to seek for adequate causes to explain the conditions which he
has pointed out, we must seek for mental, not physical causes.

If we look back over organic nature we shall see that, in the progress
of evolution, the nervous system has come to play a progressively more
and more important part until we get to the higher animals, the
vertebrates, in which the brain comes to be of paramount importance.
The brain of civilised man has, as it were, become the storm-centre of
the organism.

Thus far, in his attempt to account for the geographical distribution
of insanity in the United States, he has discarded the influences of the
physical environment as being efficient causes, because of their indirect¬
ness ; and has appealed to the immediate results of mental stress, the
results of the contact of man with man in the struggle for existence—in
short, the results of that struggle itself as exemplified in civilisation.

He then proceeds to show in great detail how this contention is borne
out by facts, showing that insanity is most prevalent in those localities
where civilisation is furthest advanced, where the social institutions are

Digitized by v^.ooQLe

ETIOLOGY OF INSANITY.

I9O30

729

stable, where class distinctions have crystallised—in short, where the
stress of intellectual life is greatest.

The author also brings forward much collateral evidence along the
lines of suicide, pauperism (but, strangely, does not refer to criminality
in this connection), insanity among the negro population, etc., in proof
of his conclusion that the proportion of insanity is highest where we
find the greatest congestion of population, and, therefore, where the
stresses incident to active competition are most severe.

Finally, he enters into a discussion of causes of insanity with a view
to indicating some general conclusions relative to the comparative
influence of the mental stresses to which he has referred in the actual
production of insanity. He rightly holds that the true underlying con¬
dition, in all cases where a so-called exciting cause (such as domestic
trouble, business worry, loss of relations or friends, etc.) is given to
account for a person’s alienation, is the predisposition to insanity. This
may be either inherited or acquired. By the former he indicates
hereditary insanity, by the latter that brought about by alcohol and
syphilis. Of all the causes of insanity, heredity is recognised as being
by far the most important and as being most frequently present.
Alcohol and syphilis act as true exciting causes of insanity at times. It
is conceded that both of these causes are much more prevalent in
civilised communities, and, in fact, seem to be fostered by that irregular
life which the active struggle after wealth necessitates.

In conclusion the author says, while civilisation furnishes the environ¬
ment that makes a bad heredity doubly dangerous, still it is the heredity
which is the prepotent factor, and not the environment. A bad heritage
is always a source of danger, and its possessor can never know when the
environmental conditions may appear which will make its latent activity
kinetic. A. W. Wilcox.

Tabes and Marriage : a Study of the Fertility of Tabetics and the Future
of their Offspring \Tabes et Mariage: Etude sur la ficonditi des
tabitiques et Pavenir de leur descendance]. (Journ. de Med. de

Bordeaux,fuly 12 tk, 1903.) Pitres .

The author has analysed 240 cases of tabes with a view to determining
the influence of the disease on the fertility of the patients and on the
vitality of their children.

Of the 240 individuals, 209 (87 per cent.) were married, this being a
proportion considerably higher than in the general population. This
greater frequency of tabes in the married has been noted by other
observers. Of the 209 patients (148 men and 61 women) married to
non-tabetics, 42 (20 per cent.) were absolutely sterile; 32 (15 per cent)
had 67 children, who all either were dead-bom (46 cases) or died in
infancy (21 cases); the remaining 135 (65 per cent.) had 416 children,
of whom 130 were dead-born or died in infancy, while 216 (2*11 per
family) lived beyond childhood. Absolute or relative sterility was much
more marked in the female tabetics than in the male.

The high infantile mortality—197 out of 483 (407 per cent.) —could
not, however, be attributed to tabes. For of these 483 children the 393
which were born before the first evidence of the spinal disease showed

Digitized by CjOOQle

730

EPITOME.

[Oct,

a mortality of 44 per cent, (23 per cent, stillborn and 21 p>er cent, dead in
infancy), while the 90 bom after the definite appearance of tabetic
symptoms had a mortality of only 28 per cent. (12 percent, dead-bom
and 16 per cent, dead in childhood). The cause of the low vitality of
the offspring was therefore operative before the development of tabes;
and since in the majority of cases of that disease syphilis is an ante¬
cedent, it suggests itself at once that the syphilitic infection may be the
cause of the high infant death-rate. And this idea is borne out by
further inquiry. Thus the mortality in the children of fathers who were
certainly syphilitic was found to be 33 per cent., while in the children of
possibly non-syphilitic paternity it was only 20 percent.

Nothing abnormal was noted in the children of tabetic parentage who
lived beyond childhood. With few exceptions they were mentally and
physically quite sound. W. C. Sullivan.

5. Clinical Neurology and Psychiatry.

On Heredity and some Clinical Symptoms in Relation to the Genesis
and Pathology of Feeblemindedness [ Dell 9 ereditd e di aleuni sin -
tomi clinici in rapporto alia patogenesi nelle frenastenie (con tabelle
dimostrative) ]. (Ann. di Freniatr., Giugno , 1903.) Pellizzi\ G. B.

In a paper of thirty-nine pages, Dr. Pellizzi considers the attempts
which have been recently made to square the clinical symptoms of
idiocy with the pathological alterations already noted. There are some
forms in which during life the pathological lesions cannot be presumed
or guessed; these forms he calls degenerative, genetous, evolved, or
common idiocy. In other cases, there are definite symptoms indicating
a precise lesion, such as infantile hemiplegia, diplegia, and other paralyses
which have been well described by Tanzi. Kdnig has put the question,
are idiocy and cerebroplegia not the same thing? But this Pellizzi
justly thinks is going too far. We have found the congenital forms of
idiocy much commoner than the acquired forms, though it need not be
disputed that further research will tend to reduce the number of the
former. In the cases analysed, Pellizzi found a proportion of 5 2 per cent of
the evolved form (evolutiva) and 32 per cent, of the pathological; the rest
were doubtful. Pellizzi has most carefully studied forty selected cases,
which are tabulated and analysed, having in view their physical and
mental condition and their capacity for receiving education. He has
found neurotic heredity in the cerebroplegic cases, though not so fre¬
quent as in cases of bom idiocy. As one result, he has arrived at the
conclusion that infantile spastic diplegia may be the result of the arrest
of development. Besides his original investigations, which have been
prosecuted with great diligence, there are two pages at the end of the
article filled with references to contributions upon the pathology of
idiocy in many European languages, which shows that the subject of
idiocy is at present receiving considerable attention from pathologists.

The following passage gives the most recent results concerning these
curious forms of amaurotic idiocy observed in New York, principally

Digitized by v^.ooQLe

I903-] CLINICAL NEUROLOGY AND PSYCHIATRY.

731

amongst children of Jewish origin. B. Sachs, in 1896, published the
first cases; others were described by Tay-Sachs, Kingdon, Carter,
Magnus, Wadsworth, Goldzieher, Hirschberg, and Stars. In these
cases flaccid paralysis and spastic paralysis appeared in almost equal
proportions.

The anatomical and microscopical studies of Sachs and Kingdon
exclude the existence of a pathological process. There was no pro¬
liferation of the neuroglia, nor traces of inflammatory processes, nor
alteration of the vessels and membranes of the brain. We have here
to do with a true agenesia of the cerebral cortex, as shown by imperfect
differentiations of the layers of the cortex, and embryonic character of
the nerve-cells, and anomalous appearance of the pyramidal layer.
Further chemical observations have been made by Falkenheim, Frey,
Hirsch, Kuh, Higier, and Patrick; and the anatomical and microscopical
investigations of Sachs have been confirmed by Russell, Peterson, Frey,
and Hirsch.

From the cases of amaurotic idiocy it appears that all the muscles,
including those of the trunk, neck, and head, may be affected with
paralysis or contraction ; the morbid process goes on with more or less
rapidity, seizing upon one side or one limb after another. The
paralysis may be spastic or flaccid, total or partial hemiparesis or para¬
paresis, and the flexors and extensors of the limbs may be more or less
rigidly contracted. William W. Ireland.

On the Diagnostic Value of Irregularities of the Pupil [Ueber den
diagnostischen IVerth der Unregelmdssigkeiten des Pupillarrandes
bei den sogen organischen Nervenkrankheiten\ (Neurologisches
Centralblatt , Juli u. Aug., 1903.) Piltz,/.

In these two numbers of the Centralblatt Dr. Piltz gives the results of
a very careful study of the irregularities of the pupil in nervous diseases.
Half a century ago, the frequency of this symptom in general paralysis
was noted by Baillarger ; since then many observations have been made
by physicians upon the state of the pupil in insanity. Many of these
have been cited by Dr. Piltz in the good old German way of reviewing
the whole state of our knowledge of the subject before giving us the
result of his clinical observations and experiments upon animals. The
articles are illustrated by some instructive engravings giving the varying
shapes of the pupils and the anatomical distribution of the nerves of
the iris.

Dr. Piltz thus sums up the result of his clinical observations and
experimental researches:

1. There are temporary or shifting irregularities which are caused by
unequal movements of portions of the iris.

2. By disturbances in the position of the whole pupil.

3. By persistent irregularities of the edge of the pupil. All these
pathological alterations in the edge of the pupil are common in general
paralysis, tabes dorsalis, and lues cerebro-spinalis.

They are often observed in the course of other mental diseases;
rarely in healthy people.

XLIX. 50

Digitized by

Google

732 EPITOME. [Oct,

4. Shifting disturbances and unequal motions of the iris are some¬
times observed in katatony.

5. Irregular shapes of the edges of the iris are often observed before
the appearance of the Argyll-Robertson symptom, and have thus much
importance in diagnosis.

6. Alterations in the form of the pupil, similar to those observed in
disease, may be produced experimentally; hence we may suppose that
these changes signify an irritation, paresis, or paralysis of portions of
the iris dependent upon pathological affections of the short and long
ciliary nerves and their nuclei.

7. Unequal reactions of single portions of the iris are dependent upon
paresis of the corresponding branches of the ciliary nerves—paresis
iridis partialis.

8. Disturbances of the position of the whole pupil indicate a com¬
bined irritation, paresis, or paralysis of the branches of the short and
long ciliary nerves.

9. Constant irregularities of the whole pupil constitute a sign of
paralysis of some section of the iris—iridoplegia partialis.

These are most probably the result of diseased conditions of the
ciliary nerves or their nuclei (atrophy of nerve-cells).

William W. Ireland.

Delirium in Febrile Conditions . (Dub. Joum. of Med. Sci., June, 1903.)

Jones , K. IV.

The author of this thesis, in speaking of delirium or febrile insanity
and post-febrile insanity, says that the latter is a very rare condition,
and is, generally speaking, incurable, as it is not due to the wasting and
exhaustion alone, but that the specific poison of the fever is a factor in
its causation. The former he classifies into simple delirium, the so-
called busy delirium, delirium ferox, and low-muttering delirium. He
observes that febrile insanity is most common in typhus fever (and is
generally so, as in all fevers, in the male sex), then in smallpox, enteric
fever, pneumonia, and erysipelas. In scarlet fever and measles it is
rare. In the treatment of simple and low-muttering delirium he has
found paraldehyde the most useful hypnotic. In busy delirium and
delirium ferox all the ordinary hypnotics, in his experience, were prac¬
tically useless. The one drug which he found to act was apomorphin
in -jV gr. doses to adults. In Dr. Jones’s hands this drag had a
hypnotic but no emetic effect, but he does not tell us in how many
cases he obtained this result, nor as to the mode of its administration.
He found—by chance, he says—that it acted better when given about
ten minutes after a hypodermic of £■ gr. morphin. A. W. Wilcox.

Psycho-motor Hallucinations and Double Personality in a case of Paranoia.
(Joum. of Nero, and Ment. Dis., May , 1903.) Pickett, IV.

In this article, the author describes an interesting case of paranoia
which has been under his care for some years. The patient is a
'German, 35 years of age on admission, a boiler maker by trade. His

Digitized by

Google

1903.] CLINICAL NEUROLOGY AND PSYCHIATRY. 733

family history is unknown. Three years before admission he had
received a blow on the head from a falling log. Two years later he
began to complain of pain in the head, heard vague sounds continually,
was sleepless, restless, and had fears of harm and misfortune. He had
a number of outbreaks of excitement, during which he would destroy
the furniture of his house. He explained to his wife that these were
due to “ nervousness,” and advised her to keep out of his way lest he
might harm her. He then developed a fixed delusion that certain of
his fellow-workmen at the shipyard where he had been employed were
“ robbing him of a patent on a ship ” which he had devised but “ was
too poor to put through.”

This delusion was the prominent feature of his case on admission, and
has persisted, though now overshadowed by the notions about to be
described.

Two years after admission it was observed that he was continually
uttering, in a mechanical way, certain strange expressions, the one that
most frequently occurred sounding like “ Boon knecht.” When asked
what this meant he replied, “ I don't knowwhy he said it, “ I don't
say it.” Urged to explain, the patient insisted, “ I do not say these
words, but the man on my back says them.” He added that this man
on his back does various things with his (the patient’s) body, moving his
arms, as well as his lips and other organs of speech. Recently he has
gone so far as to set aside a portion of his meals regularly for the
nourishment of this imaginary host (sic) on his back.

This patient, the author believes, is one whom certain French writers
(S£glas and Ballet, to wit) would describe as suffering from verbal
psycho-motor hallucination with “doubling of the personality.” He
then gives the explanation of these authors as to what they understand
by these two terms.

Briefly stated, a psycho-motor hallucination is due to the excitation of
a cortical motor centre exactly as a psycho-sensory or ordinary halluci¬
nation is due to excitation of a sensory one.

Their explanation of “ double personality ” is that as in an ordinary
(sensory) hallucination, such as of hearing, the voices, etc., are promptly
“ exteriorised,” *. *., ascribed to outside agencies, etc., so in a psycho¬
motor the hallucination impresses the patient as being due to a
mysterious agency within himself; and so in time he forms the concep¬
tion of a new strange being inhabiting his body or in intimate association
with his body. This is exemplified in the author’s patient with “ a man
on his back.”

The term “ double personality ” is unfortunate, since it has been
employed as a synonym for “ double consciousness ” in the sense of
alternating consciousness. Pickett suggests the term “ accessory
personality ” in its stead.

He then deals at considerable length with the literature on the
subject of this article, and arrives at the conclusion that we may accept
the theory of psycho-motor hallucinations by reason of its plausibility;
that psycho-motor hallucinations are not so rare as we have supposed ;
that double personality, however, is a very rare sequence of them, and
when it is present it is an accidental conception born of ordinary
processes of reasoning over strange sensations.

Digitized by v^.ooQLe

734

EPITOME.

[Oct.,

He concludes by mentioning a case of his own, in which both verbal
and common-motor hallucinations, present in abundance, were ascribed
by the patient to outside agencies, and believes that psycho-motor
hallucinations are often thus exteriorised. A. W. Wilcox.

Mirror Writing [La scrittura speculart\ (II Manicomio , anno xix y
No. i.) Tomas ini.

In this paper, the author records rather summarily a clinical observa¬
tion of mirror writing, and in connection therewith gives a short critical
review of the literature of the subject

The observation referred to a patient set. 23, an hereditary degenerate
suffering from cocainic insanity characterised chiefly by mental debility
without much sensory disturbance. He was a person of superior
education, and at the time of his illness was a student of law. His
aptitude for mirror writing was discovered accidentally just before his
discharge from the asylum ; he was trying for amusement to write with
the left hand, and, after some unsuccessful efforts to produce the letters
in the ordinary manner, he suddenly and in an apparently involuntary
way began to trace the lines well and rapidly in mirror writing. He was
positive that he had never written in that fashion before. He was
neither left-handed nor ambidextrous in respect of any fine movements.
A facsimile of his mirror writing given in the paper shows a clear facile
hand differing somewhat from his ordinary caligraphy.

The author points out that the sudden manifestation of this aptitude
in a right-handed adult not suffering from any functional incapacity of the
right hand is rather rare. The phenomenon has been more often met with
in hemiplegia with some degree of dementia, in left-handed persons and
in children. To explain its occurrence in cases such as that lvhich he
records, the author supposes that Exner*s graphic centre is represented
in both hemispheres, but that normally the left centre is dominant;
when for any reason—in this case the paralysing effect of the intoxica¬
tion—the left hemisphere has lost its functional supremacy, the right
graphic centre may come into play. In this way, if, as Abt has pointed
out, there are no impeding conditions— e. g ., too vivid visual images of
the letters to be traced,—mirror writing may result, since the abduction
movements which it involves are the true homologues for the left hand
of the motions of the right hand in ordinary writing.

W. C. Sullivan.

6 . Pathology of Insanity.

On the Alterations in the Nerve fibres of the Spinal Cord and the
Spinal Ganglia in some Forms of Chronic Insanity [Sulle alterasioni
delle fibre nervose spinali e dei gangli interoertebrali in alcune forme
di psicosi croniche]. (Ann. di Freniatr., Giugno , 1903.) Burzio.

Dr. Burzio has made a laborious investigation of the state of
the spinal cord in fifteen cases, which include imbecility, epileptic

Digitized by v^.ooQLe

1903.] PATHOLOGY OF INSANITY. 735

insanity or idiocy, primary dementia, melancholia, senile insanity, and
secondary dementia. He has not made a special study of the cord in
general paralysis and pellagrous insanity, as this has been already care¬
fully examined. In the beginning of his contribution Dr. Burzio cites the
previous observations of Stewart, Feist, Mondio, and Petrazzani. In his
important work “On the Anatomical and Pathological Differences
between Primary and Secondary Degenerations of the Nervous Centres,”
which appeared in the Rivista Sperimentale di Freniatria , vol. xxi, 1896,
p. 788, Vassale has shown the general characters of degeneration of the
spinal cord in dementia, and admitted their primary nature. After detail¬
ing his methods of investigation and preparation, Dr. Burzio describes
his fifteen observations. In three of these, two cases of melancholia
and one of senile insanity, no lesions were found in the spinal cord; in
the others some alterations were found, the most common being de¬
generation of Golfs tract (eleven times), occasionally combined with
degeneration of the crossed pyramidal tract (three times). Hypertrophy
of the neuroglia was rare. Degeneration of the nerve-cells of the spinal
ganglia was also frequently met with. These alterations in the nerve-
fibre of the spinal cord and of the spinal ganglia were sometimes
associated with atrophy of the cerebral convolutions and of the cells of
the grey substance of the spinal cord, and were often accompanied by
a diseased condition of the liver, kidneys, and spleen.

Vassale has laid down that in secondary degenerations there occurs a
destructive process, both in the medullary sheath and in the axis-
cylinders, which soon leads to a total disappearance of the nerve-fibre;
while in the primary degeneration there is a gradual disappearance of
the myelin, while the axis-cylinder persists for a much longer time.
As the result of his operations Burzio concludes that the degenerations
he has noted in the spinal cord of the chronic insane are primary
simple atrophies. His view is confirmed by some destructive lesions
practised upon dogs. Burzio also finds these lesions analogous to those
observed in pellagra, and after intoxication with some drugs and
bacteria. This, he thinks, confirms the hypothesis of the toxic origin
of the insanities. He regards the degenerations observed in the liver,
kidneys, and aorta as further proofs of the action of a toxin within the
system. William W. Ireland.

The Pericellular Nerve-mesh in the Cortex [Z’ intreccio nervosoperieellulare
nella corteccia cerebrale\ {Ann. di Freniatr. Giugno t 1903.
Roneoroni.

Entirely distinct from the radiating and tangential fibres of the cortex
cerebri Professor Roneoroni describes a mesh of very fine fibrils
surrounding the nerve-cells and their protoplasmic prolongations, and
sometimes winding over from one neuron to another.

Nissl admits the existence of a continuous fine net of elementary
fibres which unites all the nerve-cells in the grey substance of the brain.
The fibrils described by Roneoroni are also to be found in the white
substance and in the medulla, pons, and crura cerebri, though less
abundantly. They are scarce in the olfactory bodies, and cannot be
traced in the cerebellum, in the retina, or in the ganglia of the sympa-

Digitized by v^.ooQLe

EPITOME.

736

[Oct.,

thetic. No traces of myelin could be detected around the fibrils.
Roncoroni has found them in some of the lower animals. He thinks
that these fibrils have a nervous or psychical function; but this does
not go beyond speculation. William W. Ireland.

The Changes found in the Central Nervous System in a case of Rabies
with Acute Mental Disturbance . (Journ, of Nerv, and Ment. Dis. %
May , 1903.) Allen, C. Z.

Before proceeding to a description of the case which came under
his personal observation, the author gives a risume of the literature on
the subject of the pathological anatomy of rabies.

This case was that of a farm labourer set. 32, who, whilst intoxicated,
was bitten on the hand by a dog. The dog was said to be mad, and
killed, but no examination of its body was made. The man, who was
the subject of much attention and interest on the part of his neighbours,
who repeatedly detailed the symptoms of rabies to him, became nervous
and depressed, gave up work, and began to drink heavily. About
three months after receiving the bite he became excited and violent,
tore his clothes, is said to have “ barked like a dog,” was unable to
swallow, and took neither food nor drink from that time onwards.
He was brought into hospital, tied hand and foot, three days later.
He was then very restless and excited, kept constantly in motion,
secreted a great quantity of saliva, and was absolutely unable to swallow.
Apparently he had no definite delusions, hallucinations, or illusions, and
in an interval of comparative calm told the attendant that he had hydro¬
phobia and hated to die. The patient died the same evening.

On account of the questionable history the case was regarded as
being most probably one of acute excitement supervening upon alco¬
holism.

The autopsy was performed seventeen and a half hours after death.
Two rabbits were inoculated with portions of the brain and spinal cord,
with the result that each animal developed typical paralysis of the hind
limbs and died three days later, after the paralysis had ascended to the
fore limbs.

The writer then gives a detailed account of the macroscopic and
microscopic findings, which agreed in general with those which have
previously been described in rabies, but which he thinks, while strongly
suggestive in a case with so suspicious a history, would hardly have
justified a positive diagnosis if taken alone, i. e. t without the animal
inoculations. None of the changes found were characteristic of rabies
alone, but each may be present also in other diseases.

From the study of the literature of the subject, together with that of
this case, the author believes that it is justifiable to conclude that
neither the ganglionic changes of van Gehuchten and N£lis nor the
rabies tubercle of Babes are absolutely characteristic of human rabies,
though their presence in a suspicious case may be of considerable
diagnostic importance. The value of these changes in the nervous
system of a dog suspected of rabies is not yet entirely decided, but
when found in a case otherwise suspicious they are at least strongly

Digitized by v^.ooQLe

TREATMENT OF INSANITY.

1903.]

737

suggestive, and they should invariably be sought for, at any rate until
we acquire some more definite information upon the subject.

A. W. Wilcox.

7. Treatment of Insanity.

Saline Injections in the Treatment of the Psychoses [Kochsalzinfusionen
in der Terapie der Psychosen]. ( Psychiatr . Neurol. Wochenschr .)
Wickel.

Dr. Wickel draws attention to the continually increasing field of
application of subcutaneous saline injections which has been noted
within the last twenty years. This development has taken place in the
various departments of medicine, surgery, and gynaecology, and, within
the last twelve years, it has invaded also that of mental disorders.

The reasonableness of this method of treatment is quite obvious in
all forms of acute anaemia from loss of blood. In shock and collapse
its applicability is equally apparent. In the profound prostration of
cholera (Asiatica and nostras) it is held to serve a double purpose—on
the one hand by filling the depleted vascular system, and on the other
by diluting the percentage strength of the toxins in the system and
facilitating their elimination; in the latter action the improved circula¬
tion would be a factor.

On the strength of this point of view, the dilution of the poison by
the injection, the latter has been employed in various forms of poisoning,
infectious and other, including carbonic oxide and coal-gas poisoning;
also in uraemia, diabetic coma, eclampsia, the typhoid state, septicaemia,
etc. It has likewise been used in pneumonia, malignant endocarditis,
and in the primary (essential) anaemias.

From 1891 on we find records of the use of saline injections in acute
delirium with prostration (Mercklin); in mental disease with collapse
and the refusal of food (Ilberg, Emminghaus, Ziehen, de Borck,
Kraepelin, and others); in mental disease depending on infection or
auto-infection (Jacquin, Buvat). A very wide application of the method
is advocated by di Gaspero, who sees in it a very powerful means of
stimulating the whole system in mental disease attended by marked
depression or perversion of the functions, and in particular where there
is present a supposed lowering of the oxidations in the tissues. Donath
speaks highly of the treatment in general paralysis, especially in the
early stages, and Alter agrees upon the whole with Donath.

The method of procedure consists in the subcutaneous injection, with
all antiseptic precautions, of 400 to 700 c.c. (14 to 24 oz. about), and the
repetition of this dose, according to results, every fifth, third, second day,
or even every day. In general the liquid employed was a sterilised
solution of sodium chloride, 075 per cent but Donath uses a mixed
solution of sulphate and chloride of potassium, and of chloride, car¬
bonate, and phosphate of sodium ; of this he injects 18 to 35 oz. every
third or fifth day.

Digitized by v^.ooQLe

738

EPITOME.

[Oct,

On the grounds of the above-mentioned results Dr. Wickel proceeded
to treat with saline injections seven cases of dementia praecox, three
cases of general paralysis, two cases of psychosis associated with chronic
alcoholism, two of melancholia, and a case each of mania, epileptic
excitability and confusion, and mental confusion and unrest in a severe
case of typhoid. In particular the effects of the treatment were noted
on the symptoms collapse, refusal of food , and prostration, which sym¬
ptoms were selected as the indications for the injections.

In general 400 c.c. (14 oz.) of 075 per cent '. NaCl solution were in¬
jected, and this dose was repeated every second day or every day, some
twenty injections in all representing the injection “ cure.”

The results obtained were by no means encouraging; in two or three
of the whole group some benefit seems to have been effected; the other
cases appear to have been uninfluenced or certainly not improved by
the treatment. H. Sainsbury.

The Effective Dose of Bromide in Epilepsy [.La dose suffisante de brcmure
dans Fepilepsie essentielle\ ( Gaz . des Hdp., June 13/A, 1903.) Jamot.

The treatment of epilepsy has to be considered under the following
aspects :—(1) The means to be employed during the seizure ; (2) the
treatment of the stage following immediately thereon; and (3) the treat¬
ment of the interval between the seizures. The use of bromides con¬
cerns the last-named only.

An indiscriminate and unmethodical use of the bromides is the cause
of the not infrequent ineffectiveness of the drug. The rules of ad¬
ministration advocated by Dr. Jamot are those laid down by Gilles de la
Tourette in his work on the practical treatment of epilepsy: “The size
of the dose is determined by the age of the patient, his individual
tolerance of the drug, the number and intensity of the epileptic mani¬
festations.”

Children bear the drug proportionately well, but in their case, as in
all cases, the individual susceptibility must be gauged tentatively.

To establish this individual dose Gilles de la Tourette proceeds by
the method advanced by Charcot, viz., the administration in periods of
three weeks of a dose which rises and falls thus :—During the first week
the daily dose is, say, 3 f grms. (45 grains), the next week it will be 4 grins.,
and the third week 5 grms. The fourth week is restarted with 3 grms.,
the fifth week 4 grms., and so forth; the sequence proceeding 3, 4, 5—
3, 4, 5 indefinitely.

For the dosage to be really effective that number of grains of bromide
must be administered during the week of maximum dosage which shall
produce distinct physiological effects, viz., a certain degree of lassitude
and of somnolence, and in addition the “ pupil symptom,” the pupils
reacting neither to light nor accommodation and being, moreover, at
their maximum of dilatation. That maximum dose, whatever it be,
will exceed its predecessor by 15 grains, and the dose before that by
30 grains—the common difference in every series being 15 grains.

Dr. Jamot advocates the administration per os as the most satisfactory
method. H. Sainsbury.

Digitized by v^.ooQLe

I903-]

TREATMENT OF INSANITY.

739

On the Inhibiting Influence of Morphinism on the Convulsive Manifesta¬
tions of Hysteria and of Epilepsy [Action suspensive de la m or phi-
nisation surles manifestations convulsives de Phystlrie et de Pepilepsie].
(Prog. Mkd. % July 18 th, 1903.) Antheaume.

Dr. Antheaume records two cases of chronic morphia poisoning in
which, during the continuance of the habit, the convulsive seizures, to
which the patients were accustomed, ceased, to reappear with the sup¬
pression of the morphia habit. To facts of a similar kind “Auguste
Voisin, Paul Gamier, and Jules Voisin had previously drawn atten¬
tion.” Beyond the recording of the cases the writer does not proceed;
least of all does he suggest that patients suffering from convulsions
should replace their affliction by those evils which attend chronic
morphinism.

Of the value of morphia as a means of suppressing convulsions we
have a good example in its use in the convulsions of uraemia, but this
temporary employment is another matter.

H. Sainsbury.

Apomorphine Hydrochlorate : its Use in Mental Affections . ( Merck's

Report , 1903.)

The hypnotic powers of apomorphine have been overshadowed by its
action as an emetic, but that it possesses sedative and hypnotic pow r ers
appears from recent investigations. In 1901 Merck reported the results
obtained by Ch. I. Douglas with small doses, insufficient to nauseate.
The mean hypnotic dose was about 2 m.g. (-5V grain) *• e., about one
third of the emetic dose. Sleep was said to follow within five to
twenty-five minutes, and to last one to two hours. Because of the
short duration of the sleep it was advised to associate some mild
hypnotic with the apomorphine. Further reports come now from
Rabon, Coleman and Polk, and Faucher, who, working with doses
ranging between and i grain, find the drug of great use as a
sedative and soporific in states of violent excitement and restlessness.
The doses are invariably given hypodermically, and vomiting or
nausea is generally produced. Coleman and Polk have used apomor¬
phine in the excitement of alcoholics (£ grain) with much success;
Faucher in hysteria, hystero-epilepsy, and epilepsy pure and simple.
In hysteria the mental impression caused by the hypodermic needle is
probably of value in addition to the undoubted depression caused by
the vomiting.

Considering the difference of administration in the methods above
described, it would not be unreasonable to try first the smaller (non¬
emetic) dosage, and if need be to advance from this to the emetic dose.
We are inclined to think that the latter is likely to prove the more
generally effective. H. Sainsbury.

Bromipin . ( Merck's Report , 1903.)

This combination of bromine and sesame oil, like the analogous
compound iodipin, continues to hold its ground as an alternative to the

Digitized by v^.ooQLe

740

EPITOME.

[Oct.,

usual bromides. Its oily basis gives it a nutritive value in addition to
the medicinal value which attaches to the bromine element It is em¬
ployed in epilepsy, in hysteria and neurasthenia, and it has been
specially recommended in nervous insomnia, vertigo, and agoraphobia ;
also in eclampsia infantum (Wassing, Rahn). The nutritive and
strengthening properties of bromipin have been frequently insisted upon
by many observers, and more recently by Moller.

Large doses should be given in enema form, the 33^ per cent . strength
of bromipin being employed and made into an emulsion with milk.
In the case of children and infants Rahn employs the 10 per cent .
strength in enema, administering to infants as many grammes as the
infant counts months. Children of 1 to 4 years receive 160 minims up
to one half ounce; children above these ages 6 to 8 fluid drachms. To
adults 2\ to 4 drachms of the 33 J per cent should be given.

The symptoms of bromism are of much less frequent occurrence
with this preparation.

For administration by mouth the following formula has been recom¬
mended by Kothe {Merck's Report , 1901):—Bromipin (10 per cent.),
fl. oz. 3$ ; the yolks of two eggs : emulsify and then add—Cognac,
fl. oz. 4; menthol, gr. 2^. Three or four tablespoonfuls to be taken
daily. H. Sainsbury.

Lecithin [ Ovolecithin ]. {Merck's Report , 1903.)

As a means of promoting nutrition and of conveying phosphorous
action in a milder and safer way than by the uncombined element,
lecithin appears to be making steady progress, and, we are glad to learn,
it has become considerably cheaper.

Its employment in malnutrition in all its forms will interest the
alienist equally with those who work in other departments of medicine.
The drug may be conveniently given by the mouth in the form of pill
or tabloid. Merck’s tabloids contain each f gr. of lecithin, and of these
five to eight are taken before each of the two principal meals.

It may be combined with cod-liver oil in the proportion of 15 grs. of
lecithin to 8 oz. of oil, of which two to four tablespoonfuls are to betaken
at meal times. This is very large dosage of oil according to the practice
of this country, and in order to make the lecithin dose correspond to
the smaller administration a much stronger solution of lecithin would
be required. Lecithin is so freely soluble in olive oil that there should
be no difficulty about this.

Lecithin is also injected subcutaneously, in solution in olive oil which
has been previously washed in alcohol and sterilised. Eight grains of
lecithin dissolve in 10 c.c. (160 minims) of the oil, and of this 1 to 3C.C.
(16 to 48 minims) are to be injected on alternate days.

Lecithin in subcutaneous injection has been praised by Hartenberg
in tabes, general paralysis, hysteria, and various psychoses {Mercks
Report ', 1902). It is recommended also in neurasthenia, senilitas
praecox, etc. ( Report , 1903). In phthisis, administered subcutaneously,
it is much praised ; also when combined with guaiacol.

H. Sainsbury.

Digitized by CjOOQle

1 9°3-]

ASYLUM REPORTS.

741

8. Asylum Reports, 1902.

Some English County and Borough Asylums.

Carmarthen. —The Committee of Visitors report that it has under
consideration the establishment of a pension scheme. The Com¬
missioners note that the asylum is overcrowded, which will possibly
explain in part the abnormally high death-rate from phthisis. This
asylum lays itself out to receive private patients, and at the time of
report had forty-two of these, paying from ior. to £2 2s. per week.
There is a proposal to acquire fresh land and build accommodation for
them. Dr. Goodall again brings before his Committee the benefits of
boarding out patients as a means of obviating the necessity for some of
the fresh building which will otherwise soon be required.

Derby County. —The following is a point:

C. R— was brought to the asylum at 2.55 on July 17th. While sitting in the
reception room in charge of the men who brought him, and before being formally
“ admitted,” he died. At the inquest the following verdict was found “ Syncope
brought on by acute maniacal exhaustion.” I was instructed by the Lunacy
Commissioners that the case was not to be considered as an “ admission,” and
that the death was not one of a patient in tne asylum. The body was there¬
fore removed by the Chesterfield Union authorities and buried in the Mickle-
over Churchyard.

The causation by alcoholism among males was 34 in 112 admissions.

It may be recalled here that during the year the Association, through
the hospitable kindness of Dr. Legge and the Committee, had an oppor¬
tunity of making an instructive and pleasant inspection of Mickleover.

Derby Borough. —Of the Brabazon scheme Dr. Macphail writes :

It has certainly had the effect of brightening the lives of many of the
patients, and has helped in the cure of not a few. The real interest taken by
the ladies in their pupils is not confined to the two hours spent weekly at the
asylum in teaching the patients rug-making, basket-weaving, chair-caning, netting,
knitting, and different kinds of fancy work, but shows itself in various ways; it
extends to visiting patients at their houses after their discharge, and in some
instances helping them to obtain suitable employment. We are the first English
asylum to give this scheme a trial, and as our first year was tentative we have not
attempted too much. Hitherto the classes have been composed of female patients
only, but we hope shortly to start suitable employment for the men. Financially
the scheme'is self-supporting, and although you as a Committee kindly undertook
to be responsible for any loss sustained in the first year, no assistance has been
necessary, and we have a small balance in hand which will be spent in giving a treat
to the patients.

The system of instruction is excellent, as we have before pointed out
in relation to some of the Scotch asylums, but the extension of the
teachers* interest to visitation and help outside the asylum is worthy of
all praise. More than anything else it will help to break down the
invidious and prejudicial difference in the light in which the public
regard mental and general disorders.

The alcoholic causation in the males w*as even higher in the borough
than in the county, being 15 out of 41 admissions.

Digitized by v^.ooQLe

742

EPITOME.

[Oct,

Dorsetshire. —Dr. Macdonald renews an old protest, and suggests
that in some cases the greater comforts of the asylum have a determining
influence in restoring quiet orderliness, which was absent in the work-
house :

With reference to the aged cases admitted, it would seem very desirable that
patients who are only in need of ordinary attention and nursing might be cared
tor at home or in the workhouse infirmaries. It sometimes happens that the only
indication of insanity in these cases is a restlessness by night, which, while annoy¬
ing to others, is not much proof of insanity.

It is noteworthy that while three general paralytics were admitted,
and five died, nine remained at the end of the year.

Glamorgan .—The Committee report:

A few cases of scarlet fever occurred in the spring, but as they were at once
isolated the disease did not spread. To enable the Committee to refuse admission
to cases of infectious diseases, or to persons coming from districts where such pre¬
vail, they have adopted as a regulation, in accordance with Section 275 of the
Lunacy Act, 1890, sub-clause 5, the power there granted them to exclude such cases
and persons.

The general paralytic admissions included 16 females in a total of
51. Sexual intemperance accounted for two male and nine female
admissions, while venereal disease was responsible for four—all males,

Gloucester .—In dealing with the influence of heredity Dr. Craddock
gives the following instance of wilful neglect of ordinary caution. But
then it always is the madman who does mad things.

A man who had been an inmate here more than once, on the last occasion for
some five or six years, unexpectedly began to improve, and at length was so much
better that his relatives wished to give him a trial at home. I willingly assented,
and he was in due course discharged. Within a few months we heard he was
engaged to be married, and he actually was married to, it will hardly be credited,
the daughter of a woman who has been here for years, and is never likely to be
anywhere else.

Kesteven .—The opening of the new asylum at Quarrington on June
20th, 1902, is recorded in this report, and the arrangements made by Dr.
Ewan for the transfer of the patients from Grantham are warmly appre¬
ciated by the Committee. One of the wards has been set apart for
the reception of private patients at the lowest remunerative rate of pay¬
ment. The Committee have been obliged to appeal against the assess¬
ment, the local authorities having rated the institution on a much
higher basis than other asylums in the country. The cost per head,
exclusive of site and equipment, works out at £310 for 420 patients,
and when the whole accommodation for 600 is completed the cost will
probably come down to ^265.

London (City ).—This institution continues to receive a high propor¬
tion of male general paralytics, about 13 per cent, of the admissions
being due to that disease. No less than eight foreign nations have at
least one representative in the asylum. Dr. White attributes an
abnormally low recovery rate for the year to the fact that he had
received a large number of chronics as fresh cases and not as transfers.

Digitized by ^.ooQle

1903-]

ASYLUM REPORTS.

743

Monmouth ,—We can again point out some unusual facts concerning
general paralytics in this asylum. The new cases numbered nine, the
deaths twelve, while the remainder at the end of the year was twenty-
five. This state of affairs points to one of two conclusions—either
that the mental condition was of the quiet form which wastes but
slowly the small balance of vitality, or that the treatment was more than
usually successful in limiting this waste.

Nottingham (City ),—The following note by Dr. Powell will commend
itself to many who do not accept the theory of syphilis being necessary
to the causation of general paralysis :

With regard to the causes of insanity in the cases admitted, intemperance in
drink heads the list, and it is noted that the cases from this cause are practically
in equal proportions of the sexes, which is quite unusual in the general statistics of
the country. Side by side with this fact, it is of interest to find that a much larger
proportion of females to males are found to be suffering from general paralysis here
than in other places, which leads to the belief that there is a closer connection
between drink and this disease, as cause and effect, than is now admitted.

Curiously enough, however, the causation of insanity by venereal
disease among the females is abnormally high in comparison with the
three-year averages of the Commissioners. The figures are as follows :

Males. Females. Total.

Nottingham City Asylum—Admissions .

184

„ . „ „ General paralytics

„ ’ „ „ Alcoholics .

„ „ „ Venereal cases .

The Commissioners’ proportions (57th report) on the admissions are
for pauper cases:

Males.

Females.

General paralytics

11*2

2*4

Alcoholics .

238

Venereal cases

3 ‘i

o*8

Salop and Montgomery ,—The following is the appreciation of the late
Dr. Strange by the Visiting Committee :

The Visitors deeply regret to report the death of the medical superintendent of
the asylum, Dr. Arthur Strange, which occurred on May nth last. He was
appointed superintendent on March 18th, 1872, and the Visitors always considered
him a most valuable officer. Faithful and zealous in the performance of his duties,
he managed the asylum admirably. He died beloved by all who were associated
with him.

Dr. Rambaut, in adverting to the high mortality rate (17*91 per cent,
on average population), attributes it to influenza, which has been endemic
in the asylum for years. It and its complications claimed no less than
44 out of the 144 deaths.

We should have been glad to note more liberality on the part of the
Committee than is evinced by the grant of £20 per annum to a male
attendant who was incapacitated by bodily illness at the age of 57,
after 174 years’ service.

Digitized by v^,ooQLe

744

EPITOME.

[Oct.,

Some Irish District Asylums .

Armagh .—Overcrowding is here, as in many of the Irish asylums, a
very pressing evil. There were, at the end of the year, 506 patients in
accommodation suitable for 310 by day and 434 by night. It is
interesting to watch how the new authorities—the County Councils—
are facing the responsibilities cast on them. In this case, apparently,
no steps were being taken to provide the extra accommodation pressed
for in the preceding report of the Inspector, who now gives the County
Council straight notice that unless action is taken the Board will report
to the Lord Lieutenant that sufficient accommodation is not being pro¬
vided and maintained. One penalty will be the loss of the 4*.
grant, the payment of which can only be made on the fulfilment of
the condition precedent that accommodation is so provided. The
Inspector trusts that the Committee will reconsider their determination
to withhold the small allowance made to those attendants who hold the
Association’s certificate of proficiency.

He also states:

The condition of the new building continues satisfactory, and it is quite remark¬
able to find there—owing to their good surroundings—an almost total absence of
excitement or turmoil amongst the recent and acute cases. Undoubtedly this
block cost the ratepayers a considerable sum of money, but no one who is
acquainted with the condition of the institution before the erection of the building
referred to, can deny how soothing and beneficial is the effect which the good
accommodation and improved surroundings have on the patients occupying it.

Belfast .—In reviewing his admissions Dr. Graham strongly insists on
the fact that insanity is as much a physical disorder as is consumption or
smallpox. Of course we all recognise this; but the lay world, especially
those who have some influence over the life conditions of their areas,
cannot be told so too often, in the hope that they will look on insanity
as a disease that can be restricted by the adoption of preventive
measures.

Though this asylum is one of those which has led the way in
the great improvements that have been shown in late years, it is
paying now the penalty for past omissions and vacillation in the prime
duty of authorities—the provision of sufficient accommodation for their
insane. The Inspector reports that 101 female epileptics, suicidals, etc.,
have to be at night in an observation dormitory having 55 beds, so
that 46 mattresses have to be laid on the floor each night between the
beds. In the corresponding male dormitory things are not quite so
bad, 60 patients being accommodated in 46 beds and 14 floor mat¬
tresses. There are in the whole asylum at Belfast (excluding
Purdysburn, etc.) 741 patients in accommodation provided for 440 !
The Committee is going to build a new asylum on the villa colony
system. The general paralytics admitted are about 5 per cent, of all
admissions, while the alcoholics are about 8 per cent.

Dmvn .—The fact that in 184 admissions no history could be obtained
in six cases only is a good testimony of the industry of Dr. Nolan and
his staff in arriving at a conclusion as to causation. He in his last
report dealt with “ the far-reaching effects per se of parental alcoholic

Digitized by v^.ooQLe

1903-]

ASYLUM REPORTS.

745

excesses.” His observation, unsupported by figures, was subject to
criticism, and he now quotes with satisfaction Dr. Wiglesworth’s
presidential address and Dr. Tredgold’s researches in support of his
views. One reads with some impatience the strained and pedantic
arguments traversing the long experience of Dr. Nolan and, we may
say, the whole of asylum superintendents, who have as part of their
daily duties to inquire into these matters. We need hardly say that we
refer to the prolonged wrangle which started at the Swansea meeting of
the British Medical Association.

There are only nineteen patients in excess of standard accommoda¬
tion, and the Committee have already got plans passed for an extension
of 180 beds, which will cost less than jfeno each.

Dysentery, which is called the scourge of the asylum, claims 13*8
per cent, of all the deaths in the nine years 1894—1902. Con¬
sidering the care which, as stated above, was taken to get at the
probable causation, it is somewhat remarkable that in 184 admissions
alcohol could be traced in six cases only; hereditary predisposition
appeared in 64. Three male general paralytics were admitted.

We think it right to extract the following printed appreciation from
the Inspector’s report:

Each succeeding visit of inspection to this asylum satisfies me more completely
of the excellent management of the resident medical superintendent, and of the
amount of time and thought which he devotes to the efficient and economic
working of the institution. The difference between able and careful, and lax and
inefficient administration of an asylum means a difference of several thousand
pounds a year in the cost of management, and it would be difficult to find a stronger
proof of this fact than Downpatrick, where the resident medical superintendent,
by formulating for his Committee and the County Council an economical scheme
for providing for the chronic and harmless insane of the district, and by the minute
attention which he gives to the details of his duties, has effected a substantial
saving to the ratepayers.

Ennis .—The extension of the asylum, much called for on account of
overcrowding, is to be undertaken, and plans have been approved by
the authorities. The Inspector reports that the asylum population has
only been kept within reasonable limits by transferring to workhouses
patients who certainly are not in many instances suitable for treatment
in these institutions. Happy Clare has no general paralytics, and only
about 3 per cent, of alcoholics in the admissions.

Limerick .—Dr. O’Neill reports most favourably on the introduction
of weaving looms into the male wards, and hopes to see some instituted
on the female side. A satisfactory tweed is made for the patients’
clothing. He calls on his Committee at once to provide more accom¬
modation, and strongly urges them to extend the asylum in preference
to building a new auxiliary asylum or reconstructing workhouses, these
being the three modes of providing further accommodation allowed by
the Act. The Inspector enforces the demand by notifying the Com¬
mittee of the Board’s intention to act as stated above if steps are not
taken. The Inspector adverts to the fact that he found the temperature
in the male hospital to be 48 degrees only, and this in mid-winter.
There were no general paralytics in the asylum, and alcohol only

Digitized by v^.ooQLe

EPITOME.

746

[Oct,

accounted for about 7 per cent, of the admissions. In 30 per cent, of
all admitted hereditary predisposition was traced.

Some English Hospitals.

Bamwood. —We are most glad to read that out of the favourable
surplus of income no less a sum than ^4671 has been appropriated to
increasing the Pension Fund, which now stands at the value of
;£i 7,000. Nothing can react more strongly on the care of the patients
and the general progress of the institution than such a pledge to the
future. The rating authorities have suddenly raised the ratable value
of the hospital from ^807 to ^2030. Remonstrance succeeded in
reducing the latter sum to ^1800, with which, of course, the Committee
are not satisfied, and they will appeal again. The extra amount of
rates thus imposed would probably suffice to keep two patients. Dr.
Soutar mentions a case which recovered after five years* illness. No
improvement was seen till many stumps had been extracted and re¬
placed by artificial teeth. After that she never looked back.

Bethlem. —The number of admissions exceeded the average popu¬
lation, and no less than 43 per cent, of those admissions were on urgency
orders. This was a substantial increase on the 28 per cent, of the pre¬
ceding years, and resulted from the unusual number of acute cases
requiring immediate treatment. Forty-five voluntary patients were
admitted, and in the course of the year twenty of this class had to be
certified. Rather more than one third of the admissions had been
previously insane, and just about two thirds were recent cases of active
melancholia and mania.

Wonford House. —It is satisfactory to read that the Committee can
report their being satisfied that the institution is in a thoroughly sound
condition, and that steady progress is being made. Of the 131 patients
47 paid less than the actual cost of maintenance, while 16 others paid
less than the average income. The benefaction thus rendered is termed
“ assistance,” which is far pleasanter and truer than “ charity.” The
latter rather implies active monetary goodwill on the part of someone,
which is not exercisable in unendowed hospitals, since the means of
assistance can only be found in the excess payments of richer patients.
The recovery rate was unfortunately lower than it had been for thirty
years, but, as Dr. Deas points out, only thirteen out of the thirty-seven
presented any hope of recovery on admission. Three out of twenty
male admissions were attributed to sexual excess, but only one to
alcoholic intemperance.

Some Scotch District Asylums .

Inverness. —On the advice of Dr. Keay the District Board made
a determined effort in the direction of “ boarding out,” with the result
that sixty-five were removed in last year. Only seven were returned as
unsuitable. The inconveniences of having one hall for eating, recreation,
and public worship are commented on, and it is somewhat surprising to
read that two halls were originally provided for the latter purposes, but

Digitized by v^.ooQLe

I903-]

ASYLUM REPORTS.

747

were converted into dormitories under pressure of space, and remain as
dormitories to this day. In glancing through the statistical tables we
note that the causation in one case is attributed to general paralysis.
We have before adverted to this matter in connection with other
Scottish asylums. We conceive that it is not altogether an untenable
view that general paralysis might be deemed to be organic brain disease,
and thus returnable as a cause. But this can only be in a case where
the evidences of paralysis, such as are seen in a case of general paralysis
of the insane, are found in an absolutely sane man. The rarity of such a
combination of circumstances would justify a full history of any case in
which it existed. On turning to the next table (the form of insanity) we
find that two patients admitted are classified under the heading of
general paralysis.

Lanark .—The Commissioner reports :

A very pleasing feature in the treatment of the patients was the large amount of
interesting literature which was freely distributed throughout the institution. On
the tables in every ward there were found books, magazines, and newspapers.
Such a generous and thoughtful provision for the entertainment and the distraction
of the inmates of asylums is, unfortunately, not common. The number of patients
who were seen reading shows that the privilege is appreciated, and Dr. Kerr
stated that the number of books destroyed is not great. The arrangement added
markedly to the homeliness of the wards, and it no doubt increases the content¬
ment of the patients.

As far as we can calculate from the figures in the report, this excellent
asylum seems to have cost considerably less than £300 per bed, all the
later additions being included in the computation.

Roxburgh ,—This asylum had the misfortune to be the subject of an
expensive and fruitless lawsuit, which has demonstrated that the Secre¬
tary of State in Scotland can send a criminal lunatic to any asylum he
likes. The asylum authorities have to bear the cost of maintenance
unless they can saddle some parish with it. In this case no parish could
be thus saddled. As the asylum authorities could get no redress they
gave notice to all concerned that the patient would be discharged on a
certain day. This was done, but the report does not say what was the
after history. We are under the impression that such a course would be
illegal in England.

Dr. Johnstone gives the particulars of an escape. A man who had a
good deal of liberty absented himself for a few days and then returned
of his own accord. Later on he absented himself for six months,
working at his trade as an engineer near Glasgow. When he found “ the
outside world less kind than the asylum he came back and begged to be
taken in again.”

The assignment of 139 causes in 78 admissions betokens more than
usual energy in unearthing etiology. In nearly half the cases hereditary
predisposition was found.

Some Scottish Royal Chartered Asylums,

The Crichton ,—A specially designed sanatorium for the care and treat¬
ment of phthisical patients was nearly completed at the time of report.
It is built of wood on a brick foundation, with a slated roof. The wards

XLIX. 51

Digitized by v^.ooQLe

748

EPITOME.

[Oct,

open on verandahs for the better carrying out of the open-air treatment
There must have been reasons for preferring wood to stone or bricks;
but, unless it is intended to cremate the building after a time, those
reasons are not apparent to us. We are under the impression that
experienced authorities have assigned the marked phthisical mortality of
certain wards in old asylums to the retention of morbid elements by the
wood in floors and fittings.

Dundee .—In the report, dated June 15th, 1903, the Directors detail the
crisis through which this old institution is passing. The District Lunacy
Board has agreed to purchase the asylum property at West Green for
^90,000. A Bill to legalise the sale passed through Parliament, and
only needed Royal sanction to become an Act. Meanwhile, though
some suggested that the Directors should apply the purchase money in
small grants, the majority decided that a new asylum should be bought
or built

Dr. Rorie is a strong advocate of keeping recent acute cases in bed
for some time after admission, in parallel with the usual practice of
ordinary hospitals. He thinks that it tends in most cases to materially
shorten and mitigate the severity of the attack.

Alcohol took a very heavy toll in the causation, 39 of 87 males and
41 of 114 females being so classified.

Edinburgh ,—The delay and uncertainty in the completion of the new
City Asylum at Bangour continues to cause the greatest trouble here, the
pauper wards being so filled as to impede the admission of private
patients at the lower rates. Vigorous remonstrance led to the City
authorities providing temporary accommodation for 150 patients at
Bangour. Alcohol was assigned as a cause in 28 per cent of the admis¬
sions ; 13 per cent . of the total admissions were general paralytics. In
remarking on an outbreak here of asylum dysentery, which Dr. Clouston,
being then at Carlisle, was the first to describe as long ago as 1864, he
reports an entirely new and most important fact—two of the cats of the
wards being found to be affected with the disease. Dr. McRae will
probably publish a detailed account of the epidemic.

In the causation tables we note that of 189 male admissions no less
than 13, or 6*8 per cent '., were classified under syphilis. In respect of
44 venereal disease,” the five-year averages of the English Commissioners
give a percentage of 3*5 for all male admissions. When divided into
44 private ” and 44 pauper ” this general percentage is broken up into 6*4
and 3*i respectively. Of course, the discrepancy in this respect between
the two social states may be accounted for in part by the better chances
of obtaining accurate histories in cases arising in the upper classes;
but it is a point which claims some attempt at elucidation, if only for
the sake of science. We venture to suggest that a note in the Journal
by Dr. Clouston would be acceptable, seeing that at Momingside there
are large numbers of both classes, and both classes are subjected to the
same methods and the same energy of inquiry.

Montrose .—Dr. Havelock animadverts—and justly, too—against the
inconvenience that may occur from the present regulations for admission

Digitized by v^.ooQLe

NOTES AND NEWS.

749

1903]

of voluntary boarders. His remarks apply equally to England. He
had a personal application to be taken in from a gentleman. It was
explained that the previous sanction of the Lunacy Board was required.
The patient warned him that self-control was departing and that imme¬
diate care was required to obviate risk of danger. Dr. Havelock took
him in as a guest for the three days elapsing before official sanction was
received. Dr. Havelock suggests that this sanction should follow
admission, and this we entirely endorse. The following figures are
striking:

Males. Females. Total.

Total admissions . . 80 . 81 . 161

General paralytics admitted 5 . 6 . 11

Murray , Perth .—The laundry, which had been refitted and modernised
within the last ten years, was almost completely ruined by fire. Dr.
Urquhart points to one case among his admissions as notable:

A young man of limited education, who had harassed his mind with ill-considered
studies in philosophy and other difficult subjects. Passing on to dabble in
mesmerism with a friend of like tastes, he rapidly developed delusions of unseen
agency and of a conspiracy against his life and interests. How far the hypnotic ex¬
periments may have determined his insanity is of course an open question. I
believe, however, that these did more than merely tinge his morbid ideas, that they
constituted the determining cause—the last straw, so to speak, to overweight his ill-
directed activities.

Part IV—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

Annual Meeting.

The sixty-second annual meeting of the Association began at n a.m. on
Thursday, July 16th, 1903, at the Medical Society’s Rooms, 11, Chandos Street,
Cavendish Square, London, W. Dr. Wiglesworth, the retiring President, occupied
the chair.

Present: J. Wiglesworth, A. R. Urquhart, P. W. Macdonald, W. R. Dawson,
R. Jones, A. Miller, C. Mercier, G. Braine-Hartnell, H. H. Newington, A. R.
Turnbull, C. H. Bond, R. C. Stewart, H. Rayner, L. C. Bruce, C. K. Hitchcock,

E. B. Whitcombe, E. W. White, T. B. Hyslop, R. R. Leeper, J. P. Richards, L. R.
Oswald, N. T. Kerr, J. C. Johnstone, W. F. Farquharson, L. A. Weatherly, J. B.
Spence, C. A. Wigan, H. A. Benham, D. Blair, C. S. Morrison, S. R. Macpnail,
T. O. Wood, J. Rutherford, J. Chambers, R. J. Stilwell, D. Bower, D. G. Thomson,
R. Legge, F. Beach, F. Watson, H. G. Hill, W. L. Andriezen, G. F. Blandford,
J. K. Will, G. S. Elliot, G. H. Savage, C. Edwards, R. Langdon-Down, T. C. Shaw,

F. R. P. Taylor, 1 . E. M. Finch, D. Nicholson, J. W. Higginson, H. Barnett, H.
Corner, W. F. Menzies, F. H. Edwards, F. Edndge-Green, W. Douglas, J. Scott,
R. H. Cole, S. W. Lewis, F. W. Mott, E. F. Trevelyan, C. Clapham, M. Craig,
R. L. Rutherford, R. H. Steen, C.H. Fennell, W. J. Mickle, A. Wilson, H. Stilwell,
A. S. Newington, G. E. Shuttleworth, H. F. Winslow.

Visitors: Dr. Koch, C. E. Beevor, Sir Victor Horsley, C. L. Tuckey, W. Mel¬
ville, T. D. Savill, T. S. Meikle, J. Rorie, and Mr. Vincent Pantin.

Digitized by LjOOQle

750

NOTES AND NEWS.

[Oct,

First Day.

The minutes of the preceding annual meeting were taken as read, confirmed,
and signed.

Election of Officers and Council.

The President nominated Dr. Bond, Dr. Farquharson, and Dr. Hitchcock as
scrutineers. The list as submitted to the meeting was confirmed unanimously.

President Elect
Treasurer
General Secretary
Registrar

Editors

Auditors ....

Divisional Secretary for —

South-Eastern Division .

South-Western Division .

Northern and Midland Divi¬
sion .Bedford Pierce, M.D.

Scotland .... Lewis C. Bruce, M.D.
Ireland ..... W. R. Dawson, M.D.

R. Percy Smith, M.D., F.R.C.P.Lond.
H. Hayes Newington, F.R.C.P.Edin.
Robert Jones, M.D.

Alfred Miller, M.B.

( Henry Rayner, M.D.

. < A. R. Urquhart, M.D.

(.Conolly Norman, F.R.C.P.I.
f E. B. Whitcombe, M.B.

* i H. Gardiner Hill.

. A. N. Boycott, M.D.

. P. W. Macdonald, M.D.

Members of Council.

R. J. Legge, M.D.; T.Claye-Shaw, M.D.; H. C. MacBryan ; F. R. P. Taylor.
M.D.; Robert B. Campbell, M.B.; M. J. Nolan.

Election of Ordinary Members.

The President nominated Dr. Weatherly and Dr. Carlyle Johnstone as scruti¬
neers.

The following gentlemen were declared duly elected:—Collins, Michael Abdy,
M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant Medical Officer, London County
Asylum, Bexley (proposed by T. E. K. Stansfield, C. Hubert Bond, and John R.
Lord); Johnson, Alice Veville Vowe, F.R.C.S.I.,D.P.H.Cantab., L.R.C.P.&S.Edin.,

L. S.A.Lond., M.D.Brux., Assistant Medical Officer, Joint Counties Asylum,
Carmarthen, S.W. (proposed by Robert Pugh, F. W. Mott, and G. H. Savage);
Navarra, Norman, M.R.C.S., L.R.C.P., Assistant Medical Officer, City of
London Asylum, Stone, Dartford (proposed by Ernest W. White, Arthur E.
Patterson, and Robert Jones); Pearce, Francis Henry, M.B., B.C.Cantab.,

M. R.C.S., L.R.C.P.Lond., Senior Assistant Medical Officer, Earlswood Asylum,
Redhill, Surrey (proposed by Charles Caldecott, G. H. Savage, and Robert
Jones); Read, George Frederick, L.R.C.S., L.R.C.P.Edin., L.F.P.S.G., Assistant
Medical Officer, Hospital for the Insane, New Norfolk, Tasmania (proposed by
Norton Manning, Eric Sinclair, and W. H. Macfarlane); Rhodes, John Milson,
M.D., L.R.C.P., L.R.C.S., L.M., Ivy Lodge, Barlow Moor, Didsbury, Manchester
(proposed by J. Wiglesworth, T. S. Clouston, and G. W. Mold); Ridewood,
Harold Edward, M.B.Lond., M.R.C.S., L.R.C.P., Assistant Medical Officer, Clay-
bury Asylum, Woodford Bridge, Essex (proposed by C. T. Ewart, Philip M. A.
Green, and Robert Jones); Roberts, Norcliffe, M.B., B.S.Durham, Assistant

Digitized by LjOOQle

1903.]

NOTES AND NEWS.

75 I

Medical Officer, Cane Hill Asylum, Surrey (proposed by J. M. Moody, H. Gifford
Cribb, and Samuel J. Giffillan); Tredgold, Alfred Frank, Physician to the Littleton
Home for Defective Children, 2, Dapdune Crescent, Guildford, Surrey (pro¬
posed by F. W. Mott, H. Rayner, and Robert Jones); Turner, Oliver Polhill,
M.R.C.S.Eng., L.R.C.P.Lond., Second Assistant Medical Officer, Warwick County
Asylum, Hatton, near Warwick (proposed by Daniel F. Rambaut, A. Miller, and
Arthur W. Wilcox.

Report of Treasurer.

Dr. Hayes Newington. —The report is in the balance-sheet, which has been
circulated, and I shall be glad to answer any questions concerning it. Generally,
I may say that the affairs of the Association are going on very well. At the last
Council meeting I recommended that I should be instructed to invest £ 200 ; this
morning that has been done in Victoria Three and a Half Per Cent. Stock. I
have produced the stock receipts to the Council, and my action has been approved
by it.

The President. —The report is very satisfactory. In spite of the investment of
^200, our bank balance is *50 higher than it was at the corresponding date last
year, and I think that fact will satisfy us all.

Dr. Mercier. —Will the Treasurer let us know what the considerable increase in
miscellaneous expenses is due to ?

The Treasurer.— The amount so spent in the preceding year was £31 1 6s., and
that sum was made up of insurance, £1 65. 7 d. ; Irish Laboratory Committee,
£2 os. 4d. ; Educational Committee, £2 1 is. 4 d .; Address to the King, £y 2s. 8 d. ;
British Congress on Tuberculosis, £10 10s.; Irish Pathological Committee,
£4 is. 2d. ; Scottish Committee, ^4 4s. This year, 1902, the Irish Laboratory
Committee took £3 18s. gd. ; insurance the same as before, £1 6s. 7 d. ; Educa¬
tion Committee, 15s.; Parliamentary Committee, 15s. 5 d.; Tuberculosis Com¬
mittee, £66 19s. 3d. ; Rules Committee, ^9 3s. 6d .; Statistics Committee,
£S 5 s- 9*- J book presses for the library, £4 15s. 5 d.; handbook, £4 6s. 6d. ;
Sanitary Congress, £1 is. The large increase is due to the Tuberculosis Com¬
mittee, and there will yet be some additional expenses this year with regard to
rules and statistics.

The report was unanimously adopted.

Report of Auditors.

The Auditors reported.—We have examined the accounts of the Treasurer
seen all the vouchers, and certified them as correct.

July 1 $th t 1903.

James M. Moody, ) . ...

E. B. Whitcombs, j Auditors.

Gaskell Memorial Fund.

i 9 ° 3 * 1902.

£ s. d.

July 15 . Balance. 94 3 4 | July * 6 . Balance

1903 Dividends

£94 3 4

£ /• d.
... 49 9 3
... 44 *4 *

£94 3 4

In addition to the credit balance shown above, there was standing on deposit to the credit
of the Fund on July is, 1903 , a sum of £ 1^4 14 s. 6 J;

H. HAYES NEWINGTON, rnatunt.

Digitized by v^.oooLe

<o o

J €f

«c S 2 -?*

►* 2

II :

H Q

o -

O 2

GO b

< §

3 s

^5 •?

'©

§ o
o <

w g

* i
S g

55 “
Q o<
W

I^ES

|o o|
*.£.£ >
SJ 5 J 5 ?

^ « ® « « O so

M H«o X'OOC w

Vy •» yy<»» «o

w» ** «

i: ;

f|l ||^8

S Sc--8 5.3*,
i S ^3 3 n
S^siS 0 !.^
d o-<c£ <Sj

C ‘■gS

«j|l!!

«*•* J D 5
en 8 2 *■

««2?

5 "C?x'I

S-g s

JZ >

•« ♦s - | •*° I I ° ** *»

^ O ~ .n | ~>o | | o ♦ *■

v-sriii s

8 o

•*4 <*

5 go
2 S-8

•2 5

h ta-°
£<~

O rt _

8 ^g©

§o o-°.8

*3 S 8 C g

JO c c s*3

S«ltf

Hits

«|§83

• ®’o c<

! *=,$.2 *

fill!

Z'OtfSij

o mwi o
® ■ o**

8 ! o :

? =

i*!sl|

grill

a **%£

, j «m o d no i

Digitized by

Google

. HAYES NEWINGTON. Tmaivm*.

Oct., 1903]

NOTES AND NEWS.

753

Report of Council.

“ The past year has been one of further progress in the growth of the Association
the membership of which, at the end of 1902, was: honorary members 37, corre¬
sponding 12, and ordinary 586. The increase during the last five years has been
as follows:

1898. 1899. 1900. 1901. 1902.

Ordinary members ... 540 ... 560 ... 568 ... 580 ... 586

Honorary „ ... 38 ... 36 ... 38 ... 37 ... 37

Corresponding members 12 ... 12 ... 10 ... 11 ... 12

Totals ... 590 ... 608 ... 616 ... 628 ... 635

“ Two honorary members died during the year 1902, vis., Dr. Krafft-Ebing and the
distinguished Professor Virchow; and six ordinary members also died—Drs.
William Charles Hills, Arthur Strange, George Fowler Bodington (Canada),
George Mickley, Bonville Fox, and Neil Harrismith Macmillan.

“During the year forty-six members were elected, but in two of these the
election was voided by non-payment of subscription. Eighteen members resigned,
and six were removed for arrears. Two honorary members were elected, vi*. t
Edward N. Brush, M.D., Sheppard and Enoch Pratt Hospital, Maryland, U.S.A.,
and Sidney Coupland, M.D., F.R.C.P.,a Commissioner in Lunacy. Dr. Benedetto
G. S. Estense, M.D., of Rome, was also elected a corresponding member.

“ The papers which were read at the last annual meeting were exceedingly
interesting, those of Drs. Mott, Merrier, and Darner Harrison being well discussed.
The lantern demonstrations of Drs. Campbell and David Orr were much appre¬
ciated.

“The discussion, introduced by Dr. Clouston, in regard to the possibility of
providing suitable means of treatment for incipient and transient mental diseases,
the Council hope may result in arrangements being made for such cases in the
Edinburgh Royal Infirmary.

“ The paper by Dr. Bond has also resulted in a special Committee being appointed
to reconsider the Medico-Psychological Statistical Tables, and much work has
been done by this Committee, whose report is awaited with interest. The Council,
at its meeting in May, 1903, also expressed, by resolution, its approval of the
Committee having taken an opportunity of calling the attention of lunacy
authorities generally to the benefits which may be expected to arise from revision
of the present methods of noting and compiling data relating to the malady of
insanity. The Council notes with great satisfaction that there is a readiness in
every direction to collaborate, with a view to simplification, uniformity, and con¬
sequent increase in value, both locally and generally, of the work now done in
furnishing returns. The precise nature of the proposed alterations will presumably
be submitted for specific approval.

“The legal aspect of insanity in its early stages has been the theme of much
consideration and discussion. Sir William Gowers introduced the subject, from
the neurologist’s standpoint, at the November meeting in London. Drs. Ernest
White and Outterson Wood, with a fuller knowledge of the difficulties underlying
the proper treatment of the insane, continued the subject in a more special form
at the February meeting (this year), and afterwards at an adjourned meeting in
May.

“ Attention has been called to errors in the statistics of the Tuberculosis Com¬
mittee’s Report. The tables were submitted, under the direction of the Council,
to Dr. Tatham, of the Registrar-General’s Statistical Department, and were
corrected by Dr. Chapman, himself a statistician of high repute. The special
thanks of the Association are due to Dr. Chapman for his revision of the tables
and his comments thereon, copies of which have been distributed to every
member.

“The Parliamentary Committee has watched for legislation in respect to the
insane, and has taken action with the Parliamentary Committee of the British
Medical Association.

“ The Rules have been under discussion by the Committee appointed at the last
annual meeting, and their report will be laid before the Association.

Digitized by v^,ooQLe

754

NOTES AND NEWS.

[Oct.,

“ The Educational Committee has directed special attention to popularising the
examination for the certificate of the Association, granted to medical men for
proficiency in the knowledge of insanity, and a scheme, agreed upon by the
Educational Committee, is brought forward by Dr. Mercier, the secretary, whose
work in this direction places the Association under a great obligation to him.

“ Meetings of interest, held by the various divisions, have been well attended.
The extension of membership in some of the divisions has received the earnest
attention of the respective secretaries, and the following tabulated membership

and attendances is given for the five divisions:

Northern and South

Midland. Western.

South

Eastern.

Scottish.

Irish.

Membership ... 143 ...

109

.. 222 ..

66 ...

Attendances ... 13 ...

Nos. not

••• 35 ••

. 17 ..

(Two meetings in

each division) ... 13 ...

stated.

10 ..

. 18 ...

M The President has directed the course of the Association in a distinguished
and courteous manner.

11 The Association is under great obligation to the Editorial staff, the Registrar,
the Treasurer, Hon. Secretary, and other Officers who devote so much of their
time and influence to its interests.”

The report was adopted nem. con .

Vote of Thanks to the Council and Officers.

The President. —I have very great pleasure in rising to propose a vote of
thanks to the Council and officers. This is a vote which naturally occurs every
vear, and perhaps on that account we get into a perfunctory way of passing it.
I think that we hardly realise how much the Association is indebted to these
permanent officers for the amount of work which they do for the Association. I
do not think we quite realise how much they have to do. Until one comes to the
position which 1 have had the honour of occupying during the last year, one is not
brought into contact with the details of the Association. Referring to the work of
our Hon. Secretary, that connected with a single meeting takes up more labour
and correspondence than any one who has not paid attention to the subject has
any idea of, and the success of our meetings largely depends on the way in which
his work is carried out. And again, we know how deeply indebted we are to our
Treasurer, without whose hearty assistance we could hardly get along. Our
Registrar’s duties, perhaps, are not very arduous, but the duty requires to be
carefully carried out. And we know the immense amount of time our Editors
bestow on the work connected with the Journal. We receive our Journal every
quarter very punctually (hear, hear)—well, at all events, fairly punctually,—and
we are very apt to overlook the enormous amount of labour which is involved in
preparing it. Our Editors do this work in a very unpretending manner. And we
desire, therefore, to propose a very hearty vote of thanks to all those officers. The
Association is £oing on very well, and it is due to the large amount of work which
our officers do in the different departments of the Association that it does progress
in that exceedingly satisfactory manner.

The motion having been seconded, it was carried by acclamation.

Dr. Urquhart. —I have been asked to make acknowledgment in response to this
vote of thanks. The great joy that the officers of this Association have is in
seeing the Association prosper. We feel very much indebted to you, sir, for your
kind words.

Report on Prizes.

The President. —I am sorry to say that there are no prize-winners to announce.
That is partly due to the fact that the meeting is a week earlier this year. The
Gaskell prize examination has not yet taken place, but I understand there is a
candidate or candidates for it; therefore we hope the prize will be awarded at a
later date. 1 am also sorry that there are no essays for the Bronze Medal, and 1
would call your attention to the desirability of all assistant medical officers being
acquainted with the fact that the prize exists, and that the obtaining of it is not
merely getting ten guineas and a bronze medal, but the great honour of having

Digitized by v^.ooQLe

NOTES AND NEWS.

I903-]

755

received the imprimatur of the Association. I hope in future we shall not have to
complain that no essay has been received.

Report of Parliamentary Committee.

The Parliamentary Committee begs to report that it has sent to the Lord
Chancellor and the Commissioners in Lunacy a memorandum containing various
points which require alteration in the Lunacy Bill when it is brought before
Parliament. Acknowledgments of the receipt of the memorandum have been
received from the Lord Chancellor and the Commissioners in Lunacy.

A representation on the subject of pensions in district and parochial asylums of
Scotland has been sent to the Scottish Secretary, and an answer has been received
stating that the suggestion of the Association has been noted for consideration
with other proposals for the amendment of the Lunacy (Scotland) Acts, but that
his lordship could come under no obligation on the subject.

Three meetings of the Joint Committee of the British Medical Association and
Medico-Psychological Association have been held. A memorandum regarding
certain difficulties now existing in the Lunacy Act has been approved by the
Committee, and has been forwarded to the Lord Chancellor, together with a copy
of the correspondence between the General Secretary of the British Medical
Association and the Lunacy Commissioners. This memorandum has been acknow¬
ledged by the Lord Chancellor, and the Commissioners in Lunacy have applied for
several copies.

The Lunacy Acts Amendment (London) Bill, which has passed its second
reading in the House of Lords, the object of which is to enable the London
County Council to establish houses at which persons alleged to be lunatics may be
received for preliminary examination and treatment, has been reported to the
Committee. It was resolved that the provisions of the Bill require careful exa¬
mination, and, in some respects, amendment. It was decided to ask the Joint
Committee to take the Bill into consideration.

Dr. Urquhart: Might I ask what attitude the Parliamentary Committee has
assumed towards the Bill that is now before Parliament ?

Dr. Hayes Newington. —We considered it yesterday, but the time was too
short to go into the matter fully. The objects of the Bill—to provide reception
houses in London—seemed to be good, but one or two members of the Committee
took exception to the possibility of prolonged detention occurring under it. In
consequence of the necessity for all the members of Committee having to con¬
sider it, we thought it best to simply notify that we had got the matter in hand,
but that we could not go any further at present.

The President. —Is it your pleasure that this report be adopted ?

Carried.

Report of the Educational Committee.

Dr. Mercier. —The Educational Committee during the past year has done, as
usual, a very large amount of executive and disciplinary work, relieving the Council
and saving its time; and in addition it has remodelled the regulations for the
medical examination in the direction of popularisation, which we hope will result
in a considerable increase of candidates for that examination.

The report was adopted.

Report of Rules Committee.

The President. —The Rules Committee report is perhaps the most important
matter which we have to consider to-day. Each member has had a revised copy of
the rules sent to him, and I think that this report fully justifies the action of the
meeting last year in referring the auestion for a more detailed consideration. In
fact, all the rules have been fully discussed by the different branches of the
Association, and the Committee has had their reports before it. Dr. Urquhart,
as Chairman of that Committee, will move the adoption of the report. There are
items in it that may be taken exception to by some members, but in the general
broad outline the Committee has brought the rules into harmony with the inten¬
tions of the Association.

Digitized by v^,ooQLe

756

NOTES AND NEWS.

[Oct,

Dr. Urquhart. —The report of the Rules Committee is comprised in the print
which has been sent to every member of the Association. That print is to be
supplemented by another rule, which has been drafted by the Solicitor of the
Association, Mr. Wi^an, vig., “ Save so far as determined by statute or by the
Articles of the Association, the management and administration of the Association,
the rights and obligations of members, the duties, powers, and privileges of officers
of committees and divisions, shall be such as may from time to time be determined
by the bye-laws adopted by the annual meeting, or by any extraordinary general
meeting convened for the special purpose, provided that special notice shall have
been given in the notice convening such meeting or on the agenda paper accom¬
panying any such special notice.” You will see that is a rule which is merely
technical, and an addition to which nobody can reasonably object.

In proposing the adoption of the report of the Rules Committee, I have to
claim your indulgence in being permitted to read what I am empowered to ask
you to accept. The alterations presented for your consideration are complicated
in detail and affected by stringent legal provisions. I feel that there will be less
danger of discursiveness and less danger of omitting important points in thus for¬
mally dealing with the matter. First of all I would remind the meeting that the
rules of the Association have been cast into the melting-pot by the remit of the
last annual meeting. They were submitted to the Divisions for consideration of the
most drastic character. It was evident that the Association had outgrown its con¬
stitution ; and, while the Committee felt that a constitution which had permitted
of the great increase in numbers, and in influence, and in working capacity, such as
we have happily displayed, should not be changed lightly, yet they felt that the
instructions of the last annual meeting and the replies of the Divisions should be
acted upon with freedom and decision. But the replies of the Divisions showed
that there were differences of opinion in various localities. Local interests found
expression, although we may take it as fundamental that all were mainly concerned
with the welfare of the Association at large as well as with the rights and privileges
of individual members. Following on the best Parliamentary traditions of the
country, the Committee dealt with these differences in a spirit of conciliation and
compromise, and I trust that the result effected will commend itself to you as
wise and prudent.

The amended articles have been sent to each member of the Association,
according to the plan of last year’s Committee, thus showing the proposed additions
and proposed omissions by the style of type I pass over minor details, for the
time at our disposal to-day is very short. In the course of years, those who have
been responsible for the working of the Association have found certain weak points
in the rules which require remedy. These have been made good on the suggestion
of the officials. Further, all rules passed, after due notice, since last revision, are
now submitted in their appropriate connections. To come to the main points at
issue, included in a narrow compass, via., the feeling that the Divisions should have
greater internal freedom; that they should be fully represented on the Central
Council; that they should have act and part in the management of affairs to a
greater extent than in the past,—that was the mainspring of action ; and in order
to gratify the natural ambitions of Divisions, to stimulate them to still greater
activity for the common good, certain large changes have been embodied in the
draft now before you. While it is evident that the Association has been reinvigor¬
ated by the establishment of these local branches, and that much more is still to
be expected of them, the Committee have proposed these changes in no spirit of
hostility to existing methods of management. They are convinced that the affairs
of the Association have been administered both wisely and well; and, further,
that its prosperity has been directly due to those who have given so much time
and care and attention to the multitude of details which constantly have to be
adjusted in order to secure the smooth and well-ordered working to which we have
so long been accustomed. Now to come a little closer to the main changes which
have been proposed. Those who have followed the course of the business trans¬
acted at the divisional meetings last autumn will be familiar with the proposals
then submitted to the Committee. Briefly, the Divisions desired to appoint their
own secretaries and annually to return direct representatives to the Central
Council. The South-Eastern Division, however, requested that representation
should be proportional. That request came with some emphasis, for the South-

Digitized by

Google

NOTES AND NEWS.

757

I903-]

Eastern Division now numbers 222 members, compared with 109 in the South-
Western Division, 143 in the Northern, 66 in the Scottish, and 52 in the Irish
Divisions respectively. A rigid proportional representation would have borne
hardly upon the remoter parts of the kingdom, which are already under the
burden of geographical difficulties. Besides, the arrangements for the representa¬
tion of assistant medical officers had to be respected, and it was felt that the
Council should have power to nominate a few members for special reasons which
are continually arising in the work of the Association. Therefore, after very pro¬
longed consideration and discussion, the arrangement now presented to you was
adopted by the Committee. They have given effect to the representations of the
predominant partner, while conserving the interests of the smaller and remoter
divisions. They believe that a practical solution of the present difficulties has been
secured, and that there is now an elasticity of constitution which will permit of
future development without the necessity for again altering the relative regulations.
Although Article 65 is necessarily somewhat cumbrous in form, it is really a simple
statement of proportional representation adapted to the increase of the Association
in time to come. Consequentially, the rules are altered in important respects. The
Council is now subject to annual re-election, and the same principles of election
adopted for annual meetings must necessarily guide the elections at divisional
meetings. The essentially democratic procedure, the devolution of interests, which
was demanded by the Divisions, must necessarily apply to the constitution gener¬
ally, and similarly affect the Divisions in their internal affairs. Carrying out this
principle, it is proposed to add to the standing Committees an important committee
for nominations, but it is not calculated to cause any violent change in the conduct
of our affairs. Personally, I am certain that the proposed Nominations Committee
will issue in a practical assurance that the honours of the Association have
been conferred with sound judgment and after the exercise of conspicuous care.
Specially, in regard to the election of honorary members, your Committee have
reluctantly come to the conclusion that the number shall not exceed forty ; but they
have hedged about this roll of fame with such regulations as seemed desirable to
conserve it as a real honour, sparingly conferred. Very properly, the audit of the
accounts of the Association is relegated to members outside the Council. That
was so widely demanded that I need not urge it on your attention. I suppose that
it will now be necessary for the officials of the Association to look further ahead in
their prospective arrangements. It would seem desirable that the divisional
meetings in autumn should proceed to consider their nominations, so that the
voting papers may be prepared for the spring meetings ; also, that the dates of all
meetings should be fixed annually. If the Council meetings are to be so fixed, it
follows that the same rule should apply to divisional meetings. We require to so
arrange that the greatest possible number of members shall be in a position to
attend the greatest possible number of meetings. Annual revision will distribute
the dates to this ena. In Scotland it so happens that certain days of the month are
suitable for all, but there has been trouble in accommodating Scottish meetings, at
the last moment, to changes of date of the Council meetings. Many members can
so adjust their asylum committee work so as to fall in with Association meetings,
if only they know in time.

All this means a considerable increase in the duties of the officers of the Associa¬
tion. While it was a small affair it could well be managed on the lines of a happy
family; but, now that the various interests are enlarged and somewhat divergent,
changes must be adopted to suit the altered circumstances. I feel sure that the
officers will rise to the occasion. They have long borne the heat and burden of the
day, and you may load them still further without fear of undue complainings. At
least, that would be in accordance with my long and intimate acquaintance with
them, honoured as I have been with their valued friendship.

There remains the question of the division of the rules into articles and bye-laws
—/. e.,fundamental regulations , which cannot be altered without the troublesome
and expensive process in which we are now engaged; and temporary laws, which
may require alteration from time to time in the varying circumstances of the Asso¬
ciation. That is, obviously, largely a legal question. Your Committee has had the
benefit of Mr. Wigan’s advice in regard to these and similar details, but we could
not go to the expense of adopting that advice until the finding of the Association
is made known. Briefly, your Committee desired to have as few articles and as

Digitized by ^.ooQle

758

NOTES AND NEWS.

[Oct.,

many bye-laws as possible, and Mr. Wigan has prepared a preliminary report on
this matter, which I shall only read if desired. It is severely technical, and, in the
opinion of the Committee, must be finally adjusted by our Solicitor. Certain
Questions were also proposed to Mr. Wigan, the issue of which will be apparent in
the motion which I am about to move.

But, before I do so, I feel it to be within my right as Chairman of the Rules
Committee to make special mention of the valuable services rendered to the Asso¬
ciation in this connection by the Treasurer and Dr. Carlyle Johnstone. Dr. Hayes
Newington’s intimate knowledge of our business affairs was, of course, at our com¬
mand, but he has also devoted much time and energy to the elucidation of our legal
position. Dr. Johnstone spared no pains in critical and constructive details,
and, whatever may be the fate of the report, the Committee is largely indebted
to these gentlemen.

Finally, I have to explain that if this meeting, after due consideration, do accept
the articles as to-day submitted, it will be necessary to have two special meetings
in the autumn. At the first of these, resolutions will be proposed which, to have
the effect intended, must be passed by a majority of three fourths. At the second,
to be held about three weeks later, a simple majority suffices. I beg to explain, with
emphasis, that these formal resolutions cannot be materially altered, and that they
will give effect to the finding of this meeting if you accept these articles. Therefore,
again with emphasis, any debate must be here and now, for we ought to consider
ourselves in honour bound to carry out the intentions of this meeting in detail.

I now move that the Articles of Association of the Medico-Psychological Asso¬
ciation of Great Britain and Ireland, as contained in the report of the Rules
Committee as now presented to this annual meeting, be generally adopted; and,
further, that it be remitted to the Rules Committee as now constituted to request
Mr. Wi^an, the Solicitor of the Association, to take opinion of counsel if necessary
in so dividing the articles and bye-laws as may seem legally appropriate, preserving
the rules now adopted in their intention and scope, amending them verbally where
needful, and inserting such references as may be expedient; and also that the
Solicitor be requested to prepare resolutions appropriate to the special meetings to
be held in autumn for the adoption and confirmation of the articles and bye-laws
as prepared by him, and to lodge at Somerset House such documents and prints
as are required by law. And lastly, that the Rules Committee shall report to the
President when these matters are so far advanced as to enable him to call the
special meetings herein referred to.

Dr. Miller. —I have been asked to second the motion proposed by Dr.
Urquhart. I do so readily, although some months back I should not have risen
with any feeling of confidence to support such a motion. But after they have been
through the mill as they have been during the last twelve months, I feel sure that
this meeting will agree that further discussion will not lead to any practical good
result. These rules have been thoroughly considered; the Divisions have got—if I
may say so as a divisional man—more than they anticipated, but not more than they
were entitled to. Without further remarks I second Dr. Urquhart’s resolution.

Dr. Robert Jones. —I quite agree with everything that has fallen from Dr.
Miller with regard to the colossal task which Dr. Urquhart has had. The rules are
here for us to decide upon to-day. I was one of the earlier committee of a year ago
on these rules, and at the last annual meeting the matter was adjourned and
handed over to another committee, of which also I have been a member. The
findings of the Committee are not quite unanimous, and with your permission I
beg to call attention to one or two changes which I should still like to see made.
In the first place, regarding Rule 17.* Our Association has ordinary, corresponding,
and honorary members. At the present time we have no less than thirty-seven
honorary members. These members enjoy all the privileges of the Association
except voting; that is to say, they have notices of meetings sent to them wherever
they live—and many of them are abroad ; all the papers, including the Journal,
sent to ordinary members are sent also to the honorary members. I happen to
know the inner working of the Association, and I know that the Treasurer has a

* The numbers of the rules throughout the discussion are those submitted by the
Rules Committee , and do not correspond to the ultimate numbering of the rules.

Digitized by v^.ooQLe

1903]

NOTES AND NEWS.

759

very firm hand upon the money-bags. It is a most difficult thing to get recruits for
ordinary membership, and for every one that we see on the agenda paper of to-day
I have written perhaps half a dozen letters before the candidate came forward.
There are certain societies whose honorary members number almost as many as the
ordinary members, but I think for our Society forty is an excessive number, and I
shall be glad to propose that the number of honorary members be limited to thirty.
My resolution in that case would be, “ The number of honorary members elected
annually shall not exceed three, and the total number shall not exceed thirty.” In
future, therefore, no honorary members would be elected until the present number
be reduced to under thirty. I have no similar objection to corresponding members.
They obtain no monetary advantages, but they derive a coveted honour from
being corresponding members of our Association. I should like to see the list of
corresponding members very much amplified, and the honorary membership very
much curtailed.

The President. —It will be convenient if we take one point at a time. If Dr.
Jones will move a resolution on any point I shall ask if any gentleman will
second it.

Dr. Morrison. —May I suggest that these rules may be taken paragraph by
paragraph ? There will not be any objection to most of the paragraphs.

It was agreed to adopt this course.

The President. —We will take these seriatim:—Rule 8, agreed; Rule 9,
agreed ; Rule 14, agreed; Rule 15, agreed ; Rule 16, agreed.

Rule 17.—The number of Honorary Members elected annually shall not exceed
three, and the total number shall not exceed forty.

Dr. Jones has a resolution on this rule. I ask if anyone seconds Dr. Jones’s
resolution.

Dr. Mercier. —I second it.

Dr. Urquhart. —This is not a question that requires much discussion, and Dr.
Jones has explained exactly how matters stand. I might also say that the
American Medico-Psychological Association, numbering about 380 members, has
an honorary membership of 21 in all. Our rule permits of 40, and I am sure
that everyone here would desire that the number should be lessened. But just
consider before you vote how this is going to affect the Association. There
are 37 honorary members at the present moment. There are at least five
candidates for honorary membership at present, and you will be unable for many
years to elect any honorary member under Dr. Jones’s resolution, because you will
have to wait till at least eight of them have died before you have a vacancy for
one. The Committee considered that they could not advise the Association to
reduce the number under 40; but the matter is entirely for the Association to
decide, and you will vote now knowing the whole circumstances relevant to the
question.

Dr. Jones’s resolution was put to the meeting and lost.

The President then put the original recommendation as a substantive motion,
and it was carried.

Rule 18, agreed ; Rule 21, agreed.

Rule 26. —Upon the application of a sufficient number of Members the Asso¬
ciation, on the recommendation of the Council, may constitute a new Division
of the Association in any locality of the United Kingdom or the Colonies.

Dr. Morrison. —I beg to propose an alteration. At present it reads: “ Upon
the application of a sufficient number of members the Association, on the recom¬
mendation of the Council, may constitute a new division of the Association in any
locality of the United Kingdom or the colonies.” I propose that the words “ on
the recommendation of the Council ” be omitted. I do not see the utility of
changing this rule if the Association can only act on the recommendation of the
Council; with the Council rests the actual authority, and the Association cannot
by any independent action constitute a new Division without the recommendation
of the Council being first obtained. Let the Council retain the authority in the future
as in the past, but if a change is considered desirable, let the discretion be entirely
in the hands of the Association. The new rules are intended to advance the
authority of the Association and to widen the basis of authority, but by altering
the rule you only give with one hand and hold back by the other. The Association

Digitized by

Google

NOTES AND NEWS.

760

[Oct,

may even never hear of an application being made if rejected by the Council. I
think every application for a new Division should be determined directly by the
vote of the members of the Association without the intervention of the Council.

There being no seconder, the amendment was not proceeded with.

Dr. Mercirr. —I wish to make a very small addition to Rule 26. It runs
“any locality of the United Kingdom or the colonies,” but I think we should have
usea the words 4 * or dependencies thereof.” By the present wording we have
excluded the great dependency of India, where possibly we may wish to form a
division.

Dr. Ernest White.—I second that.

Dr. Urquhart. —Of course it would be an appropriate alteration.

Carried.

Rule 28, agreed .

Rule 30.—The dates of the Annual, General, and Divisional Meetings of the
Association and of the Quarterly Meetings of the Council for each year shall be
fixed at the Annual Meeting. All Members of the Association shall have a right to
attend any of the Divisional Meetings and take part in all business of the Meetings,
save such as refers to the internal management of the Division.

Dr. Robert Jones. —I rise to propose a modification to this rule. It is well
known to the Association that the General Secretary, whoever he may be, has the
burden and responsibility of arranging the various meetings—at any rate to a
certain extent. This Asa ciation’s meetings are not limited to London; it arranges
one of these meetings every year in the provinces. I consider that the solidarity
of our Association, and good feeling and fellowship, and the interest taken in
asylums generally, are in a great measure due to the fact that we shift our venue
from here and go to some of the provincial asylums to hold one of our quarterly
meetings. It is almost impossible for those of us who hold posts in public asylums,
as we are the servants of the committees of those asylums, to fix engagements a
year ahead. This resolution suggests that all meetings—annual, general, and
divisional—should be fixed definitely a year in advance. I plead for some change
in that regulation, a little more elasticity to allow the President and Secretary and
other officials of the Division, also our possible hosts for the time being, in the
provinces, to fix their own time to receive us. And I beg to suggest an amend¬
ment to this rule by the insertion of the words ** so far as possible ” after the word
" dates.”

Dr. Ernest White. —I have very much pleasure in seconding that. As a past
divisional secretary 1 know the importance of this, and it is absolutely impossible
to fix far ahead the dates of the annual, general, and divisional meetings absolutely
and finally. For instance, I do not know at the present time what dates my com¬
mittees will fall upon next year. I know them up to the end of December, but I
do not know after that; and it might happen if these dates were fixed that your
President would not be able to occupy the chair. That is one instance of what
might happen. I agree with Dr. Jones that there should be a certain amount of
elasticity about these dates, so that they can be adapted to the requirements of the
time.

Dr. Bruce. —As honorary secretary of a Division I cordially support the
alteration proposed by Dr. Jones, ana I hope that the Rules Committee will
accept it.

The President. —I am at one with Dr. Jones. I think that, considering the
conditions under which we live, and how we nave to adapt the dates which are at
our disposal for meetings, it will be an extremely difficult thing to arrange matters
a whole year beforehand.

Dr. Urquhart. —As business men, we prefer to know what is to be expected of
us a year beforehand at least. We have all got our fixed dates. At the beginning
of every year we know when our committee meetings are to occur, and these are
the most important fixtures for asylum physicians. But a great many members of
this Association can so modify the dates of committee meetings as to fall in with
the dates of the Medico-Psychological meetings if we know when the Medico-
Psychological meetings are going to be held, and especially when we may expect
the meetings of the Council. A representative member is bound to come up from
the country to attend these Council meetings, but he is very often prevented if he
has only a month’s or two months’ notice. If he had twelve months’ notice be

Digitized by v^.ooQLe

NOTES AND NEWS.

761

1903.]

could generally so arrange his asylum business as to attend. You have heard Dr.
Jones, and he speaks from a long experience as Secretary, laden with details of secre¬
tarial work in getting up these meetings. Very few people, except a secretary,
know how much trouble it is to arrange and so dovetail matters in as to carry on
the business of the Association with smoothness, promptitude, and regularity. If
the Association votes for Dr. Jones’s amendment they will be voting certainly to
ease the Secretaries of the Association. On the other hand, if the Association
decides that they are to have annually fixed dates, my belief is that will tend to
induce a better representation of the Association at our meetings.

Dr. Fletcher Beach. —I also have served as Secretary for a jjood many years,
and never found any difficulty in arranging good meetings within three months’
time. It seems to me absolutely impossible to arrange a year ahead. We do not
know at the present time where we are going for our provincial meeting. Since
Dr. Jones has been Secretary you have seen tne great success of the meetings. We
have had the room full every time; and I do not see why we should adopt the
yearly notice when such a good result has been achieved otherwise.

Dr. Turnbull. —I think that this is a matter for compromise, so that we may
meet the wishes of the majority of our members. Personally I sympathise with
Dr. Jones, and if he would add somewhat to his motion he will probably carry the
whole meeting with him. He does not provide for the case when, perhaps three
months after the annual meeting, some circumstance makes it desirable to alter the
dates of the other meetings. I suggest: “ That it shall be in the power of the Presi¬
dent to sanction a change of date when circumstances require it, on the application
of the responsible Secretary.”

Dr. Robert Jones. —I readily agree to that suggestion.

Dr. Hayes Newington. —I do not see the force of all the arguments which have
been addressed to the Chair and to the Committee by our officers. At the same
time, I do not suppose we can ignore them. I shall be disposed to recommend our
Chairman to accept an amendment somewhat on the lines of that proposed by Dr.
Jones, to make it the duty of the Association to fix the dates, and that those dates
shall be maintained bond fide , unless good cause to the contrary is shown to the
President. To insert just the words " if possible ” is tantamount to negativing
the proposed rule, because there will be no end of possibilities of all kinds.

Dr. Spence. —Dr. Jones’s amendment to this rule would entirely alter its
character. I suggest as a compromise that you insert the words, “ That the
dates of the meeting be decided once a year, and that should any necessity arise for
altering those dates, they may be altered on the application of tne Secretary to the
President, at least three months' notice being given of any alteration.”

Dr. Weatherley. —I second Dr. Spence’s proposal.

Dr. Robert Jones. —In arranging hospitality for provincial meetings three
months is a little too long to apply in advance. I know what it is, for I have
had several disappointments during the past seven years. Before we could meet
at any particular place there have been two or three previous applications, and
they could not be received.

The President. —What is your amendment now, Dr. Jones ? 1 think you

accepted Dr. Turnbull’s suggestion ?

Dr. Jones. —It is my original proposal with the suggestion of Dr. Turnbull.

Dr. Whitcombe. —I fully agree with the Rules Committee in regard to this
rule. I think that the rules are made for the members of the Association, and not
for individuals. I could not help thinking, as I passed through the official chair,
that anyone who is elected to such an honour should give way to the Association,
and not the Association to him. I have strongly felt that for many years, and 1
think that the Rules Committee have wisely proposed this fixity of meeting.

Dr. Rayner. —It is rather difficult for the annual meeting to fix the divisional
meetings for the year. It seems to me that is the business of the Divisions, and it
would throw a very great deal of work on the Association to appoint such a time
to suit all the divisions, some of which perhaps are not even represented at the
meeting.

A Member. —It says at the annual meeting, not by the annual meeting.

Dr. Rayner.—I withdraw my remarks.

The President. —An amendment has been proposed and seconded to Rule
No. 30, that the dates shall, as far as possible, be fixed at the annual meeting, ” but

Digitized by v^.ooQLe

762

NOTES AND NEWS.

[Oct,

it shall be in the power of the President to sanction an alteration of date on the
application of the responsible Secretaiy when, in his opinion, such a change is
advantageous."

Dr. Urquhart. —Is there no time mentioned ?

The President. —No.

The amendment of Dr. Jones was then put to the meeting and declared lost.

Dr. Hayes Newington. —It is almost a pity the compromise suggested was not
accepted. It was that the dates shall be fixed, only instead of the added words
proposed by Dr. Jones it shall be provided that should it be necessary to vary a
date the Secretary should obtain the consent of the President at least three
months before the date of the meeting. I move that.

Dr. Spence.—I second that.

Dr. Turnbull. —We have had an example this year that something less than
two months is required. The date of this annual meeting had to be changed
within a period less than the two months required by the proposed rule. And I
think that it was either last spring or the spring before that it was found desirable
to change the date of meeting of the Scottish Division, which could not be settled
till about a month before the date. Why cannot we rectify such a matter in a
Division without having to arrange it two months beforehand ?

A Member. —I second the amendment.

Carried.

The President.—I now put it as a substantive motion.

Dr. Mercier. —I propose to amend the rule further in this sense: that in the
case of a divisional meeting an alteration in date shall proceed upon the application
of the Divisional Secretary to the President.

A Member. —I second that.

Agreed.

Rule 31, agreed; Rule 33, agreed ; Rule 34a, agreed ; Rule 34, agreed ; Rule
35, agreed ; Rule 38, agreed ; Rule 41, agreed.

Rule 43.—He shall invest in securities in which Trustees are for the time being
by law authorised to invest, in his own name and those of the Trustees appointed
bv the Council in accordance with Article LXXVI, such sums of money as the
Council may from time to time direct.

Dr. Urquhart. — I would point out that it is not necessary for this Association
to have trustees under its constitution in law, and the Solicitor may alter the word
“Trustees" to "Association." The main benefit that the Association enjoys
is that it is constituted as a limited liability company, and if by some unhappy
chance the Association is sued the members are not liable for any expenses
beyond what the coffers of the Association contain.

Rule 43 a. —Two Auditors shall be appointed annually by the Association in
Annual Meeting, on the recommendation of the Nominations Committee and the
Council. These Auditors shall not be chosen from the Council, but from the
unofficial members of the Association. They shall attend such meetings of
Council as may be necessary in connection with their duties.

Dr. Whitcombe. —W’ho is to judge as to the necessity for the Auditors to
attend a Council meeting ?

Dr. Urquhart. —It is proposed that the Auditors will be requested to attend
meetings of the Council ad hoc. When they come as auditors to the Council
meeting they have no business whatever to transact, and no voting powers. They
will be present at the request of the Council to make any statement that they may
have prepared regarding the finances of the Association. There is here an attempt
to limit, so far as possible, the somewhat redundant Council of the Association.
And further, vou will note that we do not entirely depend upon our Auditors; we
really depend for a true statement of our finances upon the professional auditor,
who every year investigates the whole business of the Association in the Treasurer’s
books and vouchers. Our Auditors rather represent the Association in looking
into affairs broadly and directing the Association as to what ought to be done in
the conduct of these affairs.

Dr. Whitcombe. —I beg to move that the last clause in Rule 450 be omitted.
I think it places the Auditors in an invidious position, because they are elected by
the annual meeting, and they present their report to the annual meeting, not to
the Council. I have held the post of Auditor for a long time and see no objection

Digitized by UjOOQle

NOTES AND NEWS.

763

1903 .]

to the Auditors being excluded from the Council; but I do not think they should
be at the beck and call of the Council, as they are appointed by the annual
meeting. I

A Member.—I beg to second that.

Dr. Hayes Newington. —As a member of the Rules Committee, I think that
Dr. Whitcombe makes a very reasonable proposal, and I do not think that the
Committee saw it in that light. The idea no doubt was that the Council should
have the right to call upon the Auditors to give their account of the possible sins
of the Treasurer. It seems a little invidious, and I support the alteration.

Dr. Urquhart.—I accept it.

Agreed.

Rule 51, agreed ; Rule 54, agreed .

Rule 59 a. —All papers read at the Annual, General, or Divisional Meetings of
the Association shall be the property of the Association, unless the author shall
have previously obtained the written consent of the Editors to the contrary.

A Member.—I suggest the word “ President ” should be substituted for
“ Editors.”

A Member. — I second that.

Dr. Urquhart. —The rule as it at present stands, passed by the Association
illegally, but considered sufficiently binding to be placed before you to-day, was
modified by the Rules Committee. The rule in the British Medical Association
and other similar societies is that the consent of the Council must be obtained in
these circumstances; but we considered that the consent of the Council would
act as a deterrent, and could not be complied with in actual practice. It was
considered that, as there are three Editors, they might take this responsibility off
the shoulders of the President; that it might be rather invidious for the President,
as a single gentleman, unprotected, except by his dignity, to give a decision of
this sort, and therefore the Committee thought it desirable that the onus should
be placed upon those beasts of burden the Editors, who, I suppose, are capable
of dealing with anything which might occur.

Dr. Robert Jones. —I think this is a very sensible rule. The Association is
tied very much to its Journal. Its reputation goes side by side with that of the
Journal, and if you hand over this question of dealing with papers read before
the Association exclusively to the President there might be a case in which the
President of the Association might be the editor of another journal, and might
give easy opportunity for papers read before this Association to be printed in
another journal. I should deprecate any change in this proposed rule; I think it
is a very sensible and salutary rule.

The President. —A proposition has been made that it shall be the President,
after consultation with the Editors.

Dr. Robert Jones.—I would be agreeable to that.

Dr. Mercier. —I also concur. I have always rather objected to this power of
appropriating papers, looking at the matter from the point of view of the reader of
the paper. Other speakers have looked at it from the point of view of the Associa¬
tion. As a somewhat frequent reader of papers before this Association, it has
been my lot to read here a paper which was taken out of a chapter of a book
which I subsequently published ; and it would be exceedingly awkward to have one
chapter of a book copyrighted by one person or set of persons, and another in
another person’s name. It is an arrangement which no publisher would sanction,
and it would vitiate contracts with publishers. This is to safeguard the reader of
the paper, because we are very much indebted to readers of papers here, and I
think they deserve some consideration. Some safeguard should be raised against
a man inadvertently and unknowingly interfering with the copyright of a portion
of a book, which entirely destroys the value of that book.

The President. — I will put the amendment, which will make the rule read:
“ All papers read at the annual, general, or divisional meetings of the Association
shall be the property of the Association, unless the author shall have previously
obtained the written consent of the President after consultation with the Editors to
the contraiy.”

Agreed.

Rule 63.—He shall report to the Educational Committee and thereafter to the
Council without unnecessary delay any complaints which may be brought to his

XLIX. 5 2

Digitized by v^.ooQLe

NOTES AND NEWS.

764

[Oct.,

notice respecting the holders of the Nursing Certificates of the Association, and
shall, if instructed to do so by a minute of the Council, remove the name of any
holder from the Register, at the same time placing on record therein the reason
for doing so.

The President. —It is with the object of reducing the amount of work which
the Council has to do—sifting it out previously to bringing it before the Council.
The amended rule works very satisfactorily.

Agreed.

Rule 64 a. —The affairs of the Association shall be managed by a Council,
consisting of the Officers, who shall be ex-officio Members thereof, and at least
eighteen, non-official Members of the Association—not less than four of whom shall
be, at the time of their election, Assistant Medical Officers.

Dr. Fletcher Beach.—I should like to ask why clerical assistance to the
Registrar has been cut out; he has a large amount of work to do.

Dr. Urquhart. —By maintaining this rule as it is now, it gives the Registrar
certain clerical assistance which is apparently denied to others. It is considered
by the Solicitor of the Association that the Council, under Rule 64 a, have full
power to give any clerical assistance to any officer of the Association. “ The
affairs of the Association shall be managed by the Council,” so that Rule 64 is
unnecessary, redundant, and awkward.

Agreed.

Rule 6 5.—The number of non-official Members of Council shall be fixed at
eighteen, except as hereinafter provided, and they shall be elected annually by the
Divisions and the Annual Meeting. Each Division, as formed, shall elect two
representative Members of Council. For each complete 50 Members over 100 in a
Division that Division shall elect an additional representative; that is to say, two
representatives for 100 Members or under, three representatives for 150 Members,
four representatives for 200, and so on; provided that of the representatives
returned bv a Division of 200 Members one representative shall be an assistant
medical officer. The Council shall nominate for election by the Annual Meeting
the remaining third of the eighteen non-official Members of Council, including four
assistant medical officers, unless one or more shall have been returned a repre¬
sentative Member, in which case the Council may nominate such person or persons
as they may deem suitable. In the event of new Divisions being formed, or the
number of Members in a Division or Divisions increasing so that the representative
Members of Council are increased by two, the Council shall nominate an additional
Member for election, in order that the proportion of representative Members to
nominated Members shall approximately remain constant at two thirds and one
third respectively. No Member of Council shall be eligible to hold office for more
than three successive years, but he may be re-elected at the Annual Meeting after
that at which he retires, or at any succeeding Annual Meeting, except as provided
by Bye-law LXXVII.

The President. —This is perhaps the most important rule of all, and I think that it
has been altered to satisfy the aspirations of the most radical members of the Asso¬
ciation, and to ensure that the Association will be represented in a way in which it
has never been represented before.

Dr. Morrison.—I should like to ask a question as to representatives who have
come up from the divisional meetings. Have they to be elected again ? (“ No.”) It
says, “They shall be elected annually by the Divisions and the Annual Meeting.”
They should not be further dealt with at the annual meeting.

A Member. —I think that Dr. Morrison has some justification for his remarks ;
there is some ambiguity. If the word “ respectively ” were introduced that would
remove it.

Dr. Hayes Newington. —Twelve divisional members must be finally elected by
the Divisions, but others will have to be elected by the annual meeting.

Dr. Mbrcier. —Some are elected by Divisions, others by the annual meeting.

Dr. Turnbull. —Or that they shall be elected by the annual meeting, except as
hereinafter provided.

Dr. Morrison. —Yes, I accept that.

The President. —It is really a matter of drafting.

Agreed.

Rule 67, agreed.

Digitized by ^.ooQle

NOTES AND NEWS.

765

I903-]

Rule 68.—The General Secretary shall send to each Member of the Association
with the circular convening the Annual Meeting, a list, in the Form C appended to
these Articles, of all the Officers and Members of the Council for the year about to
expire, against the names of each of whom shall be placed the number of his
attendances at the Council Meetings in the past year, beginning with the previous
Annual Meeting.

Dr. Robert Jones.— It is known that the annual meeting does elect officers and
members of the Council. These cannot possibly attend the annual meeting at
which they themselves are elected. Their first possible attendance would be at the
next meeting in November, and consequently registration must date from that
time. If you go back to the last annual meeting, you get members who are not
elected; it is not a complete list, and it refers to parts of two different years, which,
I think, is unnecessary. In the case of those who are elected to-day as members of
the Council their first attendance will be in November. The summary for the next
annual meeting must of necessity leave out the July meeting, at which the report is
presented, because the data are not to hand, attendances not yet having taken
place.

Dr. Hayes Newington.— There is not very much in that point. Of course if
there were four meetings debited to every man and he could only attend three it
would be so, but if it is stated that there are only three Council meetings to which
the subjoined figures refer, that would cover it.

Dr. Robert Jones.— That is done at present.

Dr. Hayes Newington.— There is not much grievance.

Dr. Urquhart.—I suppose you are moving for the omission of the words
" beginning with the previous Annual Meeting ? ”

Dr. Jones.— Yes.

Dr. Turnbull.—I second that.

Dr. Urquhart.— The underlying reason is that no man gets credit for attending
an annual meeting; and what the Divisions want to know specially is how their
representatives are attending. It was hoped that, by giving credit for the previous
year in this way, that those who attend would have their names recorded. I shall
not be surprised if in a few years we find it necessary to have a meeting of the
new Council on the second day of our annual meeting. In that case there would
be no doubt.

Dr. Robert Jones.— My statement is that you are taking two years in your
statistics, and you are taking the last annual meeting of the old year and three new
meetings of another year; so you have two sets of Council members. And it is an
invidious distinction ; it is impossible for those who are elected to-day to attend
to-day.

Dr. Mercier.— It is not such a great inconvenience as the omission to record
some attendances. No doubt it is an inconvenience that there should be this dis¬
crepancy, but it is a much greater inconvenience and much more misleading to
the members of the Divisions and of the Association generally that the attendances
of members of the Council should be wrongly given.

Dr. Spence. —Would it not be well if we had two rows of figures—No. 1 row,
possible attendances; No. 2, actual attendances for two years ?

Dr. Robert Jones.—I accept that.

Carried.

Rule 73, agreed ; Rule 74, agreed ; Rule 75, agreed ; Rule 77, agreed ; Rule 77 a,
agreed; Rule 79, agreed; Rule 80, agreed; Rule 83, agreed.

Rule iot.—Standing Committees shall be appointed by the Association at an
Annual Meeting, and shall continue in office subject to any alteration in their
constitution by an Annual Meeting. They shall report to the Annual Meetings
and may report to the General Meetings. The Standing Committees shall be—

(a) Parliamentary5 (b) Educational; (c) Library; ( d) Nominations.

Dr. Robert Jones.— May I ask the reason for that ?

Dr. Urquhart.— The second half of the first sentence is inserted to cover a
possible lapse. More than once the members of this Association have been in
such a hurry to get to lunch that they did not stop to conclude the business of the
meetings; and twice it has happened that, in spite of protests, they have rushed
away without reappointing these very important committees. No one made any
overt remarks, but that is not a satisfactory way of doing business. Of course

Digitized by v^.ooQLe

766

NOTES AND NEWS.

[Oct.,

members ought to stay to the bitter end and complete the work that they are
assembled to do. This clause, therefore, has been inserted so that if by any chance
we should not have a quorum at the end of an annual meeting, these important
standing committees shall not lapse.

Agreed.

Dr. Morrison. —What is the number forming a quorum of the Association ?

Dr. Urquhart. —Ten.

A Member. —Is it not a fact that committees are appointed to remain in office
until their successors are elected ? That is a more usual form of words, and it
would cover this.

Dr. Urquhart. —The difficulty has been that a man is elected to a committee,
and there he remains, perhaps never coming to the meetings. There are some
who do not go to these meetings, but are still valuable members of committees,
doing a great deal of work by correspondence. We hope by the Nominations
Committee that we shall have these lists thoroughly revised every year; and if
members will only do their part and stay to give these formal but very necessary
votes, we shall have no difficulty.

Agreed.

Rule 103.—The Educational Committee shall be composed of those Members of
the Association who are teachers of psychiatry in the Colleges and Universities of
the United Kingdom, of the Registrar and Examiners of the Association, and of
such other Members as the Association may appoint . It * shall be entrusted with the
regulations of the Examinations for the Certificates of the Association, and such
other matters touching the teaching of psychiatry and nursing the insane as are
delegated to it by the Association or by the Council. The Registrar and the
Examiners shall be ex-officio Members of the Educational Committee.

Dr. Morrison. —May I inquire what takes the place of the provision for con¬
stituting the Educational Committee ? How was the Educational Committee
constituted ?

Dr. Urquhart. —The Educational Committee, in the embryo stage of its
existence, was a very large committee, because we thought at that time that we
ought to have every teacher of psychiatry in the kingdom directly interested in the
work, so as to bring as many fish within the net of the Association as possible. It
was done, frankly, to help the treasury as well as to urge the importance of our
specialty. This Committee is in a very different position to-day ; it is an assured
and emphatic success, and it does not require to be laden with all the teachers of
psychiatry in all the colleges and universities of the kingdom. The present constitu¬
tion really means that the unfortunate Secretary of this Committee has to send a
great many communications to men who do not take the smallest interest in the
work. Our idea is that the Nominations Committee will name the men whom they
think best qualified to carry out the intentions of the Association with regard to
education, and that they will place these names before the Association for amend¬
ment, rejection, or endorsement.

Dr. Morrison. —Is that made clear in the Rules?

The President. —It is ; in Rule 103 b. We shall come to that presently.

Dr. Morrison. —I do not think that the difficulty is removed, because the
few members who are interested in the matter will continue in office from time to
time—in fact, for all time,—because the Council has still the nomination. And the
easiest way of getting over the difficulty for the Council is to appoint the same
men. By the present rule you have a much larger field, and though occasionally
you may have some members not attending the Educational Committee Meetings
you have the advantage of their opinion and their views on any question of policy
coming before the Association. You have a certain number, not a close borough ;
but that is what we shall work to in time. You provide against that by the rule,
which has worked satisfactorily up till now, though it has given a great deal of
trouble to the energetic Secretary, whose services we value and appreciate. I beg
to move that that portion of the rule should be maintained.

Dr. Braine-Hartnell.—I second that.

* The words which the Rules Committee proposed to delete were in their
report printed in italics.

Digitized by v^.ooQLe

NOTES AND NEWS.

767

>903-]

Dr. Hayes Newington. —There is no greater curse in the intelligent manage¬
ment of any lar^e machine like this Association than having a committee over¬
large and comprising people whom you know certainly will not come at the time
they are wanted, and may turn up at the time they are not wanted. We have
experience of that, and what the President said about the work of the officers applies
to the work of the committees. 1 don’t suppose anybody knows the work which
has been done by three or four committees of this Association during the past
year. Every now and then a man attends who has not been present for a long time,
and it then becomes a question of re-converting him and wasting time in the
process. If any gentleman, by being ex-officio or by appointment, Ts on a com¬
mittee, there should be some way of removing him if he does not take up the honour
which has been conferred upon him—that is, by attendance. I think this is a
splendid omission of a number of names of those who never do attend, and who
should not appear on our lists as members of committees.

Dr. Urquhart. —I think that Dr. Morrison is under a misapprehension. The
Standing Committees, by Rule 101, are appointed by the Association at the
Annual Meeting. The Association appoints its own standing committees, and the
Association has it in its power at any time to place on these standing committees
whom it likes and to reject whom it likes. I despair of the intentions of the
Divisions and the intentions of this committee being generally understood when
Dr. Morrison says that this could possibly work out as a close borough. The Nomi¬
nations Committee are appointed directly by the members of this Association, and
if that Nominations Committee is not doing the work entrusted to it to the satis¬
faction of the Association, it is the easiest thing possible for the Association to alter
the personel entirely at the next annual meeting. The whole work of the
Rules Committee has been to make the Association an absolute democracy. (Hear,
hear.)

Dr. Robert Jones. —At the expense of being considered one of those referred to by
the Treasurer as turning up at most unwelcome times (*' No, no,” from the Treasurer),
I cannot help thinking that there must be something radically wrong in omitting
from the Educational Committee those who are in touch with the students. (No,
no.) At the previous Council Meeting we deplored the insufficient number of can¬
didates at the examination for the diploma in psychological medicine, and, as a
matter of fact, although our examinations for nurses have gone ahead enormously,
there are not half a dozen—and I do not think there is a member in this room—who
have gone in for the examination for the Diploma of the Medico-Psychological
Association. We want to popularise this examination. I speak of Dr. Mercier’s
special knowledge on this question with great deference, because he has taken great
trouble to bring up the scheme for making this Diploma attractive, and it seems to
me that if you want to {popularise this examination, you are rather cutting the
ground from under you by taking away compulsorily, as is now proposed, those who
are in touch with teaching. The omission of this clause proposed in the new Rules
seems to suggest that.

Dr. Carlyle Johnstone. —I should like to endeavour to remove the misconcep¬
tion under which Dr. Morrison is labouring, and also, I think, from which Dr. Jones
suffers. What is proposed in the amended rule is, that in future the Educational
Committee shall be placed in the same position as the Parliaments™ Committee
and the Library Committee,—that is to say, they shall be constituted of members
elected for that particular purpose. At present the Educational Committee consists
almost entirely of official members, and if any person takes the trouble to look over the
list of attendances he will see that the majority of those official members never
darken the doors of a meeting of the Educational Committee. But in future all
those Committees are to consist of persons who are especially fitted for the work of
those Committees. Whether they are teachers or not does not matter if they are
fitted for the work of the particular committee. 1 do not understand Dr. Jones*
misconception, because it seems evident on the face of it that every member who
is particularly adapted for that particular work and committee will be nominated
by the Nominations Committee, and that Nominations Committee is an essentially
popular body, representing directly the individual members of the Association.

Dr. Robert Jones. —We have already heard that a very great amount of the
work of these committees is carried on by correspondence. To cut off with a
clean sweep those who have not attended seems to be a drastic measure.

Digitized by v^.ooQLe

768 NOTES AND NEWS. [Oct.,

The President. —Dr. Morrison’s amendment is that the old rule shall replace
the rule suggested by the Rules Committee.

The amendment, on being put to the meeting, was declared lost, and the
suggested alteration of the Rules Committee was then put as a substantive motion
and carried.

Rule 103 a, agreed.

Dr. Morrison. —May I suggest that, like any other standing committee, the
Library Committee should present their report to the Association ? We should
like to know what is being done by the Library Committee, and if any useful
additions are being made to the library.

Dr. Whitcombs. —I would ask a question of Dr. Urquhart. He says you can
have a Nominations Committee which you can sweep away if you like if you are not
satisfied. I think you cannot. After you have got this approved by the Board of
Trade how can you alter it, unless you alter the Treasurer and President ?

Dr. Urquhart. —That is the way.

Rule 103 b. —The Nominations Committee shall consist of the President, the
Treasurer, the General Secretary, the Divisional Secretaries, and one of the
Editors, it shall nominate to the Council at the Meeting held at least two months
before the Annual Meeting Members for the official appointments of the Associa¬
tion, and at least one third of the non-official Members of the Council, with the
exception of the President and such nominations as are made by the Divisions.
It shall also annually revise the lists of names on the Standing Committees, and
adjust the same for the consideration of the Council. It shall also, in its discretion,
nominate as Honorary and Corresponding Members those whose names are
proposed under Bye-law 18 for the consideration of the Council.

Dr. Whitcombe. —I think that this proposed rule is a retrograde movement; it
seems to me you are taking the representation entirely out of the hands of the
annual meeting. It is all very well to say that the annual meeting has the power
to vote against the nominations which are made, but my own idea is—and I think
it is pretty general—that whenever an official body nominates there is generally a
strong feeling that they should be supported. I cannot help remembering that
twenty years ago I was sent to the Council by the vote of the assistant medical
officers—a very strong body of members of this Association ;—and I think, sir, that
the annual meeting is the only body which should deal with this matter. It is very
seldom we have many assistant medical officers here, and they should have their
voice in the general management of the Association. I am strongly of opinion
that this Nominations Committee is a great mistake. I move the omission of this
proposed Rule 1036.

Dr. Robert Jones. — I second that. I can see that this Nominations Committee
is going to swamp the “ Old Guard ; ” I believe with multiplication of Divisions you
will have the whole question of the policy of the Association decided bv the
divisional secretaries. It is rather a serious thing to place so much responsibility
in the hands of a very junior assembly—I take myself to be a little more than
junior,—but although I am General Secretary I should not desire to undertake so
great a responsibility as to decide the future policy of the Association, more
particularly as the policy concerns the election probably of President, because I
see the President-elect may be nominated by this Committee. It is a little
premature. I think we should advance festina lente in this direction. I would
much rather that the Nominations Committee consist only of ex-presidents,
via., those who have already passed the chair.

Dr. Johnstone. — I cannot agree with what Dr. Jones says. I do not take it at all
that this Nominations Committee elects anybody. Ail the rule says is that they are
to nominate the Council. If the Council do not take up the nominations so made
they must make their own, and that final nomination by the Council comes to the
annual meeting, as now.

Dr. Spence. —I have some sympathy with what Dr. Jones says, because I
feel—although I am sure you will quite understand that as one of the past presi¬
dents of the Association I am not making a personal matter of this—it would
not be a bad thing if you had some of the older members of the Association
on the Nominations Committee. (“You have.”) The President, yes; but the
President may or may not be a senior officer of the Association, and the
General Secretary may not be, nor need the past-president nor the Divisional

Digitized by ^.ooQle

NOTES AND NEWS.

1903 ]

76 9

Secretaries. I suggest that two or three past-presidents should be added to this
Committee.

The President. —We are on Dr. Whitcombe’s amendment.

Dr. Robert Jones. —The present suggestion in the new rules is a subtle
attempt to control the Association from outside, because the President-elect has
been omitted, and comes directly under the suggestion and proposition of this
Nominations Committee, consisting possibly of quite junior men, who would elect
the President. (“ No, no.”)

The President. —We are getting away from the amendment, which was that
there should be no Nominations Committee. I shall put Dr. Whitcombe’s
amendment to the meeting in the first place, and we shall see the result.

Dr. Urquhart. —It seems to be taken for granted that this Nominations
Committee is to nominate the President; but you will see that the President is
excluded.

Dr. Robert Jones. —It was the President-elect who was referred to. There is
nothing excluding his nomination by this Committee, and of course once he is the
President-elect the Presidency devolves upon him.

The President. —That is an important point.

Dr. Carlyle Johnstone. —It is moved that the whole of this proposed rule be
deleted. That would be very unfortunate. The whole point of it is that the
nominations of officers of this Association have been made in an obscure manner,
and they have been made in an unauthorised manner, because there was no law.
The nominations were obscure because no one knew how they were made. It is
proposed that in future a Nominations Committee shall be appointed, with older
members of the Association upon it, and that that Nominations Committee shall
select whomsoever seems to be a suitable person for a particular office. I do not
see how reasonable objection can be taken to that. Of course you can go back to
the old way, and have your officers selected in an unsatisfactory manner.

The President. —Do you adhere to your original amendment, Dr. Whit-
combe ?

Dr. Whitcombe.—I do, sir.

The President. —The amendment is that Rule 103 b be deleted altogether.

This was put to the meeting and lost.

The President. —I think, Dr. Spence, your idea was that the Nominations
Committee should be increased ?

Dr. Spence. —I propose that the Nominations Committee shall consist of the
President, two Past-Presidents, the Treasurer, the General Secretary, the Divisional
Secretaries, and one of the Editors.

Dr. Hayes Newington. —The two immediately preceding Past-Presidents?

Dr. Morrison. —You may have a member from outside the Nominations Com¬
mittee.

Dr. Spence. —I refer to the two immediate past-presidents.

Dr. Wratherley. —I second that.

The President. —The Nominations Committee is somewhat small, and it would
be well to increase it slightly. I will put Dr. Spence’s amendment to the meeting,—
that is to say, 103 £ as a substantive motion with Dr. Spence's amendment.

Agreed.

Dr. Turnbull. —I think the rule should be “with the exception of the
President-elect.”

The President. — I think it is a necessary point.

Dr. Urquhart. — I agree to it.

Dr. Jones. — I second that, and it is my contention.

Carried.

Rule 104/7, agreed ; Rule 107, agreed; Rule 108, agreed.

Rule no.—A notice may be served on behalf of the Association upon any
member either personally or by sending it in a prepaid registered letter through the
post addressed to such Member at his registered address in the current volume of
the Medical Register, and all such registered notices shall be deemed sufficient for
the purposes of these Articles and Bye-laws.

Dr. Mercier.— -There are some small clerical errors by the printer which
require alteration. He has put in the word " registered ” three times, when once
is sufficient. It is a pure matter of form, but this meeting ought to sanction every

Digitized by v^,ooQLe

NOTES AND NEWS.

77 o

[Oct,

alteration made in the rules. The word “ registered ” on the third and fifth lines
should come out, that on the fourth line remaining.

Agreed.

The President. —Before passing to the other business we ought to acknowledge
in a special manner the great indebtedness we are under to the Rules Committee,
and especially to the Chairman, Dr. Urquhart, for the enormous amount of time
and trouble they have spent over this matter. The result has been presented in a
very complete way, and it is a very great compliment to Dr. Urquhart and to the
Rules Committee that these complicated questions, involving a complete revision
of the constitution of the Association, have been passed with so little trouble at
this meeting. (Applause.)

Dr. Urquhart.—I am very deeply indebted to you, sir, and to you, gentlemen,
for the reception you have given to our labours, and the happy issue that has
attended them.

Library Committee.

Dr. Fletcher Beach submitted the following report and moved its adoption .—
" We beg to report that Dr. Seymour Tuke has submitted to us a list of books for
the library, from which we have made a selection, and these are now being
purchased and added to the library. We beg to ask that we may be reappointed.’'
Agreed.

Statistical Committee.

The President. — I will call upon Dr. Bond to submit his report.
Dr. Bond read the interim report, and it was agreed to.

Statistical Committee’s Report.

As a preliminary step the Committee issued a circular to all the members of the
Association in order to ascertain their views as to what alterations in the Associa¬
tion’s tables were desirable. The suggestions so obtained were duly considered at
the first meeting of the Committee. This was held in London on November 19th
and 20th last year, when Dr. Yellowlees was elected chairman and Dr. Bond
secretary.

The Committee have since held four other meetings:—February 13th at Derby,
April 22nd and 23rd at Bethlem Hospital, June nth and 12th at the York Retreat,
and yesterday in London.

But though they have thus so far devoted more than seven whole days to the
work, the subject matter has proved so extensive, and the wisdom of the work
being done thoroughly and without hurry so obvious, that the Committee are not
prepared at this annual meeting to do other than present an interim report. They
also realise that at least another year will be required before they can issue a full
report.

Their endeavour so far has been to make the tables at once simpler and more
useful. The experience of more than twenty years which have elapsed since the
present forms were settled shows that much complicated compilation, while it has
its own value, has not proved to be so generally useful as to justify the amount of
labour expended on it.

In the course of their work the Committee has been greatly impressed with the
desirability of obtaining identity of form in the statistics presented by the various
asylums and by the different Boards of Commissioners.

The Committee felt that such identity would save an enormous amount of
clerical work, and indefinitely increase the value and accuracy of the statistics, and
would make them for the first time fully available for comparison and deduction.

The Committee have been in unofficial communication with the Lunacy Com¬
missioners in each of the three Divisions of the kingdom, a procedure which has
been endorsed by the Council. They have much pleasure in reporting that the
idea was cordially received by all these Boards, and that all have expressed their

Digitized by

Google

NOTES AND NEWS.

1903.]

77 1

willingness to consider fully any suggestions made by the Committee, and to meet
them in conference if desired.

It is of course understood that no such scheme could be adopted until submitted to
and sanctioned by the Association, but the Committee hope that their present
endeavour to secure such identity of forms of statistics will be approved.

Dr. Chapman’s Report upon the Report of the late Tuberculosis

Committee.

The President. —The next point is the presentation of Dr. Chapman’s report
on the Report of the late Tuberculosis Committee, which I have been asked to
bring before the meeting. Dr. Chapman has done his work in a very masterly
manner, and this report which he has presented has added very much to the value
of the statistics collected by that Committee. I would call particular attention to
the point which he brings out with regard to indigenous phthisis, which, I think, is
a very important condition. Generally speaking, Dr. Chapman’s report justifies
some of the criticisms which were passed upon the original report as regards errors
in the tables; but, at the same time, Dr. Chapman arrived at the very satisfactory
conclusion that this report does not traverse any of the conclusions in the Report
of the Tuberculosis Committee. That is the kernel of the matter, and the fact is
that the conclusions are correct. And now the statistics are corrected we are
placed in a better position than before; and the Council proposes that this report
shall be published in the Journal, and that copies shall also be sent to the
medical journals for review, and that a certain number shall be printed and dis¬
tributed to any institutions or individuals who may desire them. I also wish
to move a very hearty vote of thanks to Dr. Chapman for his assistance in
this matter. It was no light task to go through this drudgery, and I think this
Association is extremely indebted to him for so freely spending his time over it.

Dr. Hayes Newington. —I beg to second that—not only the general remarks
which have been made by the President on the receipt of this amended report,
but especially with regard to what he said as to Dr. Chapman. Our President has
had the advantage, as others have, of seeing the work which he has done; it has
been limitless, and the cheerful way in which he has taken up that work is
worthy of our warmest thanks.

Dr. Urquhart. —Will it be an instruction to the General Secretary to record this
vote of thanks to Dr. Chapman as one of the most honoured and one of the oldest
members of this Association and to communicate our appreciation to him ?

The President. —Certainly; that is understood.

Agreed.

Elections.

Parliamentary Committee.

The President.— You will see many blanks in the attendances, but there has
been very little business before the Committtee in the last year. I shall now receive
nominations.

Dr. Robert Jones. —I should like to propose an additional name, that of Dr.
Hyslop.

A Member. —I second that. Is there any number limit ?

The President.— No.

Dr. Mercier. — I propose that the name of Dr. Claye Shaw be added. He is
not as constant in his attendance at these meetings as I should desire, but he is in
a position of greater ease and less responsibility, he proposes to take a more
active share in the proceedings of the Association, and he has expressed a wish to
take part in the labours of the Parliamentary Committee. We know that one
volunteer is worth ten pressed men. I hope that Dr. Claye Shaw will be accepted.

The President. —I am sure we shall be extremely glad to welcome Dr. Claye
Shaw.

Dr. Carlyle Johnstone. — I move that the name of Dr. Weatherly be added.

Agreed.

Digitized by LjOOQle

77 2

NOTES AND NEWS.

[ Oct .,

Dr. Urquhart.—T his is a delicate question, but it should be faced. I see, for
instance, Mr. Rooke Ley’s name. Is it possible Mr. Rooke Ley will take any
interest in the business of the Parliamentary Committee ?

The President. —Has he attended any of the meetings during the last three
years ?

Dr. Urquhart. — I cannot speak in regard to the last three years.

The President. —If he has not attended during the last three years, his name
should be deleted.

Dr. Urquhart. — I move that those who cannot show an attendance at the
Parliamentary Committee meetings during two successive years be deleted.

Dr. Hayes Newington. —That would be a little hard, I think. If you were to
make it five years it would be right enough. (No, no.) For the last two years
there has been no Bill to deal with, so as to bring the members of the Committee
together.

Dr. Urquhart. —Well, I shall say for the last three years.

Dr. Bower. —I suggest that it might very well be left to the Council to see who
the men are who do not attend.

The President. —We have to deal with it now.

Dr. Bower. —Could we not follow our previous practice of re-electing now, and
leave the delicate duty of cutting out names to the other members of the Com¬
mittee ?

The President. —We should not shirk our duty. The proposition is that those
who have not attended for three years be deleted.

Carried.

The President. —We cannot tell just now who comes under that ruling.

Dr. Carlyle Johnstone. —To avoid misconception, as Dr. Benham’s name is
unofficial, I beg to propose that Dr. Benham’s name be added to the Parliamentary
Committee.

Dr. Robert Jones. —That is understood, and I have much pleasure in second¬
ing it.

Educational Committee.

The President. —This is a very large Committee, and there are not so many
absences.

Dr. Mercier. —I suggest the omission of the name of Dr. E. C. Rogers, who
has been on the Committee for ten or twelve years and has never attended a
meeting. The same may be said of Dr. Kennedy Will. And, while I had the
pleasure to propose Dr. Claye Shaw for the Parliamentary Committee, I have the
pain to request that he be removed from the Educational Committee for non-
attendance—he has never attended a meeting of that Committee.

Dr. Carlyle Johnstone. —If these gentlemen are teachers they cannot be
removed. I beg to move that those members who have attended at least one
meeting during the past year be re-elected; and it is open to any member to
propose additional names. Those who are teachers are official members, but
there are various added members.

Dr. Robert Jones. — I have pleasure in seconding this hardy annual of Dr.
Carlyle Johnson’s,

Dr. Mercier. —There is another motion under the head of Complimentary
Motions.

The President. —I want to know if Dr. Mercier is speaking to this motion.

Complimentary Motion.

Dr. Mercier. —I rise, sir, to propose a resolution which is not on the agenda, but
when the purport of it is known the irregularity will be not merely condoned, but
applauded. Since we last met it has pleased His Majesty to confer a signal mark
of his favour and approval upon a gentleman who is regarded by everyone in this
country who has had charge of the insane for any time within the last five and
twenty years, as a true and dear friend; and I shall move that the warmest
congratulations of this Association be tendered to Sir Charles Bagot on his retire-

Digitized by ^.ooQle

NOTES AND NEWS.

77 3

1903 .]

ment from his long service on the Lunacy Commission. (Loud applause.) Among
people who know him so well there is no need for me to enlarge upon this theme,
for who is there here who' has not been impressed by Sir Charles Bagot’s
kindliness, his old-world courtesy, his unfailing patience, by the benevolence which
took all the sting out of reproof when reproof had to be inflicted, and by his rigid
sense of justice? How, among the innumerable multitude of patients that he
had to visit officially, he could remember the names and peculiarities of so many,
and discuss with knowledge their private affairs, has always been to me a wonder;
and it is no exaggeration to say that to many of them the Lunacy Commission was
summed up in his person. They looked forward to his visits, feeling that in him
they had a friend and protector; and the volume of their correspondence with him
individually must have been no small embarrassment. I beg to move that the
warmest congratulations of this Association be tendered to Sir Charles Bagot on
the honour which has been conferred upon him by His Majesty, and that this Asso¬
ciation trusts that he may long enjoy his well-earned leisure.

The President. —I am sure we shall all agree with that.

The motion was carried by acclamation.

The meeting then adjourned.

The meeting having reassembled at two o’clock,—

The President. —Gentlemen, there is only one duty for me to perform, and
that is the pleasing one of vacating this chair and handing it over to my suc¬
cessor, Dr. White. Dr. White requires no word of introduction on my part. He
is well known to you all who are of our specialty, and I am confident he will fill
the chair with great credit to himself and with honour to the Society.

Dr. Ernest W. White then took the chair.

Vote of Thanks to the President.

Dr. Savage. —Mr. President, this is the first time I have had the honour of
addressing you as President, and my first duty is a very pleasing one, and that is
to express my own personal thanks, and the thanks of the Association, to the late
President, Dr. Wiglesworth, for the most efficient way in which he has carried out
the affairs of the Association. Nothing could have been better than the way in
which he has presided over the general meetings, and dealt with the very large
amount of work that does not appear on the surface. In saying good-bye to
Dr. Wiglesworth I am sure we all feel that he has done his work thoroughly well,
and we wish he may have a good and recreative holiday. And even though he
does not visit the wilds of St. Kilda and study birds, and risk his neck in the
process, one is sure that his healthy general tastes will enable him to enjoy the
retirement from his official work. I will not detain you further except to express
most heartily the thanks of the members for the kind and efficient way in which
Dr. Wiglesworth has performed the duties of President.

Dr. Spence. —Mr. President, I have been asked to second this vote of thanks to
the outgoing President. I would look upon Dr. Wiglesworth’s career from another
point of view than that from which Dr. Savage regarded it, that is not altogether
in his professional capacity or as President of this Association, but as a man, and
as the individual whom we all delight to honour in his private capacity. When he
commenced his career as President of this Association by the magnificent reception
he gave us at Liverpool, we felt sure we had the right man as President, and
during the time he has filled the chair he has shown so much kindness in his
dealings with fellow-members that he leaves with the most affectionate regard of
every member of the Association with whom he has come in contact. It gives me
very great pleasure in seconding this vote of thanks.

Carried by acclamation.

Dr. Wiglesworth. —I thank you very heartily, Dr. Savage and Dr. Spence,
for the manner in which you have referred to my poor services. It has been
exceedingly gratifying to me that you should have expressed yourselves as you
have done. When I was first asked to take the Presidency I felt considerable
diffidence, but I have had such hearty and loyal support on all hands in the Society
that my work has been helped tremendously, especially by Dr. Jones and the Hon.
Treasurer. The careful way in which gentlemen have lent themselves to the work

Digitized by v^.ooQLe

774

NOTES AND NEWS.

[Oct.,

has made the task exceedingly light. I shall always look back to my period of
office with great pleasure. A great honour was bestowed upon me by putting me
in the chair.

The President. —We have several distinguished visitors from the United
States, whom I am sure you will welcome here to-day. (Applause.)

The President (Dr. Ernest White) then delivered his presidential address (see
page 587).

Dr. A. R. Turnbull opened a discussion on “Female Nursing of the Male
Insane ” (see page 629).

Second Day.

Dr. Mott gave a lantern demonstration on “Tumours of the Brain in Asylum
and Hospital Practice.” The publication of this contribution has been unavoidably
postponed.

Dr. Bruce read a paper contributed by himself and Dr. Peebles, entitled
“ Clinical and Experimental Observations on Hebephrenia and Katatonia ” (see
page 614).

Dr. Charles H. Fennell read a paper on “ Mongolian Imbecility.”

Dr. Albert Wilson contributed an account of “ A Case of Double Conscious¬
ness " (see page 640).

Council and Committees.

In connection with the Annual Meeting there were meetings of Educational,
Parliamentary, Rules, and Statistical Committees. The Council met on July 16th,
The following members were present:—

C. H. Bond, G. Braine-Hartnell, L. C. Bruce, C. K. Hitchcock, M. Craig,
W. R. Dawson, H. Gardiner Hill, Robert Jones, P. W. MacDonald, C. A. Mercier,
A. Miller, H. Hayes Newington, H. Rayner, R. L. Rutherford, J. B. Spence,
R. C. Stewart, A. R. Turnbull, A. R. Urquhart, E. B. Whitcombe,E. W. White,
J. Wiglesworth (chairman).

The usual official reports were received and dealt with.

IRISH DIVISION.

The Summer Meeting of this Division was, by the kindness of Dr. T. Drapes,
held at the Wexford District Asylum, Enniscorthy, on Friday, July 3rd.

The morning was occupied by a visit to some places of interest in the neighbour¬
hood, notably the historic Vinegar Hill, after which the members present inspected
the asylum, and a number of interesting cases were demonstrated.

The members were entertained to luncheon by Dr. Drapes, after which the
meeting took place.

Dr. Drapes occupied the chair, and there were also present Drs. Conolly Norman,
M. J. Nolan, R. R. Leeper, J. J. Fitzgerald, H. M. Eustace, F. J. Kennedy, and
W. R. Dawson (Hon. Sec.). Apologies for non-attendance were received from
Drs. Oscar Woods and R. L. Donaldson.

The minutes of the previous meeting were taken as read and signed, the essentials
having already been published in the Journal.

Letter.

A letter was read from Dr. Seward, of Colney Hatch Asylum, thanking the
members of the Irish Division for the vote of sympathy passed by them at their last
meeting. It was directed that it should be entered on the minutes.

Date and Place of Next Meeting.

It was decided to hold the next meeting of the Division in November. An
invitation from Dr. R. R. Leeper to meet at St. Patrick’s Hospital, Dublin, on that
occasion, was unanimously accepted with thanks.

Digitized by v^.ooQLe

I903-]

NOTES AND NEWS.

775

Election of Ordinary Member.

The following was unanimously elected: P. O’Doherty, B.A., M.B., B.Ch.,
B.A.O.(R.U.I.), Assistant Medical Officer, District Asylum, Omagh (proposed by
Drs. Conolly Norman, J. M. Redington, and W. R. Dawson).

Motion.

The following motion was brought forward by Dr. M. J. Nolan :—“ That
inasmuch as the Lord Lieutenant has appointed a Commission inter alia 'to
inquire and report whether any, and what, administrative and financial changes are
desirable in order to secure a more economical system for the relief of the sick, the
insane, and all classes of destitute poor in Ireland, without impairing efficiency of
administration,’ it is expedient for the Irish Branch of the Medico-Psychological
Association to confer on the points affecting the insane, and, if it be deemed
necessary, to formulate the expressions of their special experience on such
important matters.”

Dr. Conolly Norman seconded the motion, and in the course of the discussion,
which was also joined in by Dr. R. R. Leeper and the Chairman, a letter was read
from Dr. Oscar Woods. Finally the motion was put to the meeting and passed
unanimously.

A small committee, consisting of Drs. Nolan, Leeper, Norman, and the Hon.
Secretary, was appointed to give effect to the resolution.

Communications.

i. Dr. Conolly Norman brought forward a communication entitled " The
Unpardonable Sin as Obsession,” in which he touched upon the nature of
obsessions in general, drawing attention to their connection with morbid impulse,
hallucination, and melancholia; and then gave a number of cases bearing upon the
particular form of obsession under discussion.

Dr. Drapes said he found it difficult to obtain an exact definition of the term
“obsession,” which was not mentioned at all in most of the text-books; but he
took it to mean the same as 11 imperative conception.” Such he considered to be,
not a separate form of mental disease, but merely stages in the development of
delusions, and he did not know that there was anything special in that concerning
the unpardonable sin. As for confounding obsession with melancholia, he did not
think that possible, as it was in his opinion merely a symptom of melancholia.
Again, Dr. Norman had spoken of psychical anaesthesia as accompanying obsession,
but he thought the case cited, in which the patient was greatly distressed by the idea
that she had been unkind to her sister, did not bear out this contention. The case
which resulted from a disappointment in love was an instance of the well-known
association of erotic and religious ideas in the insane ; and although the reason for
this association was not obvious, he thought that if we could know all that was in
the patient’s mind a connection would be found. As regarded the unpardonable
sin, sane persons often had the idea that they had committed it, but it was
especially in melancholia that this idea arose.

Dr. Nolan did not agree with Dr. Drapes that obsession was merely a phase of
any form of mental disease, and thought the cases detailed by Dr. Norman were
remarkably striking examples of the evolution of obsession, illustrating particular
phases of it. The idea of having committed the unpardonable sin was limited to
the members of certain religious bodies, and Roman Catholics and Methodists,
owing to their particular religious beliefs, were free from it no matter how depressed
they might be.

Dr. Norman, in replying, defended the use of the term “ obsession ” on the
ground of convenience. He said that the distinction between obsession and
melancholia could not always be made in practice, but theoretically the difference
was that whereas the melancholic patient is persistently depressed and under the
influence of melancholic insane ideas, the patient suffering from pure obsession is
not persistently depressed; his general and emotional state may be unaffected, and
his mind lucid. He resists the continual intrusion of the idea or word into his
thoughts, and is acutely conscious of his mental state, but not necessarily melan-

Digitized by v^.ooQLe

776

NOTES AND NEWS.

[Oct,

cholic. Obsession was an elementary disturbance in the sense of personality, but a
very common condition apart from ordinary insanity. Such cases were seen
oftener in private practice than in asylums, and although they seemed to be
trembling on the verge of melancholia they did not pass it. Obsession, however,
sometimes ended in fixed delusion.

2 . Dr. R. R. Leeper read a paper entitled “ Notes on the Treatment of Acute
Cases' 1 (see page 689).

3. Dr. Dawson read “ Notes on two cases illustrating the difference between
Katatonia and Melancholia Attonita ” (see page 686).

Vote of Thanks.

A vote of thanks was passed to Dr. Drapes for his kind hospitality, and he
having responded, the proceedings terminated.

BRITISH MEDICAL ASSOCIATION.

Annual Meeting, Swansea, 1903.

Section op Psychological Medicine.

President: Robert Jones, M.D. Vice-Presidents: J. Glendinning, M.D.,
Edwin Goodall, M.D. Hon. Secretaries: R. S. Stewart, M.D.; R. H. Cole, M.D.,

The section was well attended, and the papers read were fully discussed.

President’s Address.

Dr. Robert Jones delivered an address on " The Development of Insanity
in regard to Civilisation,’* and demonstrated that with the progress in civili¬
sation mental breakdown became more serious and more frequent, and the
varieties of insanity were more chronic and less curable now than when life was
simpler and men more content. The care and cure of the insane was hardly
known as a subject of serious study 100 years ago. The last century had been
the most marked of any of its predecessors in regard to the material, mental, and
moral progress of mankind ; yet this advance had not been without sacrifices, for
in the struggle that civilisation entailed the path of progress had been freely
strewn with mental wreckage and physical degeneration.

As to what constituted insanity, delusions or hallucinations alone did not
suffice, neither was it exclusively an intellectual disorder. Exaggerations and
fluctuations of normal tendencies rendered individuals unstable, untrustworthy,
and even dangerous, yet there might be hardly any loss of mind; nevertheless
they were fit and proper persons to be detained in asylums; many of these cases
were born constitutionally insane.

In primitive states of society insanity was rare, though idiocy and imbecility
might be as prevalent, and the tendency to dementia was quite uncommon. The
progress of mankind had caused a more or less complete change in the types of
insanity during the past half-century. An inherited instability of nervous organi¬
sation was more frequent to-day, being responsible for more than one third of all
occurring insanity. Amongst the causes of insanity both physical and mental
stress had to be reckoned with. Charles Booth, in a recent publication Life and
Labour of the People , had stated that the anxieties and uncertainties of pro¬
fessional life in the middle and lower classes were responsible for a very large
proportion of insanity, which was to some extent due to loss of trade affecting
bodily health ; that provided wages were regular, although low, and there was no
nervous strain, the tendency to insanity was slight. In their efforts to rise to the
higher level of work and capacity demanded by modern civilisation, many failed
owing to mental, physical, or moral deterioration. Civilised society, in forcing the
pace, manufactured its own unfit—its lunatics, paupers, and criminals. London alone,
in this respect, was responsible for the production of over seventy insane persons

Digitized by v^.ooQLe

NOTES AND NEWS.

777

1903 .]

per week, and this number was apparently destined unrelentingly to increase. The
only neutralising agency was the fact that sterilisation followed in the wake of
three or four generations of town-bred people—a natural law which ensured that
the unfit should cease to encumber the earth. In cities, where the population had
to accommodate itself to the pressure of competition, the tension of mind was more
continuous; artificial desires multiplied, unhealthy activities were created, and
ambition further forced the overwrought brain. Kraepelin had shown that
muscular exhaustion weakened brain power in definite curves and ratios. It was
not, however, overwork so much as worry and anxiety which caused actual
insanity. Civilisation brought to the idle rich sensuous luxuries of all kinds; and
to the poor lack of proper food, overcrowding, unsuitable surroundings both
moral and hygienic, alcoholic indulgence, poverty, and crime, all of which bore a
very intimate relation to insanity. Overcrowding led to physical discomforts and
gave rise to facilities for moral contamination. Crowds of the dwellers in slums,
stifled by the unattractive nature of their environment, sought to drown their
misery in alcohol. One fifth of all the cases of insanity occurring in men, and more
than half this proportion in women, were due to alcoholic intemperance. The
crowding into towns of the country dweller had contributed to the deterioration
of the physique of the nation in spite of the progress of sanitation, and deaths from
cancer and nervous diseases had markedly increased. Athleticism must be
regarded as a corrective of neurotic heredity, but if carried to excess must be
attended with the danger of areterial overstrain, which was harmful to future
generations. The present system of education had doubtless raised the general
intelligence of the community, but it had a tendency to destroy individuality, and
promoted useless cramming. Altruism had lessened and selfishness increased,
charity being doled out with less liberality than heretofore. Legal statistics
showed that certain offences were increasing; that marital inconstancy was more
frequent, and that there was a laxity of morals amongst women, especially of the
** smart setthat commercial morality had declined, as evidenced by the number
of crimes of embezzlement and betrayal of trust; and that gambling, especially in
women, was becoming more general.

Syphilis was probably more common now than it was a century ago, and the
increase of general paralysis of the insane—a result of syphilitic disease of the
nervous system—pointed to the increasing ravages of the virus. Fanatics and
faddists had raised'such “conscientious objections” that there was but little hope
of limiting the spread of syphilis by legislative regulation of contagious disease.
Dementia praecox—a disease rare at the beginning of last century—was now as
common as it was incurable, attacking some of the most promising of our youth
who had succumbed to the existing mental overstrain. There was also an increased
tendency to melancholia, especially amon^ the educated and private class, with a
less favourable prognosis than occurred in mania. The recovery rate therefore,
from a combination of causes, had fallen pari passu with the alteration in the types
of occurring insanity, which had been one feature in the production of the increase
in insanity. Spiritual influence and the education of public opinion should be
promoted to prevent the extension of lowered mental and physical vigour in our
civilised communities.

The Pathology of General Paralysis.

Dr. W. Ford Robertson, pathologist to the Scottish Asylums, opened a
discussion on this subject, illustrated by lantern demonstrations. He stated that the
pathogenesis of general paralysis was still unknown with anything like accuracy, and
that therefore we had no right to conclude that it would always remain incurable.
The syphilitic origin of the disease, though held by the majority of neurologists at
the present day, was not yet sufficiently proven. Against the essentially specific
theory was the fact that many observers had seen or reported cases of general
paralysis in which syphilis had not previously occurred, congenitally or otherwise,
and that many cases were now known in which the virus was contracted after the
onset of the symptoms of general paralysis. Although statistics might show a high
percentage of antecedent syphilis in cases of general paralysis, the fact was
incontrovertible that only a very small proportion of syphilised persons ever
developed general paralysis or tabes dorsalis, and that therefore the doctrine—no

Digitized by v^.ooQLe

77 «

NOTES AND NEWS.

[Oct,

syphilis, no general paralysis—could not be entertained. Similar statistical evidence
could be adduced showing that very high percentages of persons affected by tuber¬
culosis had previously had measles, yet they did not believe any direct causal
relationship existed. Moreover the syphilitic hypothesis did not explain the
established fact that there were other conditions, such as chronic alcoholism, lead¬
poisoning, and excessive meat diet, which favoured the development of general
paralysis. Post-mortem examination of the non-nervous organs or tissues of the
body in cases of general paralysis showed that an active bacterial toxaemia was
present. Dr. Lewis Bruce and Dr. Robertson had directed attention to the gastro¬
intestinal disorders that occurred in cases of general paralysis, and had published
their belief {Brit, Med. Journ. t June 29th, 1901) that general paralysis was
dependent upon a toxaemia of gastro-intestinal and bacterial origin; but Dr. Bruce
had since modified his view so as to regard toxic infection by the Bacillus coli as a
secondary or terminal infection. More recently Dr. G. D. MacRae, Dr. John
Jeffrey, and Dr. Robertson had advanced the hypothesis that general paralysis was
the result of a toxaemia dependent upon the excessive growth of bacteria, not
onlv in the alimentary canal, but in the nasal tract and throat; and especially that of
a diphtheroid bacillus, which gave the disease its distinctive characters. The
recognised causes of general paralysis—syphilis, etc.—appeared to act as stimulants
of the leucoblastic tissue of the bone-marrow, or directly damaged this tissue, so
that the defences of the body against the invasion of bacteria were diminished or
damaged. The protective functions of the body were thus impaired, and in such
circumstances the bacteria normally present as saprophytes assumed a pathogenic
character by reason of the protective forces of the body being weakened. The view
was advanced that the special infective agent was an attenuated form of the Klebs-
Ldffler bacillus. The symptoms during life and the appearances post mortem were
all in favour of the hypothesis of bacterial infection. Cultures were made in post¬
mortem examinations of twenty cases of general paralysis, the nasal or intestinal
contents being used for this purpose. In seventeen of these cases, in addition to
other bacteria, the diphtheroid bacillus was found in the cultures, whilst in the
remaining three the bacillus was found by other means of detection. In eight out of
the twenty cases this diphtheroid bacillus was found in very great numbers. A
recent senes of cultures from the secretions of the nose and throat of ten general
paralytics in the Edinburgh Royal Asylum showed that the diphtheroid bacillus was
present in nine cases. Out of sixteen cases of general paralysis where cultures were
made from the brain post mortem , four showed the presence of the diphtheroid
bacillus. The bacillus in these four cases must have obtained an entry either by the
blood or by local infection through the nose. Experiments had been made with the
diphtheroid bacillus introduced into the alimentary canal of rats with positive
results—showing changes in the nerve-cells of the brain. The whole body of facts
therefore supported the view of the specific bacillary origin of general paralysis of
the insane.

Cavities in the Spinal Cord.

Dr. R. S. Rows, pathologist to the Lancashire County Asylum, Whittingham
read a short paper and exhibited lantern slides illustrating three different cases in
which cavities in the spinal cord were found. In the first of these the cavity formation
was due to atrophy of the nervous tissue and neuralgia, in the second to syringo¬
myelia, and in the third to haemorrhage into the perivascular spaces and substance
of the spinal cord.

Alcohol in its Relation to Mental Diseases.

Dr. Theo. B. Hyslop opened the discussion on this subject, and read a paper on
the relationship of alcohol to physical and mental processes. He maintained that
the rdle of alcohol in the healthy body was more harmful than good, and that its
use was abuse. In debilitated and neurotic persons its use was comparable to a
loan raised at a heavy rate of interest, which might be employed to cope with
immediate and pressing needs, but which constituted a heavy burden on the bor¬
rower until repayment was completed. Alcohol produced an illusory sense of
well-being and of mental energy and capacity without in any way enhancing
mental power. On the contrary, it tended to lower the ability of performing the

Digitized by v^.ooQLe

NOTES AND NEWS.

779

1903 .]

more complex actions, both physical and mental. Alcohol caused acceleration and
confusion of ideas, and stimulated the subject to restlessness and over-action. The
vascular system reacted to the presence of alcohol by vaso-dilatation and by
increased exudation of lymph into the perivascular tissues, and in chronic
alcoholism characteristic morbid changes were produced in the brain. The in¬
creased exudation of lymph from the blood-vessels carried with it an increase in
the number of extravasated leucocytes which thereafter underwent dissolution.
Alcohol also acted deleteriously by absorbing oxygen from the blood-corpuscles or
plasma, depriving the nerve-cells of normal oxidation processes. The effect of
alcohol on the renal organs and the action of defective elimination on the cerebral
tissues were also referred to. The neuron theory was discussed and the co-ordinate
relationship shown between the microscopic changes found in the brain of chronic
alcoholic insanity and certain psychological phenomena, more especially amnesia
and slowness in reaction-time. He did not consider that alcohol per se caused
general paralysis of the insane.

Human Evolution with Especial Reference to Alcohol.

Dr. G. Archdale Reid, of Southsea, read a paper embodying propositions from
which he concluded that alcoholism in the parent did not prejudicially affect offspring.
He submitted that human individuals differed in their power of resisting diseases,
and that the progeny tended to inherit this parental power or weakness. As races
in bygone years had been addicted to excessive use of alcohol and had become
temperate by the elimination of the unfit, so in individuals drunkenness in the
ancestry might be regarded as the cause of temperance in the descendants. He
considered that more definite proof was needed to support the view generally held
that alcoholism in the parents produced degenerate offspring.

The Action of the Blood Serum from Cases of Mental Disease upon
the Bacillus coli communis .

Miss Alice Johnson, of Carmarthen Asylum, read this paper (contributed
jointly with Dr. E. Goodall), illustrated by charts. The examination of twenty-five
cases of insanity showed that in 60 per cent, of the cases the blood serum caused
agglutination of cultures of the Bacillus coli. A leucocytosis count was made in
cases of insanity, and it was found that leucocytosis was high in acute mania, or
when patients were passing through acute exacerbations, whereas in states of remis¬
sion and of recovery the leucocytosis tended to fall. The observations showed
that the Bacillus coli communis was an important source of toxaemia in certain
forms of insanity, and that the study of leucocytosis was valuable as an index of
exacerbation, remission, or recovery'.

The Nature of Fragilitas Ossium in the Insane.

Dr. W. Maulb Smith, pathologist to the West Riding Asylum, Wakefield,
contributed this paper, in which he stated that undue fragility of the bones in the
insane was commonly met with after middle life, the ribs being mostly affected.
An analysis of 200 cases from the post-mortem records of the Wakefield Asylum
was made, the investigation consisting of an estimate of the breaking strain of a
rib as tested by hand; and a microscopical examination was made as to the condi¬
tion of the Haversian spaces. It appeared that dementia, chronic melancholia,
chronic mania, and general paralysis showed an undue fragility of bones in 77*7
per cent., 76*4 per cent., 66*6 per cent., and 657 per cent, respectively. In epilepsy
22 per cent, of cases exhibited fragility of bones, whilst in idiocy and imbecility
there was practically no fragility at all. He concluded from these observations that
fragility of bones in the insane was rare below the age of forty-five, except in cases
of general paralysis, and that, associated with this fragility, degenerative changes
were to be met with in the posterior root-ganglia of the spinal cord.

Some Slighter Forms of Mental Defect in Children, and their

Treatment.

Dr. G. E. Shuttleworth, in reading this paper, referred especially to his
experience of three years as examiner of children for admission to the Special
VOL. XLIX. S 3

Digitized by LjOOQle

780

NOTES AND NEWS.

[Oct,

Instruction Schools of the London School Board. Many of the lighter shades of
mental defect were observed, corresponding to the more pronounced types. These
included : submicrocephalic cases with head measuring circumferentially not more
than 18 or 19 inches (7 per cent.), large heads suggesting hydrocephaly (3 or 4
per cent.), mongoloid cases of weakmindedness (2 to 3 per cent.), scrofulous cases
(over 10 per cent.), cases with cerebral or spinal paralysis (about 2 per cent.),
cretinoid cases (2 to 3 per cent.), syphilitic cases bearing characteristic stigmata
(about 1 per cent.), and a few cases of post-febrile or traumatic origin. There was
a large group of cases which could only be characterised as “ neurotic. 1 ’ Of the
epileptic cases 17 per cent, were estimated as fit to continue in ordinary elementair
schools. Rickety skulls were met with in pauper children, and sometimes in well-
to-do families who brought up their children on artificial foods.

The Classification of Insanity.

Dr. Mercier read a paper on this subject, and drew attention to the distinction
between psychological forms and true varieties or types of insanity. The former
comprised various symptoms—depression, exaltation, etc.,—whereas the latter were
comparable to diseases—general paralysis, alcoholic insanity, etc.—which ran a more
or less definite course, in which the former symptoms occurred from time to
time. He advocated the classification by types as published in his recent Text-book
on Insanity.

The Care and Treatment of Incipient Insanity.

Dr. Ybllowlres opened the discussion on this subject with a paper in which
he regarded the term incipient insanity as the mental condition during the period
between the first manifestations of mental disorder and the development into
certifiable insanity. He also included cases of insanity where the insanity, although
obvious, was of recent origin, and had not become permanently established. The
general indications for treatment were removal as far as possible of the cause of
the disorder, removal of the patient from existent surroundings, experienced
nursing, wise medical treatment, pleasant companionship, good food, sufficient
occupation, and suitable amusements, with discrimination and judicious applica¬
tion of the same. Dr. Yellowlees also dealt with the accommodation and size of
asylums for recent and acute cases, and with the question of mental wards in
general hospitals. He considered that any institutions, whether called “ reception
houses ” or by other names, which received incipient cases of mental disorder for
care and early treatment, should be under the jurisdiction of the Commissioners in
Lunacy, and the resident physician by whom the cases were to be examined should
have had wide experience of insanity in all its phases.

The Use and Abuse of Psycho-therapeutics.

Dr. A. T. Schofield, of London, read a paper urging the necessity of greater
attention to the subject of psycho-therapeutics, which in the hands of unscrupulous
persons brought discredit on the profession, to the detriment of the public in
general.

The Relationship of Wage, Lunacy, and Crime in South Wales.

Dr. R. S. Stewart, of Bridgend Asylum, read this paper, which was of marked
local interest.

Owing to lack of time the following, among other papers contributed to the
section, were taken as read, vie. :—“ The Premature Dementia of Puberty and
Adolescence,” by Dr. Andriezen ; ” The Relation of Hysteria to Insanity,” by Dr.
Edridge-Green. The meeting concluded with the passing of a resolution that the
name of the section should be the Section of Psychological Medicine, the name
adopted for it at a meeting of the Council a year previously, and that the attention
of the Council should be drawn to this matter.

Digitized by

Google

1903.]

NOTES AND NEWS.

7 8 i

OBITUARY.

Frederic Norton Manning, M.D.St. And., M.R.C.S., L.S.A.,
Sydney, New South Wales.

We deeply regret to record the death of Dr. F. N. Manning, of Sydney, New
South Wales, which took place on June 18th, after a lingering illness, in his
65th year. The following notice from the pen of one who knew him well, and
which we fully endorse in all that eulogises his character and work, appeared in
the British Medical Journal of August 1st, 1903 :

Frederic Norton Manning was born at Rothersthorpe, in Northamptonshire, in
the year 1839. He studied medicine at St. George’s Hospital, and in i860
obtained the diploma of the Royal College of Surgeons of England and the
Licence of the Apothecaries’ Hall in London. Two years later he obtained the
degree of M.D. from the University of St. Andrews. Having got an appointment
as surgeon in the Royal Navy, he served on H.M.S. “ Esk,” and saw considerable
service in New Zealand during the Maori war.

In 1867 there were only two asylums for the insane in New South Wales, and
the management of them and of the patients within their walls is said to have been
atrocious. Sir Henry Parkes, who was at that time Premier of the Colony,
recognised the urgent need of a complete reform. Happening to meet Manning,
whose ship, the “ Esk,” was then in Sydney Harbour, he was so impressed with his
character and abilities that he offered him the task of reorganising the asylums.
This offer Manning accepted, and he was appointed Medical Superintendent at
the Gladesville Asylum, or, as it was then called, “Tarban Creek.” In the
following year he was commissioned to visit Europe and America to report on the
management and construction of lunatic asylums in those countries. On his
return to Sydney he wrote a valuable report, which gained for him a high reputa¬
tion, and was for a long time regarded as a standard work. He was subsequently
appointed Inspector of Hospitals for the Insane, and on the passing of the Lunacy
Act he became Inspector-General of the Insane. This position he retained for
twenty years, retiring in 1898. During his tenure of office he thrice visited
Englana, and on each occasion he took the opportunity of inquiring into the latest
methods of treatment of the insane. He was thus able to render an immense
service to New South Wales, the newer asylums at Callan Park and Kenmore
having been practically designed by him. One of the last occasions on which he
appeared before a gathering of the medical profession was a meeting of the New
South Wales Branch of the British Medical Association two or three years ago,
when he read a paper on a subject which was near to his heart, “ The Establish¬
ment of Farm Colonies for Epileptics.” Unfortunately he did not live long
enough to see this realised.

Dr. Manning held several appointments at various times. He was the Visitor to
Court patients under the Lunacy Act, a position which corresponds to that of the
Lord Chancellor’s Visitor in England. He had also held the positions of President
of the Board of Health and Medical Adviser to the Government. He was
formerly Lecturer on Psychological Medicine at the University of Sydney, a
Trustee of the National Art Gallery, a local Director of the Equitable Life
Assurance Society of the United States, a Director of the Carrington Convalescent
Hospital at Camden, and lately President of the Australasian Trained Nurses’
Association.

On his retirement from the position of Inspector-General of the Insane he
became a consultant in mental diseases, continuing to render valuable assistance to
the Government in many matters bearing on the management of the hospitals for
the insane. His health began to fail some two or three years ago, and the last
year of his life was spent in much pain and suffering.

Dr. Manning was a bachelor. Of his personal and professional qualities it is
hardly possible to speak too highly. He was a perfect type of an English gentle¬
man, and he was indeed beloved by all who knew his sterling worth and kindly
disposition. Few men have done more than he to adorn and exalt their profession,
ana his death is felt as not only a national loss but as a real personal one by many
of his professional friends and others who never sought his help or advice in vain.
Testimonies to his worth were uttered in the Supreme Court by the Chief Judge in

Digitized by

Google

782

NOTES AND NEWS.

[Oct, 1903.

Lunacy, and these were re-echoed by the leaders of the Equity Bar. But no
stronger manifestation of the esteem in which he was held could be given than the
imposing funeral procession which followed his remains to their last resting-place
in the cemetery which is attached to the institution where he had spent his
best days, and which he had himself selected some time ago for his grave. As the
coffin was borne to his grave by four senior attendants of the different hospitals for
the insane, a large number of the attendants followed, and he was laid to rest in the
presence of a very large gathering of the medical profession, the judges of the
Supreme Court, members of Parliament, and representatives of many of the institu¬
tions with which he had been connected.

The memory of Norton Manning will ever remain green in the minds of those
whose privilege it was to know him as a friend and adviser, and the profession in
New South Wales mourns to-day the loss of one of its brightest ornaments.

A memorial is being raised by his Australian friends.

NOTICE BY THE REGISTRAR.

The next examination for the Certificate of Proficiency in Nursing will be held
on Monday, November 2nd, 1903.

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, November 18th,
1903.

Northern and Midland Division .—The Autumn Meeting will be held, by the
courtesy of Dr. Macdowall, at the Northumberland County Asylum, Morpeth, on
Friday, October 9th, 1903.

South-Eastern Division .—The Autumn Meeting will be held, by the courtesy of
Dr. Rawes, at St. Luke’s Hospital, on Thursday, October 29th, 1903.

South-Western Division .—The Autumn Meeting will be held, by the courtesy of
Dr. Craddock, at the County Asylum, Gloucestet, on Tuesday, November 3rd,
1903 -

APPOINTMENTS.

Campbell, Alfred, F.R.C.S.Edin., M.R.C.S.Eng., Assistant Medical Super¬
intendent of the Hospital for the Insane at Toowoomba, Queensland, vice A. Price,
M.B., Ch.B.Edin., resigned.

Leslie, W. L. A., M.B.Aberd., has been appointed Assistant Medical Officer to
the Grahamstown Asylum, South Africa, vice A. B. S. Powell, resigned.

Mendes, Thomas A., L.R.C.P.&S.Edin., L.F.P.&S.Glas., Second Assistant
Medical Officer to the County and City Asylum, Hereford.

Rowell, Thos., M.B., B.S.Durh., Second Assistant Medical Officer at the City
Asylum, Newcastle-on-Tyne.

Shepherd, J. H., M.B., Ch.B., Second Assistant to Dundee Royal Lunatic
Asylum.

Thomson, Eric M., M.A., M.B., Ch.B.Aberd., to be Assistant Medical Officer,
Government Lunatic Asylum, Kingston, Jamaica.

Mr. G. W. Mould having at his own desire retired from the office of Medical
Superintendent of the Royal Asylum, Cheadle, Cheshire, has been appointed Con¬
sulting Medical Officer and Superintendent of the Welsh houses connected there¬
with.

Mr. Walter Scowcroft, M.R.C.S., L.R.C.P., who has been Mr. Mould’s assistant
for twenty-three years and Resident Deputy, has been appointed Resident Super¬
intendent; Mr. John Sutcliffe, M.R.C.S., L.R.C.P. (second Assistant Medical
Officer), has been appointed Senior Assistant Medical Officer; and Mr. Philip G.
Mould, M.R.C.S., L.R.C.P., has been appointed Second Assistant Medical Officer.

Digitized by v^,ooQLe

INDEX TO VOL. XLIX.

Part I.—GENERAL INDEX.

Abdominal surgery in the insane, 299

Aberdeen Royal Asylum, Dr. Alexander assaulted, 385

After-care association, 324

„ of convalescent insane, 345
Agrammatism following inflammation of the brain, 180
Albany Hospital, mental diseases at, 522
Alcohol and human evolution, 779

„ in relation to mental disease, 778
„ is it a food P 367
Alcoholic insanity, 518
Alcoholism and tuberculosis, 188
Alexander, Dr., assaulted, 385
Alienist physician, position of, 339
Amentia, 712
American psychiatry, 152

Anatomical note: deformity of arm in insane, 546
Aneurysm, obscure case of, 516
„ thoracic, 311
Anthropometric variations, 721
Anxious states in mental disease, 157
Apomorphine hydrochlorate in mental affections, 739
Archives of neurology, English, 315
Asexualism and imbecility, 175
Asphyxia, intra-cranial circulation in, 164
Association of ideas, 535
Astasia-abasia in epileptic child, 176
Asylum patients treated outside, 335
„ reports, 368, 741

„ workers' association, 579

Attendants, education and training of, 340
Australian scandal, 525

Auto-intoxication as cause of mental disease, 163, 725
Autopsies, superfluous, 188
Autoscopy, internal, 547

Bacterial and clinical observations on blood in mania, 219

Bagot, Sir Charles, 705, 772

Barbazon scheme, 741

Belgium, progress of psychiatry in, 335

Biography of a fixed idea, 179

Blood, alkalinity of, in mental disease, 71

„ serum from cases of mental disease, action on B. coli communis, 779
Brain hypertrophy, 352
„ investigations upon (Hitzig's), 142, 350
British Medical Association, section of psychological medicine, 776
Bromipin, 739

Digitized by LjOOQle

784

INDEX.

Cambridge anthropological expedition to Torres Straits, 537
Care and treatment of insane in private houses, 245
„ of chronic insane in Ireland, 319
„ of insane families, 316
Case-book form, 267

„ taking in large asylums, 45
Castration, effects of, 542
Causes of insanity, 131
Cerebral cortex, structure of, 1

„ tumour with alcoholic insanity, 511
Chapman, Dr., revision of tuberculosis report, 711, 771
Children, care of backward, 340

,, idiot and imbecile, treatment of, 341
„ mental defect in, 779

Choline test for active degeneration of nervous system, 718
Chorea and pregnancy with insanity, 486
Chromatolysis, 409
Clinical and pathological notes, 291
„ cases, 321
Colney Hatch fire, 322, 588
Confusional psychoses, 181
Consciousness, double, 640
Criminal lunatics (pseudo) in Spain, 575
„ sociology, 186

» suggestion in a paretic alcoholic, 187

Cysticercus cellulosae causing insanity, no
„ „ of the brain, 115

Deaf, dumb, and blind, case of, 543
Degeneracy, abnormalities of palate in, 81
Degeneration, physiological stigmata of, 231
Degenerate, unrecognised, punished by law, 546
Delirium in febrile conditions, 732
Delusional ideas of the insane, 362
Dementia praecox, 356, 360, 361
Derby dinner, 328

Dieting of pauper lunatics in asylums, etc., 527
Digestion in mental diseases, 165
Dying, psychology of, 546
Dysentery, 127, 715

Electricity, treatment by, 371
Employment, 336

Epilepsy, autocytotoxins and anti- in, 725

„ bromide in 738

„ hysteria and idiocy, 529

„ Jacksonian, 420

„ morphinism in, 739

„ myoclonus, 174

„ not caused by toxaemic conditions, 665
„ serum, therapeutics of, 184
„ suppression of salts of chlorine in diet, 185, 554
„ Toulouse-Richet method of treatment, 554, 185
Epileptic fits, electrical resistance, etc., before and after, 725
Epileptics, care and treatment of, 575
Epilepticus, status, with scarlet fever, 313

Family, care of insane, 316, 337, 345, 524
Feeblemindedness, heredity and clinical symptoms, 730
Female nursing of male patients, 629
Fire at Colney Hatch, 322, 588
Fragilitas ossium in the insane, 779

Digitized by v^,ooQLe

INDEX.

7»5

France, progress of psychiatry, 154
Frontal lobe, functions and diseases of, 351

Genera] paralysis, accommodation, reflex, 177
„ „ conjugal, 170

„ „ granular ependyma in, 483

„ „ in twins, 180

„ „ light reflex, 177

„ „ observations on, 178

„ „ pathology of, 777

„ „ septicaemic, 551

„ „ utility of lumbar puncture, 549

Germany, progress of psychiatry, 157
Gonorrhoea, effect on nervous system, 164
Gout and neuroses, 165
Gowers, Sir W., address, 189
Graves’ disease with mania, 701

Hallucinations, 272, 454, 169

Hand-loom, Flower’s, 211

Hasheesh, insanity from, 96

Headaches in Tomsk, 165

Hebephrenia, 303

Hemianaesthesia, cerebral, 351

Hereditary nature of the occurrence of twins, 365

Heredity and degeneration of the Spanish-Hapsburgs, 171

Hospital treatment of insanity, 378, 379

Hypnotism and suggestion, 536

Hysterical psychoses, 163

Hystero-epilepsy, 179

Idiots and imbeciles, care and training, 560
Imbecility and asexualism, 175
Increase of insanity, causes of, 592
Inebriety, treatment, 184
Infantilism, 722
Insane, bed treatment, 186

„ care of chronic in Ireland, 319
„ family care, 316, 524, 708
„ in private houses and nursing homes, 245
„ pauperisation of, 707
„ poor under private care, 123
,, registration of, not confined in asylums, 344
„ self-accusing, 154
Insanity and life assurance, 121
„ and marriage, 367

,, as regards civilisation, 776

„ classification, 780

„ from Hasheesh, 96

„ geographical distribution, 727

„ incipient, care and treatment, 780

„ in imbeciles, 19

„ temporary treatment of, 706

„ toxic, 507

„ visceral lesions in, 491

„ with chorea and pregnancy, 486
Italy, progress of psychiatry, 158

lews, physical anthropology of, 724
journal, a new, 523

Juvenile murderers and homicides, 556
Katatonia and dementia praecox, 361

Digitized by v^.ooQLe

786 INDEX.

Katatonia and melancholia attonita, 686

„ clinical and experimental observation on, 614
Keller, Helen, case of, deaf, dumb, and blind, 543
Korsakow’s disease in women, 673

Labour among primitive people, 724
Lecithin, 740

Liberty of the lunatic, 122
Licensing acts amendment bill, 327
Logic, morbid, 533

Lunacy administration in Victoria, 579
„ and law, 189, 561, 260

„ Commission, inadequate, 521

„ geographical distribution, 575

„ law reform, 117
„ prophecy, 125

Madrid, International Medical Congress, 526, 574
Malignant oedema in melancholia, 504
Mania, acute adolescent, 441

Medico-psychological Association Annual Meeting, 703

„ „ „ meetings, 189,380,501, 749

„ „ „ Report of Rules Committee

Melancholia, evolution of delirious ideas, 575
„ with disease of heart, 297

„ „ eczema, 295

Memory in normal and pathological individuals, 716
Mental examination of accused persons, 557
Mirror writing, 734

Morphinism in hysteria and epilepsy, 739

Nerve-fibres of spinal cord, alterations in, in chronic insanity, 734

Nerve mesh in the cortex, pericellular, 735

Neurasthenia and troubles of speech, 575

Neurology, English Archives of, 315, 712

Nietzsche’s works, 531

Nomenclature of mental diseases, 236

Nurses, training of, 37, 124

Obituary—Dagonet, H., 214; Falret, Jules, 212; Gasquet, J. R., 2X2; Gind y
Partag&s, T., 386; Manning, F. N., 780
Obsessions and fixed ideas, 164
„ homicidal, 172

„ theory of, 168, 775

Palate, abnormalities, as stigmata of degeneracy, 81
Paraldehyde as a hypnotic, 552
Paralysis, bulbar, of vascular origin, 164
„ progressive, definition of, 164
Paralytic dementia, 714

Paranoia, psycho-motor hallucinations and double personality, 732
Parliamentary notes: Lunacy in Ireland; mental derangement; treatment of
harmless lunatics, 385
Patients treated outside asylums, 335
„ where shall they be sent ? 525
Pellagra, law for prevention and treatment, 162
„ pathology of nerve-cells, 164
Phthisis, treatment of, by urea, 52
Plantar reflexes, 167
Plethysmographic curves, 353

„ investigations in the insane, 355

Political assassins : are they all insane P 368

Digitized by v^.ooQLe

INDEX.

787

Polydactylism and epilepsy, 545
Polyneuritic mental confusion, 550
„ psychosis, 173

Porencephaly, changes in nervous system, 389
Post-mortem examinations, 127
Post-operative psychoses, 551
Presidential address, 587
Prison hospital nursing, 332
Proportions of the adult, 349
Pseudo-criminal lunatics in Spain, 575
„ epilepsies and relief by thyroid, 555
„ sclerosis, 575
Psychological studies, 539

Psychoses at their beginning, best means of dealing with, 344

Psychotherapeutics, 780

Pupil, diagnostic value of irregularities, 731

Rabies, changes in central nervous system, 736
Reception house and general hospital, 325, 598
Religious experience, varieties of, 146
Right-handedness and left-handedness, 547
Rolandic cortex, action of, 420
Royalty, mental and moral heredity, 727
Russia, progress of psychiatry, 163

Saline injections in the treatment of psychoses, 737

Sanity and insanity—lunacy and law, 189

Scarlet fever and status epilepticus, 313

Scientific laboratories in asylums, 343

Self-accusing insane, 154

Senses and of art, pleasures of, 328

Septicsemic general paralysis, 551

Sex and degeneration, 366

Skull, artificial deformity of, 729

Sligo District Lunatic Asylum, 325

Spain, progress of psychiatry in, 166

Spinal atrophy, treatment, 164

Spirit world, 326

Statistical tables, 128, 614

Stereoplasm of the nerve elements, 382

Suicidal tendency and suicide in insane, 175

Suicides in public asylums, 447

Superannuation allowances for Scottish asylums, 474, 522, 576
Swallowing foreign bodies, 291
Syphilis in the central nervous system, 163
Syringomyelia, affections of bones, 163

Tabes and marriage, 729
Teaching of psychology, 659
Tent life for the insane, 324
Thyroid in pseudo-epilepsy, 555
Tramps, psychoses among, 354
Treatment of acute cases, 689
Tuberculosis Committee, report, 123, 322, 711, 771
„ statistics, 127, 381, 606

„ in public asylums, 589

Tumour, cerebral, complicated with alcoholic insanity, 511
Tumours, cerebral, softenings surrounding, 168
Urea in phthisis, 52

Venereology, social, 558
Vidal, the murderer, 362
XLIX.

Digitized by v^.ooQLe

788

INDEX.

Visceral lesions in acute insanity, 491
Voluntary boarders in asylums, 520

White, Dr. E. W., presidential address, 587
Will, the, 330

Winsley Sanatorium for Consumptives, 523
Women, physiological feebleness, 540

Yellowlees, Dr., presentation to, 207

Part II.—ORIGINAL ARTICLES.

Barratt, Dr. J. O. W., the changes in the nervous system in a case of porencephaly,

389

Baskin, Dr. J. L., the treatment of phthisis in asylums by urea and its salts, 52
Benham, Dr. H. A., some remarks on suicides in public asylums, 447
Blachford, Dr. J. V., frequency of occurrence of granular ependyma in general
paralysis, 4°3

Black, Dr. R. S., a case of cysticercus cellulose causing insanity, no
Bruce, Dr. L. C., bacteriological and clinical observations on the blood of cases
suffering from acute continuous mania, 219
„ further clinical observations in cases of acute mania, particularly

adolescent mania, 441

„ clinical and experimental observations in katatonia, 614

Dawson, Dr. W. R., note on a new case-book form, 267
„ a case of hebephrenia, 303

„ notes on two cases illustrating the difference between kata¬

tonia and melancholia attonita, 686

Goodall, Dr. E., the case of an unrecognised degenerate punished by the law, 231
Greene, Dr. G. W., a case of status epilepticus complicated with scarlet fever, 313
Grieves, Mr. J. P., notes on a case of Graves’ disease with mania, 701

Hall, Dr. W. H., that epilepsy cannot be caused by toxaemic conditions, 665
Harrison, Dr. E. H., the abnormalities of the palate as stigmata of degeneracy, 81
Hotchkis, Dr. R. D., malignant oedema in a case of melancholia; rapid fatal
termination, 504

J ohnstone, Dr. J. C., superannuation allowances for Scottish asylum workers, 474
ones, Dr. R., a case of chorea and pregnancy with insanity, 486
„ remarks on a case of cerebral tumour, 511

Kingsford, Dr. A. B., on the action of the Rolandic cortex in relation to Jacksonian
epilepsy and volition, 420

Leeper, Dr. R. R., notes on the treatment of acute cases, 689

Myers, Dr. C., the teaching of psychology in universities of the United States, 659

Nolan, Dr. M. J,, clinical and pathological notes, 291
Norman, Dr. Conolly, notes on hallucinations, 272, 454

Pierce, Dr. B., on the training of nurses in institutions for the insane, 37
Pugh, Dr. R., the alkalinity of the blood in mental diseases, 71
„ an obscure case of aneurysm, 516

„ a case of thoracic aneurysm simulating mediastinal growth, 311

Rambaut, Dr. D. F., case-taking in large asylums, 45
Revision of the statistics presented by the committee on tuberculosis, 606
Ridewood, Dr. H. E., a case of cerebral tumour complicated with alcoholic con-
fusional insanity, 511

Digitized by

Google

INDEX.

789

Sullivan, Dr. W. C., a case of cysticercus cellulosae of the brain, 115

Thompson, Dr. E. M., notes on three cases of insanity, toxic in origin, 507
Tredgold, Dr. A. F., insanity in imbeciles, 19

Turnbull, Dr. A. R., female nursing of male patients in asylums, 629
Turner, Dr. J., some new features in the intimate structure of the human cerebral
cortex, 1

„ concerning the significance of central chromatolysis with dis¬

placement of nucleus in the cells of the central nervous system of
man, 409

„ twelve cases of Korsakow’s disease in women, 673

Urquhart, Dr. A. R., nomenclature of mental diseases, 236

„ superannuation allowances for Scottish asylum workers, 474

Wamock, Dr. J., insanity from hasheesh, 96
Watson, Dr. D. C., some visceral lesions in acute insanity, 491
White, Dr. E. W., the care and treatment of persons of unsound mind in private
houses and nursing homes, 245
„ presidential address, July, 1903, 587

Wilson, Dr. A., a case of double consciousness, 640

„ Dr. G. R., some visceral lesions in acute insanity, 491
Wood, Dr. T. Outterson, lunacy and the law, 260

Part III.— Reviews.

Bain, Prof. A., Dissertation on leading philosophical topics, 718
Bourneville, Dr., Recherches cliniques et thlrapeutiques sur l’£pilepsie, l'hyst^rie,
et l’idiotie, 529

Bruce, Dr. A., and Dr. E. Bramwell, Review of neurology and psychiatry, 334

Chase, Dr. A. M., General paresis, practical and clinical, 334
Clapar&de, Dr. E., L’association des id£es, 535
County and borough asylums reports, 127

Daffner, Dr. F., Das Wachstum des menschen (the growth of man), 719
Defendorf, Dr. A. R., Clinical psychiatry: a text-book for students and physicians,
abstracted and adapted from the sixth German edition of Kraepelin’s Lehrbuch
der Psychiatrie, 150

Deny, D. G., et P. Roy, La dlmence pr^coce, 721

Dunlop, Dr. 1 . C., Report on dieting of pauper lunatics in asylums and lunatic
wards or poor-houses in Scotland, 527

Hitzig, Prof., Old and new investigations upon the brain, 142
Hughes, Mr. R. E., The making of citizens: a study in comparative education,
> 5 *

James, Dr. W., The varieties of religious experiences : a study in human nature,
146

Keller, Miss Helen, The story of my life. With her letters (1887—1901) and a
supplementary account of her education, including passages from the reports
and letters of her teacher, Anne Mansfield Sullivan. By John Albert Macy, 543

Lange, Prof. Carl, Sinnesgenusse und Kunstgenuss (the pleasures of the senses
and of art), 328

Macy, Mr. J. A., see Keller

Mobius, Dr., Sex and degeneration (Geschlect und Entartung), 366
„ Ueber das rathologische bei Nietzsche, 531
„ On the physiological feebleness of women, 540
„ Ueber die Wirkung der Castration (on the effects of castration), 524
Mott, Dr. F. W., Archives of neurology: from the pathological laboratory of the
London County Asylum, Claybury, 712
Munsterburg, Prof. H., Harvard psychological studies, 539

Digitized by v^.ooQLe

790

INDEX.

Naegeli, Dr., The hereditary nature of the occurrence of twins, 365
Nietzsche, F., The dawn of day, 531

Paulhan, F., La volontd, 330

Reports of Commissioners in Lunacy, 1902, 126

„ „ „ for Scotland, 1902, 132

„ of Inspectors of Lunatics (Ireland), 1901, 136

„ of the Cambridge anthropological expedition to Torres Straits (physiology
and psychology), 537
Richer, Dr. P., L’Art et la mldedne, 150
Rogues de Fursac, Dr. J., Manuel de psychiatrie, 331

Smalley, Dr. H., Prison hospital nursing: a manual of first aid and nursing for
the prison hospital staff, 332

Triboulet, M., Is alcohol a food ? 367

Vaschide, N., et Vurpas, C., Drs., La logique morbide: I. L’Analyse mentale, 533

Watson, Dr. C., Encyclopaedia medica, 720
Wilcox, Dr. A. W., Insanity and marriage, 367

AUTHORS REFERRED TO IN EPITOME.

Alessi, 725

Allen, C. L., 736

Halmi, 554

Picqu£, 551

Hitzig, 350

Pierce-Clark, L., and Prout,

Antheaume, 739

T. P., 174

Anton, 351, 352

Tamot, 738

Pteron, H., 546

Amaud, 168

Joffroy, 549

Piltz, J-, 73*

Baer, 556

Jones, K. W., 732

Pitres, 729

Bargaras, 554

Kelynack, 188

Raviart, 170, 180
Roncoroni, 184, 735

Briaud, 551

K^raval, 170, 180
Komfeld, 188

Browning, 555

Royer, Rebatel, 362

Bumke, 552

Krayatsch, 560

Burzio, 734

Slglas, J., 361

Lacassagne, 362

Serbs Id, Vladimir, 360

Camia, M., i8x

Lai, 545

Slrieux, P., 356

Cappelletti, 185

Lombroso, 187

Shaefer, 167, 182

Capriati, V., 167

Shaffer, 351

Casper, 179

Mariani, 172

Sollier, P., 547

Ceni, 725

M a ran don de Montyel,

Soukhanoff, 178

Clado, 558

177

Spitzka, 368

Clark, 174

Mayet, 546

Stekel, 352

Crocq, 550, 551

Mercier, 549

Tomasini, 734

Crothers, 184

Merck’s report, 739
Mobius, 366

Muller, R., 353

Cunningham, 547

Triboulet, 367

Delisle, F., 723

Multever, 179

Vaschide and Vurpas,

De Moor, 557

,69

D’Ormda, 185

Esposito, 173

Naegeli, Aekerblom, 365
Niceforo, 186

Vogt, Ragner, 355

Von Straaonitz, 171

Obersteiner, 352

White, W. A., 727

Ferrari, 362

Wickel, 737

Fishberg, M., 724

Papillault, G., 721

Wilcox, 367

Pellizzi, 168, 730

Wilmanns, Karl, 354

Gabbi, V., 176

Pfitzner, 349

Woods, F. A., 727

Gannouchkine, 178

Pianetta, 546

Giuffrida-Ruggeri, 722

Pick, 180

Zingerle, 351

Gucci, 175

Pickett, W., 732

Digitized by v^.ooQLe

INDEX.

791

ILLUSTRATIONS.

Two photographs of nerve structure to illustrate Dr. J. Turner’s paper, 12
Woodcut „ „ „ 13

Tables I and II, showing alkalinity of blood in epileptic states, 79
Twelve photographs of the palate to illustrate Dr. E. H. Harrison’s paper, 90
Woodcut of male figure to illustrate Dr. J. G. W. Barratt’s article, 391
Woodcuts of brain „ „ „ 393, 394

„ sections of spinal cord to illustrate Dr. J. G. W. Barratt’s article, 396,
398 , 399 . 401—403

Four photographs of brain to illustrate Dr. J. G. W. Barratt’s article, 393, 394
Table of curves to illustrate Dr. L. C. Bruce’s article, 445

Chart „ „ Dr. G. R. Wilson and Dr. D. C. Watson’s paper, 496

Twelve photographs of mucous membrane of stomach, intestines, and lung to
illustrate Dr. Wilson and Dr. Watson’s paper, 500
Chart to illustrate Dr. Bruce’s paper, 617—619, 621
„ „ Mr. Grieves’ paper, 702

PRINTED BY ADLARD AND SON,

BARTHOLOMEW CLOSE, E.C .; 20 , HANOVER SQUARE, W.
AND DORKING.

XLIX. S 5

Digitized by

Google

Digitized by v^.ooQLe

Digitized by

Digitized by v^.ooQLe

345771

fccsz/

<j . <^3

UNIVERSITY of CALIFORNIA LIBRARY

ONE DAY

B* A LOGY
library

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. 49.1903 California"

See other formats